Khadija Khaja, Kathy Lay, Stephanie Boys. Health Care for Women International. Volume 31, Issue 8, 2010.
Female circumcision is a cultural traditional practice where female genital organs are partially or completely removed without medical justification, primarily to protect a woman’s virginity and honor (Women’s Health in Women’s Hands, 1999; World Health Organization, 1998). Girls can be circumcised anywhere between the ages of 1 week to their later teens, based on local customs (Barstow, 1999; Council on Scientific Affairs, American Medical Association, 1995; Khaja, 2004). Even though some women have been circumcised at older ages, this practice is less frequent. There has been a global outcry against the practice because of the serious health consequences on the physical well-being of women (Khaja, 2004). To understand female circumcision, researchers need to take into account the perceptions of women who have experienced the practice. In this article we will elaborate on partial findings of an exploratory dissertation study that provided circumcised women an opportunity to voice their perceptions about the practice and make recommendations about what strategies health care providers need to take into account when designing interventions to deal with the practice. The authors also will describe the types of female circumcision, the health concerns, and how the international women’s health discourse has shut out circumcised communities, and how we can reshape our discourse on female circumcision more sensitively if we wish to assist women whose health has been adversely affected by the practice.
Types of Female Circumcision
In 1997, a collaborative statement was declared by the World Health Organization, the United Nations Children’s Economic Fund, and the United Nations Female Population Fund that distinguished the types of female circumcision, because each type affected the gravity of health consequences (World Health Organization, 1998). Circumcisions usually are performed by females who are respected elders, midwives, or doctors. Circumcisers can be given payments in the form of food, livestock, money, or all of these (Khaja & Briar-Lawson, 2000). The procedure of female circumcisions can occur in a rural setting without anesthesia being administered to females, or in a medical setting. In rural settings very crude instruments like a razor blade, knife, or sharp stone may be used. The most widespread type of circumcision is known as “sunna” whereby the clitoris or clitoral hood is cut (World Health Organization, 1998). The second-most-frequent type of circumcision is called “excision or clitoridectomy” in which the clitoris is entirely cut off, with part or all of the labia minora removed. The first two types of circumcision described represent about 80% to 85% of the practice (Toubia, 1999). Approximately 15% to 20% of females experience a third type of circumcision known as “infibulations/pharonic,” where some or all of the internal and external genitalia tissue and skin is removed, with the vaginal hole stitched and narrowed (Joseph, 1996; Toubia, 1999; World Health Organization, 1998). A tiny opening the size of the tip of a pencil is left for menstrual and urine flow, about 2 to 3 centimeters wide (Khaja, 2004; Worsley, 1938). This type of circumcision is most common in countries like Somalia, northern Sudan, and Djibouti. The “unclassified” circumcision is known as the fourth type of the practice, where a tiny part of the clitoris, vagina, or both is pricked, pierced, or burned. The frequency of type of circumcision can differ radically from 98% of Type III being performed in Somalia, to less than 5% of Type I or II in areas such as Uganda (World Health Organization, 1998).
Health Consequences
There are many documented short-term and long-term health consequences associated with female circumcision, with the health risks varying based on the gravity of the procedure performed (Khaja, 2004; World Health Organization, 1998). The sanitary condition of cutting instruments, the ability of the circumciser, severity of cutting, and the health of the girl or woman often can determine the health risks. If death has occurred, it often has been due to severe bleeding, pain, infection, oozing pus, gangrene, tetanus, chronic ulcers, or all of these conditions (Khaja, 2004; World Health Organization, 1998). Fistulae can build up when there has been damage to the vagina, urethra, and rectum, leading to steady leaking of urine and feces. Severe swelling near wounds has led to urine retention that lasted for hours or even days (Khaja, 2004; World Health Organization, 1998). Dermoid cysts as big as large fruits or footballs, bleeding from the clitoris, urinary tract infections, tumors, and women experiencing chronic pain during sexual intercourse can occur (Khaja, 2004; World Health Organization, 1998).
Female circumcision has led to severe urinary tract infections, large cysts, hemorrhages, high-risk pregnancies, tetanus, and even death. The far-reaching physical, emotional, mental, and sexual trauma that can result from the practice has led some to label it “barbaric, abhorrent, and equated to torture” (Barstow, 1999; Khaja, 2004, p. 15). The mainstream general media has favored using the term “female genital mutilation” to describe the practice, because while the intent was circumcision of a woman’s vagina, the result was severe mutilation of her vagina (Toubia, 1999).
Method
This exploratory qualitative dissertation provided a forum for 17 circumcised Somali women living in Ontario, Canada, and Salt Lake City, Utah, to share their perceptions about the practice. Somali women were specifically chosen for this study as it is reported that approximately 98% of them go through the most severe form of female circumcision (infibulation) back in their home country (Toubia, 1999). Face-to-face interviews were conducted with Somali women who ranged in age between 20 and 79, with all experiencing some type of circumcision in Somalia between the ages of 6 and 10. Twelve of the women had been circumcised in their homes, and five were circumcised in a hospital setting. Nine of the women had undergone infibulations or pharonic circumcisions, four had experienced excision circumcisions, and four had gone through sunna circumcisions. Nine of the women lived in Ontario and eight lived in Salt Lake City. Almost all the women had migrated to North America due to the civil war that took place in Somalia between 1985 and 1995 (Khaja, 2004).
Findings
We Feel Like Health Specimens
Some women felt that if health care providers knew they were Somali that they would become more interested in their circumcisions rather than focusing on the reason why the women were seeking treatment. Others reported that their friends had told them that some North American doctors would show their vaginas to medical students and nursing students as though they were specimens.
You Were Never Circumcised
Women were clearly angry toward some Western women’s health advocacy organizations. They reported that such organizations often had an agenda of focusing on the most severe type of circumcision known as infibulation, almost sensationalizing the practice because they were not as vocal in mentioning that the most common type of female circumcision was sunna, the mildest form. They were upset that many Western women’s organizations had described female circumcision as child abuse as though Somalis did not care about their children. They felt women’s health advocacy organizations needed to focus on the health implications of the practice instead. Other women also reported that Somalis were the first community to speak out against the practice with honesty and openness, but instead of applauding them, Western women’s health organizations had condemned them. One woman reported:
Somalis are outspoken. They are the only community that come out and talk about it open. All other communities are very secretive. A lot of others will try and avoid, saying they are not done to themselves. We are only people that say it’s a culture, it’s a practice that we have, are not proud of but are trying to fight … But we want (it done) in sensitive way. The barriers are when media did sensational things and some of our women went to the television and health practitioners talking about abuse of mothers to their children. You know, changing from health focus to this practice is abuse of children. Feminism comes and that is where the outcome we were looking little bit it hurt the community. A lot of people start saying we don’t want to talk about this. They don’t have any right to say to us.
The way circumcisions had been described had silenced many communities who engaged in the practice.
Stop Judging Our Mothers
Women interviewed believed laws enacted to ban all types of circumcisions implied that they came from a generation of abusers, their ancestral traditions labeled as uncivilized:
Even though I have no mother, I know my people … My Mom feel sorry; she say “I don’t mean to harm you … You can see a person how they treat you. … You know how they are treating you … I want you to be educated, … want your well-being…” I would like to deliver this message as a sensitive issue, that’s it. It’s a very sensitive issue about Somalis, or even other countries that women have circumcision in. And when addressing this issue to talk more sensitively, more about health. Educate people to know it’s religiously the way they believe, give them advice it’s not there in religion. This is about a health issue for your daughters. Instead, you’re showing they are less than this, that my family or my father or mother want to harm me.
Somalis felt insulted that while they clearly loved and adored their children, international laws against circumcision made them look like abusers. Laws had insulted their mothers, their communities, their country, and African ancestry.
Insensitive Debate
A great deal of frustration was expressed about the cultural insensitivity in dialogues dealing with circumcision:
If they can’t say why, I believe they have to stop talking … The way that it was a culture, that was there a long time … I am not saying it’s wrong that we don’t have to talk or we don’t have to educate the people. But to show to the other people that we are mutilated, we are less than other women, we don’t have feelings. I disagree.
Respondents reported that they were still sexually active, but dialogues on the practice made them appear as though their sexual lives were flawed. Leonard (2000) found that many Western feminists had estranged circumcised women they wanted to advocate for because they used language that was provocative and horrific. Cultural insensitive discourse inadvertently had led to circumcised women feeling defensive and distrustful:
Educate the family, that’s the right way educate them. Tell them it’s not right. Use religious part, the medical part. You can explain the consequences, what is going to happen. She may have psychological trauma, bleeding, she may get infection, it may affect fertility, may infect. They will understand. The Somalian people understand when you explain to them and make them understand. They just need explanation. People on television telling she tortured you, no one tortured you. They like to educate the daughters. The want daughter to be well-educated, respected when she is married, to be with a good man. To say, “The girl I marry, her family is well respected.” Like they want their reputation to be well.
The general consensus of women was that educating on the health consequences of female circumcision would have been and will be a more culturally sensitive way of dealing with the health consequences of the practice. Boyle (2002) reported that advocacy efforts that ban all types of female circumcision yielded poor results. North Americans have enacted criminal legislation to ban female circumcision rather than being more vocal on advocating for supportive health care education (Gunning, 1991). It is impossible to regulate a culture or tradition (Hernland, 2000).
We Are Trying to Change
Some women had become advocates to ban all types of circumcisions because they were quite troubled about rural areas in which the practice occurred, as such areas had poor access to information on health dangers associated with the practice. Since the 1970s Somalis had been active at grassroots levels to try and deal with health implications of the more severe forms of the practice:
They organized an international conference. The participation came from Sudan and other Africans. This was about 1978 … The Minister of Health talked, so lots of things were done. There was a campaign to deal with circumcision. The government also did a ban that it could not be done outside. It had to be done in a hospital to minimize the harm, it was a reduction strategy. They started doing circumcisions in hospitals. They started not cutting the complete clitoris. You know, doing the suture, not cutting the labia majora or labia minora.
Some women expressed anger that Somalis never received any acknowledgment for their efforts to deal with the practice. For example, Somalis attempted to have more minor forms of the practice performed in sanitized conditions in health care settings feeling it would have been difficult to ban all types of the practice. The civil war that devastated Somalia during the 1990s had wiped out many hospitals, however, with many doctors and nurses being killed or those surviving fleeing the country. One woman said, “We discovered health problems related to it and what it can cause. We began to change. Especially young women doctors fought against it.” The young educated women of Somalia were described as the social movement makers and leaders that had demonstrated the bravery to speak up against female circumcision. Dahabo Farah, Dean of Languages for the University of Somalia, was mentioned by a number of respondents in the study as she organized the first global conference on circumcision in Somalia. It is important to note that to date her name is hardly ever acknowledged in Western women’s discourse on female circumcision, yet Dahabo Farah has been active since the 1970s to speak out vehemently that all forms of the practice had to be banned. The first author had the privilege of meeting her some 25 years ago.
Condemnation, Prevalence, and Challenges
Many women’s health organizations, international human rights activists, nongovernmental organizations, and international children’s welfare rights groups have condemned the practice. While they acknowledge the practice is based on cultural tradition, they also describe it as violence against women and female children, due to undesirable affects on health. Although international policies and laws have been enacted to ban all forms of female circumcision, it still continues as part of daily life, and it is widespread in half of the countries in Africa. In Ethiopia, Eritrea, Djibouti, Somalia, and Northern Sudan about nine out of 10 women are circumcised. In Burkina Faso, Kenya, Benin, Chad, Egypt, and Gambia, about 50% of females are circumcised. Globally, 130 million females have been circumcised, with two million females circumcised yearly, and six thousand circumcised each day (Khaja, 2004; Toubia, 1999).
In spite of the enormity of the practice and documented health consequences, female circumcision is difficult to address. Circumcised women and children are hesitant to speak about their experiences because of the “fear of being judged, labeled and attacked” (Khaja, 2004, p. 9) as a barbaric, uncivilized population. Even when circumcised women themselves have spoken out to eradicate the practice completely, they have been described as betrayers or sellouts by their own communities, viewed as women who have dishonored sacred cultural traditions (Khaja, 2004). In many circumcised communities, there is a conspiracy of silence due to the distrust of global female circumcision eradication agendas because general discourse on women’s health issues stemming from the practice has been viewed as sensationalized, ethnocentric, racist, culturally insensitive, and simplistic (Khaja, 2004).
Women who have been circumcised and choose to speak out against this cultural practice face multiple levels of stigmatization. Initially, they are stigmatized because they are from a nondominant culture; second, because they have experienced a cultural practice that has been identified by Western discourse as harmful; and by their own cultural group as a betrayer of their culture. The costs of stigma, which are socially defined, include social and psychological consequences (Dovidio, Major, & Crocker, 2000). Stigma serves to elevate one over another by a “downward comparison” (Dovidio et al., p. 7). This is useful for those who want to advance a Western discourse about quality of life, but perhaps this actually serves to undermine the practice of care toward the very individuals who are faced with decisions about female circumcision.
The intent of Western discourse is not to do harm; however, when women’s voices are excluded, there is power over another and the result is oppression. Decision making, theorizing, creating rules and laws about quality of life, health care, and care in general is evidence of power (Fletcher, Silva, & Sorrell, 2002). “Oppression is associated with abusive or unreasonable use of decision making … which results in the oppressed feeling diminished as a valued person” (Fletcher et al., 2002, p. 3). The abuse of power by excluding the very voices of those impacted may result in unwarranted resistance in an effort to maintain a sense of agency over one’s own body and culture. It is for this reason our discourse must be inclusive of all, those with a variety of strengths and expertise, in order to produce decisions that are collaborative, that is, with as opposed to doing to others.
It is imperative to procure the voices of women who have experienced circumcision to avoid misconceptions regarding the practice. Research has shown that the practice is viewed from a Western ethnocentric perspective that often is counter to the actual experiences of the women. For example, Leval, Widmark, Tishelman, and Ahlberg (2004) found that the majority of midwives in Sweden made an incorrect assumption that circumcised women no longer have any sexual desires. The midwives expressed anger at the cultural tradition and expressed with distaste, “They can’t possibility get any enjoyment from their sex life” (p. 749). Another assumption is that circumcision is performed only in rural, impoverished areas of Africa. The assumed correlation between circumcision and poverty is no longer accurate, as the practice is growing among the more urban areas in Africa and educated populations (Douglas, 1998).
Strategies to Proactively Address Female Circumcision
The difficulty in addressing female circumcision is to sensitively “include, and validate” the voices of circumcised women so their perspectives are valued (Khaja, p. 12, 2004). Western tradition generally has controlled the dialogue on quality of life and human rights since the eighteenth century; hence, many Western international women’s health rights activists see female circumcision as a grave human rights violation (Ife, 2001). Mutisya (2000) argues that when all types of female circumcision are expected to be banned by dominant voices—outsiders—that African women are again being defined or controlled by others, as opposed to being given the capacity to define and empower themselves. There is a growing critique that many Western international women’s organizations have rather naïvely forced their cultural values on people from other parts of the world, in essence telling circumcised communities their culture is inferior, and their traditions are uncivilized (Khaja, 2004). This, in turn, can reduce the self-esteem of circumcised women and impede their social development as they grow from girl to woman (Woods, 2009). Naiveté is, from a novice position, one who tells others what to do and expects compliance (Benner, 1984).
Laws are a product of accepted cultural norms and practices in any given area of the world, and Western laws are no exception. An example of the conflicts that can arise from ethnocentric definitions of religious freedoms can be found in the United States’ interpretation of its constitutional rights granted in the Free Exercise Clause, which grants freedom of religious practices. The clause was a recent source of controversy between the U.S. Supreme Court and the congressional branch of government. In 1990, the Supreme Court ruled that general laws established for public policy reasons could not be sidestepped for religious reasons. In Employment Division v. Smith, the court upheld a denial of unemployment compensation for Native Americans who were working as addiction counselors and were fired for regular use of peyote as part of their religious practices (1990). The majority opinion of the Court, penned by Justice Scalia, reasoned, “the government’s ability to enforce generally applicable prohibitions of socially harmful conduct, like its ability to carry out other aspects of public policy, ‘cannot depend on measuring the effects of a governmental action on a religious objector’s spiritual development’” (Employment Division v. Smith, p. 885). The U.S. Congress disagreed with the Supreme Court’s disregard for religious practices, and mooted the precedent of the case by passing the Religious Freedom Restoration Act of 1993 (RFRA). The law had the affect of expanding freedom of religious practices by requiring that neutral laws that inadvertently inhibit the religious practices freedom of individuals or groups may be enforced only against those individuals when the state has a compelling reason for enforcement, such as safety. The RFRA establishes a presumption that religious sects may engage in otherwise illegal activities.
Although the RFRA allows some laws to be circumvented for religious reasons, female circumcision does not fall in the exception category. The practice is prohibited in the United States by child abuse laws (Annas, 1996). The specific wording of state child abuse laws vary, but all states have laws prohibiting parents to inflict or allow the infliction of permanent physical injury to their child. While the results of female circumcision are easily legally classified as permanent injury, some may see them as in conflict with another set of state laws in the United States, which requires parents to act in the best interests of their children. If purity is believed to be the only way a child can live a moral life and find peace in the afterlife, and circumcision is the only way to achieve this purity, how can it be argued that circumcision is not in the best interest for parents holding these religious beliefs? It is this discourse of purity and belief in the best interest of children that advocates must be sensitive to when attempting to change cultural practices. Parents and young girls indoctrinated into a culture where circumcision is practiced, and even required, do not regard it as abuse. The legal discourse is not congruent with religious practices, and, therefore, a more culturally sensitive discourse must be developed to proactively affect change.
