Female genital mutilation (FGM): overview, types, health effects and responses

In 1995, the World Health Organization (WHO) presented a classification to distinguish between different types of female genital mutilation, which was adopted in a joint declaration by WHO, UNICEF and UNFPA in 1997. This typification was revised in 2008 and has since been endorsed by other United Nations agencies and programmes, including OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNHCR and UNIFEM, in addition to those already mentioned. The classification serves as a basis for understanding the object of study in research and is intended to ensure the comparability of data collections. However, such a grid always implies simplification; indeed, there are many variants combining different interventions. Even within a region or ethnic group, considerable differences in the form of circumcision can occur.

Accordingly, the following four types can be distinguished according to the extent of the change:

• Type I: partial or complete removal of the externally visible part of the clitoris (clitoridectomy) and/or the clitoral hood (clitoral hood reduction).
• Type Ia: Removal of the clitoral hood
• Type Ib: Removal of the clitoral prepuce and the clitoral glans
• Type II: partial or complete removal of the externally visible part of the clitoris and labia minora with or without circumcision of the labia majora (excision).
• Type IIa: Removal of the labia minora
• Type IIb: Removal of the labia minora and total or partial removal of the clitoral glans.
• Type IIc: Removal of the labia minora, labia majora and all or part of the clitoral glans.
• Type III (also infibulation): narrowing of the vaginal opening with formation of a covering closure by cutting open the labia minora and/or labia majora and joining them together, with or without removal of the externally visible part of the clitoris.
• Type IIIa: Covering by cutting and joining of the labia minora
• Type IIIb: Covering by cutting and joining of the labia majora
• Type IV: This category includes all practices that cannot be assigned to one of the other three categories. The WHO mentions, for example, piercing, cutting (introcision), scraping, cauterization of genital tissue, cauterization of the clitoris or the introduction of corrosive substances into the vagina.

The various ritual interventions grouped in the fourth category are far apart in terms of background and consequences and are less researched overall than those of the other three types. Some practices, such as cosmetic surgery in the genital area or restoration of the hymen, which are legalised in many countries and are not fundamentally assessed as genital mutilation, can also be subsumed under this typification. From the WHO perspective, it is considered important to define female genital mutilation broadly in order to close gaps that could justify the continuation of the practice.

The proportion of different forms of intervention to each other could only be estimated so far. The largest amount of data exists on circumcised African girls and women older than 15 years. About 90 % of these show genital alterations of types I, II and IV, 10 % of type III. Other estimates deal with girls younger than 16 years and found a higher proportion of circumcisions of the most severe type III in this age group. It is believed that up to 20% of all circumcised girls have had Type III changes.

The most invasive practice is type III infibulation, also called pharaonic circumcision. The girl's legs are bound together from hip to ankle for up to 40 days to allow the wound to heal. The skin over the vaginal opening and the exit of the urethra grows together and closes the vaginal vestibule. Only a small opening for the exit of urine, menstrual blood and vaginal secretions is created by inserting a thin twig or rock salt into the wound. This obstruction results in additional pain and risk of infection. Further health risks and complications arise from the fact that the vulva has to be cut open again (medical term: defibulation) to enable sexual intercourse. If the man is unable to open the vagina by penetration, the infibulated vaginal opening must be widened with a sharp object. Additional wider defibulation is often necessary for delivery. Sometimes infibulation is performed on uncircumcised pregnant women before delivery because it is believed that touching the clitoris causes miscarriages. In some areas, this is followed by another infibulation, called re-infibulation or refibulation, after the birth.

Antiquity and the Middle Ages

The origins of female circumcision could neither be clearly determined in time nor geographically. Already in antiquity, scholars dealt with the subject of circumcision, which at that time was known mainly from ancient Egypt. Descriptions are found in Galenos, Ambrosius of Milan and Aetius of Amida. On a papyrus from 163 B.C., the era of ancient Egypt, circumcision of girls is mentioned. Mummies have also been found showing signs of circumcision. Male circumcision can also be dated to this period. According to the Greek historian Strabon, circumcision was performed on both sexes in Egypt; likewise, Philon of Alexandria, who lived around the time of Christ's birth, reports that "among the Jews only the males are circumcised, but among the Egyptians both males and females are circumcised." The ancient authors assumed that women were circumcised for aesthetic reasons, in order to correct or improve the appearance of the female genitals.

It is assumed that circumcision spread from ancient Egypt across the African continent. The routes of its spread as well as its time course cannot be clearly reconstructed.

In the Middle Ages, descriptions of circumcision are found in the Canon medicinae of Avicenna (980-1037) and in Abulcasis (936-1013), where it was recommended in cases of overly pronounced genitalia.

Modern Europe and North America

European engagement with the practice intensified at the time of colonialism in the late 19th century. At this time, the first descriptions appeared in early ethnography. The distinction between "clitoral" and "vaginal" orgasm proposed by Sigmund Freud subsequently led to a disdain for "clitoral sexuality". Clitoral sexuality, according to Freud, had to be overcome in order to arrive at mature sexuality. The psychoanalyst Marie Bonaparte criticized the Freudian notion of the necessary detachment of the clitoris as an erogenous guidance zone. In 1935, a meeting took place between the future Kenyan Prime Minister Jomo Kenyatta, the anthropologist Bronislaw Malinowski and Marie Bonaparte. Through Malinowski, she learned about female genital mutilation in Africa. With Kenyatta's support, Bonaparte conducted field studies in East Africa in the years that followed, examining the circumstances of circumcision and the consequences for women, and representing the first scientific research on the subject.

During the 16th, 17th, 18th, and 19th centuries and up to the 1970s, clitoridectomies and other surgical procedures such as cauterizations and infibulations were performed on female genitalia in Europe and North America. This was done to "cure" supposed female "ailments" such as hysteria, nervousness, nymphomania, masturbation, and other forms of so-called female deviance. In 1866, the English gynecologist Isaac Baker Brown promoted clitoridectomy as a method of treatment in his work on the "Curability of Various Forms of Insanity, Epilepsy, Catalepsy and Hysteria in Women." It was well known that the female libido could be irreversibly damaged by such procedures. In 1923 Maria Pütz wrote in her dissertation: