This chapter should be cited as follows:
Kihara AB, Koigi PK, et al, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.417803
The Continuous Textbook of Women’s Medicine Series – Gynecology Module
Volume 1
Female genital mutilation
Volume Editor:
Professor Anne-Beatrice Kihara, University of Nairobi, Kenya,
President-elect. The International Federation of Gynecology and Obestetrics FIGO
President, African Federation of Obstetricians and Gynecologists (AFOG)
Chapter
The Intersectionality of Female Genital Mutilation/Cutting
First published: July 2022
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INTRODUCTION
Female genital mutilation is a violation of girls’/women’s rights
Female genital mutilation/cutting (FGM/C) is a multi-faceted catastrophe that traverses multiple levels of the feminine experience. It constitutes multiple violations of human rights,1 specifically being “an extreme form of gender-based violence; a specific form of violence against women and girls (VAWG); a sexual assault; domestic violence; child abuse; a human rights abuse; a human rights violation; and a development impediment that afflicts more than 200 million women and girls worldwide”.2 FGM/C is associated with a myriad of irreversible complications and consequences.3 The two key factors that influence FGM/C are the prevailing social and gender norms;4 and the bio-ecological context of the victim/survivor.5,6 An intersectionality nexus exists amongst ethnicity, religion, sexuality, education, anthropology, feminist interpretive network, legislature, prevention, and protection policies.7,8
FGM/C is not just about physical complications9 – it is a complex issue that requires a holistic approach that involves medical, human rights, cultural, psycho-sexual, legal, and religious dimensions.10 It is also important to ensure that there is a broader understanding of the psychosexual drawbacks of the practice.11 Although previously resistant, it is important to integrate existing silo programs with broader SRHR packages; engage theory of change that addresses politicians, gatekeepers/agents, and the affected communities.12 Core to zero-rating FGM/C is the employment of media, monitoring of legislation and penalties; sociocultural practices and services that include sexual education, male engagement,13,14 conduct of research, and advocacy by civil societies within societies and amongst duty bearers.15,16
INTERSECTIONALITY2,17
This is an approach to feminism and social causes. It is a term that was coined by Dr. Kimberlé Crenshaw referring to a theory about how systems of power intersect and reinforce each other. There are different forms of oppression (e.g., racism, sexism, homophobia, disability, migration, religion, etc.). However, they do not exist separately, but are overlapping and affect individuals simultaneously. Regarding feminism, it means that no one experiences life as “just a woman”. Other aspects such as race, class, and disability play a role in the forms of discrimination that people are exposed to. Therefore, there is an increasing need to increase intersectional campaigns that address all these issues, therefore “leaving no one behind”.
ANTHROPOLOGY
The actual origin of FGM/C remains unknown. Historically, the oldest records of FGM/C date back to the 2nd Century BCE in Egypt, where it was performed as a customary practice, and is thought to have spread with the progressive permeation of the slave trade.18 According to Arnold van Gennep (1960), rites of passage represent a common structure and are divided into three stages: separation; marginalization; and aggregation.19 When contextualized to FGM/C, these stages would be as follows: the physical stage, where the cut is made (separation); the cultural stage, that lasts for the duration of healing, which represents the time when the worldly wisdom of the women is transferred to the girls (marginalization); and the social stage, when the girl is publicly presented to the community that acknowledges her new condition and social status (aggregation). The methodological proposal of “initiation without mutilation/cutting” seeks to preserve the two latter ritual stages that confer ethnic and gender identity, but eliminate the physical aspect (when the cut is made),20 that violates human rights, women’s and girls’ rights to physical and mental integrity and directly affects their sexual and reproductive health,21,22 anthropologically presenting as a marker for gender, age, and ethnicity.
THE FEMINIST FRAMEWORK
Feminism, in its broad context, refers to “an intellectual commitment and a political movement that seeks justice for women and the end of sexism in all forms”.23 The feminist interpretive framework arose out of the conflict amongst the following: cultural social control of women’s sexuality (i.e., “social reproduction”); devirilization of women; establishment of patriarchal power dominance; and social institutionalization that involved the communities.24,25 The feminist issues and documented health consequences seen in FGM/C26 call for raising of voices by activists and feminist movements.
CONVENTIONS AGAINST FGM/C
FGM/C is condemned by a number of international treaties and conventions, as well as by national legislations in several countries. These include the following:
- Article 25 of the Universal Declaration of Human Rights,1 where FGM violates the right to health and bodily integrity.
- In relation to the International Covenant on Civil and Political Rights (ICCPR), FGM constitutes cruel inhumane and degrading treatment that does not uphold the principle of "free consent" envisaged in Article 7 of this covenant.27
- When placed into context as a form of violence against women, FGM directly goes against the UN Convention on elimination of all forms of discrimination against women of 1979.28
- Similarly, contextualizing it as a form of torture brings it under the rubric of the Convention against Torture and other Cruel, Inhuman, or Degrading Treatment or Punishment.29
- The United Nations Convention on the Rights of the Child was established as a legally binding international agreement on the rights of the child in 1989. Specifically, Article 5 mandates authorities to abolish "traditional policies prejudicial to the health of children", which specifically encompasses FGM/C.30
- The Organization of African Unity’s Ordinary Session of July 1990 adopted the African Charter on the Rights and Welfare of the Child (ACRWC), in which FGM/C falls under the harmful social and cultural practices adversely affecting the welfare of the child.31
- Moreover, since FGM/C is considered a traditional practice that is often performed on minors and prejudices their health, it directly violates the Convention on the Rights of the Child.30 In 2008, 10 United Nations' organizations issued an Inter-agency Statement on Eliminating FGM/C.10
- In addition to this, Article 5(b) of the Maputo Protocol to the African Charter on Human and People’s Rights on the Rights of Women in Africa expressly prohibits FGM/C, whereas Article 5(d) corroborates the need for and mandates the protection of those at risk.32
- Legislature and harsh penalties were imposed on health providers and parents amongst those who sought medicalization of FGM/C after the International Conference on Population Development in 1994.33
LEGISLATURE AGAINST FGM/C
In the World Bank’s Compendium of International and National Legal Frameworks on Female Genital Mutilation,34 it is shown that 51 of the 92 countries in which FGM/C is practiced have legally proscribed the practice. This is most prevalent in Africa, where over half of the countries with these legislations lie (28 countries). The diaspora communities beyond Africa have 41% of the total laws against FGM/C, including 16 European countries, the United States of America, Canada, Australia, and New Zealand. In the Middle East, only Iraq and Oman have legal provisions against FGM/C, whereas none exist in Asia or Latin America.
PREVAILING ATTITUDE TOWARDS FGM/C
The attitude and intentions of girls and women towards FGM/C vary widely.35,36,37,38 The highest prevalence and levels of support for the continuation of the practice are found in Mali, Sierra Leone, Guinea, Gambia, Somalia, and Egypt, where over half of the female population are pro-FGM/C.39 However, in most countries in Africa and the Middle East with representative data on attitudes (23 out of 30), the majority of girls and women think it should end (ibis). The single most significant determinant of the risk of undergoing FGM/C is likely to be the attitude of the parents of the girls,40 followed by maternal age, lower educational status, religiosity, rural residence, and communal poverty.41
STRATEGIES TO ERADICATE FGM/C
The campaign to eradicate FGM/C is based on the theories of social conventions and social change.18,42 However, the pace of social change is slow, and measuring changes accrued takes valuable time.8 FGM/C needs to be tackled with a multi-faceted approach that is adaptable to diverse situations, both in the countries of origin and in the countries of immigration.10 FGM/C has adverse bearings on women’s sexuality.43,44,45 The scientific approaches towards women’s sexuality are heavily influenced by social norms and representations.46 In addition, there is a hiatus created by the lack of consensus on the choice of tools for measuring the quality of sexual function and sexual life.44,47
In the cases of medicalization of48 and cross-border FGM/C, there is a greater need for girls and women to hear women’s lived experiences.49 Strategies towards abandonment of FGM/C include the following: being non-judgmental; community-led efforts; intersectoral approaches; and showcasing wider changes to inspire other actors working on female circumcision.7,15 However, there is consensus to approach the subject through a social and gender norm and power approach as illustrated in the Flower Conceptual Framework within the socioecological contextual domains as shown in Figure 1.50
1
The dynamic flower framework for social change. From Cislaghi and Heise, 2019, reproduced under Creative Commons license.50
The attributes of this framework include the following:50
- It acknowledges the central role of power as the factor underlying gender and social norms, socioecological domains, gender dynamics, and health outcomes.
- On the model, gender norms are essential to understanding the drivers of health outcomes and gender dynamics.
- The potential for change is found at the intersection of the overlap of the petals, thereby forming the “normative space”.
- The framework’s focus on social norms neither undermines nor supersedes the structural factors’ importance to power, gender dynamics, and health outcomes.
In the application of this framework, it is crucial to understand the social context that influences the norms.51
EXAMPLES OF POSITION STATEMENTS REGARDING FGM/C
- FIGO’s stance on FGM/C:
The 1994 FIGO Resolution on FGM/C52 encouraged FIGO societies to urge national governments to sign up to international human rights agreements condemning the practice and to support the work of national authorities, non-governmental organizations (NGOs) and inter-governmental organizations working to eliminate FGM/C.
The FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health has two guidelines opposing FGM, the most recent concerning medicalization (London, 2006). FIGO continues to recommend that individual obstetricians/gynecologists explain and educate about the consequences of FGM/C, while supporting community members opposing its continuation. Organizations and individuals are further encouraged to support research on the prevalence and effect of the practice, while opposing any attempts to medicalize the procedure or allow its performance by health professionals in health establishments.53,54 - Africa Medical Research Foundation (AMREF) Health Africa’s position statement on FGM/C:55
AMREF Health Africa has committed to support the WHO’s efforts to eliminate FGM/C by focusing on the following: advocacy; social mobilization; developing publications and advocacy tools; undertaking research to generate the knowledge base on the causes and consequences of FGM/C; integration of anti-FGM/C in the classroom and in out-of-school teaching; creating and supporting anti-FGM/C youth groups in the various societies; encouraging community health workers (CHWs) and traditional birth attendants (TBAs) to integrate anti-FGM/C education during their care of pregnant mothers; educating and strengthening traditional leadership. - 2008 UN Inter-agency position statement on FGM/C:10
This was a landmark declaration by the United Nations that generated massive support by numerous NGOs, professional health bodies, and human rights associations. The recognition of FGM/C as a violation of human rights and hence a barrier to the achievement of the millennium development goals inspired a resolution that called on all member states to accelerate efforts towards elimination of the practice, including the following: development, enactment, and enforcement of relevant proscriptive and protective legislations; development of social and psychological support services; enhanced efforts towards research; guideline development; and initiation of community-based action. - The United Nations Resolution to Intensify global efforts for the elimination of female genital mutilation of 2013:56
This was adopted to intensify global effort to eliminate female genital mutilation. This adoption was a reflection of the fact that FGM/C constitutes a violation of human rights, hence a dire need to end the impunity that is perpetuating FGM/C. - The United Nations Human Rights Council Resolution on the elimination of female genital mutilation of 2021:57
There was recognition of the fact that Covid-19 may divert efforts away from the prevention and elimination of FGM/C, potentially resulting in 2 million avertable additional cases. It was also noted that despite increased efforts, the practice persists globally, with the concurrent advent of new forms of FGM/C. The council noted a need for states to take measures to prevent and eliminate FGM.
CONCLUSION
In conclusion, FGM/C is a cross-cutting global problem with an unacceptably high prevalence. As such, efforts towards its eradication can only be successful if an intersectional approach that targets all stakeholders is applied.
PRACTICE RECOMMENDATIONS
- FGM/C is not only a physical cut on the external female genitalia but a complex issue requiring a holistic approach involving medical, human rights, cultural, psycho-sexual, legal, and religious dimensions.
- FGM/C entails the physical stage of cutting (separation); the cultural stage associated with imparting wisdom to the girls (marginalization); and the social stage, when the girl is publicly presented to the community that acknowledges her new social status (aggregation). Anthropologically an alternative rite of passage followed by marginalization and aggregation is deemed culturally acceptable.
- There are several treaties and conventions ratified legislatively that seek to eliminate this harmful practice, which need to be implemented.
- More needs to be done to eliminate medicalization and cross-border FGM/C.
- Integration of FGM/C with the broader SRHR issues and conduct of implementation research is needed.
- FGM/C can be tackled by addressing the social norms, gender norms, and power relationships within the socio-ecological model (flower framework) for better health outcomes.
CONFLICTS OF INTEREST
The author(s) of this chapter declare that they have no interests that conflict with the contents of the chapter.
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