Civil unrest has become a growing obstacle when international organizations try to help women where female circumcision is practiced. Turshen and Twagiramariya (1998) have reported that 75% of the countries in Africa are going through violent conflicts, and 80% of refugees are women and children. Getting families to understand possible health consequences of female circumcision will take a back burner in violent zones, because families are barely surviving, their priority is finding food and water to survive; therefore, potentially harmful cultural practices that effect women and children cease to be a priority. It is for this reason that we must continue to keep a dialogue alive that is inclusive of the very women who are impacted.
Discourse of Care
Perhaps what is called for is a discourse that is inclusive of women’s voices. This calls for ethical practices that are sensitive to the political, social, and cultural realities of all. Tronto (1993) has identified four elements of care: attentiveness, responsibility, competence, and responsiveness. Attentiveness involves the recognition of need (Tronto). Since care is in relationship to those in need, this requires us to become knowledgeable about those who are in the experience. We cannot theorize about another’s conditions absent of their experience and voice if we are to be attentive. Inattentiveness is to be ignorant of others’ experience, which Tronto defines as a kind of moral evil. Again, absent of the intent of evil or power over, but, nonetheless, the result is a moral failure to fully care for those in need.
Responsibility, the second element of care, is concerned with our obligations to others beyond the role of political authorities that construct laws (Tronto). West (1993) challenges; we must ask questions related to who endures the social costs for any given action? What has determined the need for a law or rule and how will it be carried out in ways that do not marginalize the very ones it is supposed to protect? Failure to ask these critical questions and others may be a failure to take full responsibility for a continuum of care.
Competence requires knowledge and skill in demonstrating an ethic of care (Tronto, 1993). In the case of female circumcision, one may be competent to speak about the health consequences related to this cultural practice by having completed formal educational requirements of related disciplines such as nursing, medicine, and social work. Knowledge is incomplete, however, without the informants of the cultural experience. One may adhere to disciplinary practices, procedures, and codes of ethics; however, care occurs in a context (Tronto) and in order to be morally competent one must work collaboratively with those impacted by their care.
Responsiveness is about the care receiver (Tronto, 1993). This is to acknowledge that those in need are in a vulnerable position, and care providers always must be conscious of having power over those in need and the potential for abuses of power (Tronto). It is essential that we begin the dialogue with those impacted by female circumcision if we are to produce a caring discourse.
Conclusion
The challenge today is how to deal with the health consequences of the practice of female circumcision, as the practice still continues in many countries, predominantly in Africa (Shell-Duncan & Hernland, 2000). In Chad, the practice appears to be a new trend, probably only a generation old (Leonard, 2000). In Sudan, the practice has continued to broaden from northern to southern areas in spite of annihilation efforts (Mackie, 2000). Ironically, researchers and health care providers who try to explore the cultural context of the practice get labeled as supporting the practice (Gruenbaum, 1996; Shell-Duncan & Hernland, 2000). Notwithstanding, there must be dedication by many women’s health care organizations to provide resources for health care education in communities affected by the practice. Health care education needs to be conducted by including the voices of those who are circumcised and not isolate communities where female circumcision occurs. Developing economic compensation for circumcisers did not reduce the amount of female circumcision, because parents still wanted their daughters circumcised.
There is no doubt that grassroots outreach with communities affected by female circumcision that involves religious and community elders and leaders is important. Culturally sensitive counseling by women who have been circumcised will be enormously valuable, as they are viewed as insiders of their communities. Ahmadu (2000) found that “outsiders” perform most of the studies on circumcision and that a few well-known African women who have researched circumcision were not representative of a group that generally practiced female circumcision (Ahmadu, 2000). Hence, “insider” voices are probably the most genuine, voices that will be respected by circumcised communities.
Support of men, fathers, brothers, and partners is critical, so that girls and women feel safe to speak up against the practice. Culturally sensitive guidelines for training of health care professionals that focuses on pregnancy, delivery, and psychosexual health has been widely recommended by the World Health Organization.
Many international organizations have come together to condemn the practice of female circumcision. The dominant discourse on women’s health care is not sensitive to the voices of the very women who experience the practices of diverse cultural traditions inclusive of female circumcision. In order to advocate successfully, one must know and respect the audience. Without an understanding of the cultural context, advocacy and protest will fall on deaf ears and resistance is likely. Perhaps even more devastating, advocating without cultural sensitivity may even further alienate women being subjected to the practice of female circumcision, as they may no longer be respected by their own culture or those attempting to be their voice. We must collaboratively strive to understand diverse cultural practices and work with those who are disenfranchised from the development of policies and practices in order to ensure the health and well-being of women. Most importantly, future discourse about female circumcision needs to ensure that research and discussions are not viewed as discarding an entire people’s history, culture, population, or country of origin (Mackie, 2000).