Feminine genitalia and well-behaved women: How circumcision has adapted and why it continues

“I don’t call it circumcision, I call it “refinement.” As a doctor, I don’t do this case as female circumcision, I do it as a technical case.” — A male physician in Gharbiya¹

Female circumcision has been creating controversy and public debate in Egypt for at least 25 years. In 1994, graphic footage of a girl being circumcised by a barber was shown at the International Conference on Population and Development in Cairo, sparking a public outcry that pushed the fight against female circumcision onto the state’s agenda. But two and a half decades later, the rates of female circumcision are at 92 percent: nine out of ten married women in Egypt have been circumcised.²

Last month, 12-year-old Nada Abdel Maqsoud died after cuts were made to her genitals. The fact that her circumcision was performed in a clinic by a retired doctor is only the beginning of the answer to why, after nearly three decades of national and international campaigns against circumcision, girls like Nada are still dying from it. 

Seventy-seven percent of the cases of circumcision in Egypt today are performed by medical practitioners, making Egypt the country with not only the highest rate of medicalization in the world but the one where the trend is growing the most rapidly. Eighty-two percent of daughters have been circumcised by a medical practitioner compared to only 39 percent of mothers.³

The prevalence and medicalization rates should not be understood separately. Part of the reason circumcision has not declined substantially is precisely because it has become more medicalized. State and NGO anti-circumcision efforts have focused on the methods and circumstances of circumcision and have not tackled the cause of the practice, leading to its evolution rather than its abandonment. 

¹ *All quotes and some findings in this article are extracted from a 2017 study by the Population Council that looked into mothers and healthcare professionals perceptions of circumcision

El-Gibaly, O., Aziz, M. and Abou Hussein, S. (2019). Health care providers’ and mothers’ perceptions about the medicalization of female genital mutilation or cutting in Egypt: a cross-sectional qualitative study. BMC International Health and Human Rights, 19(1).

² El-Zanaty, F., and Way, A. (2015). Egypt Demographic and Health Survey 2014. Cairo, Egypt: Ministry of Health and Population, National Population Council, El-Zanaty and Associates, and ORC Macro.

³ Kimani, S. and Shell-Duncan, B. (2018). Medicalized Female Genital Mutilation/Cutting: Contentious Practices and Persistent Debates. Current Sexual Health Reports, 10(1), pp.25-34.

Circumcision aims to safeguard a woman’s chastity by regulating her sexual desire and libido. The procedure — which has historically been performed by dayas (lay midwives) or other traditional circumcisers who are not medical professionals — has physical risks and repercussions, including infection and death, that have and continue to take center stage in efforts the are working to combat the practice. As a result, the practice has evolved in ways that aim to mitigate these physical risks and avoid the immediate trauma of the procedure by increasingly relying on medical practitioners, who often call it by a completely different name.

The doctor who was charged with the death of Nada Abdel Maqsoud attempted to defend himself by stating that he was not circumcising her but merely performing plastic surgery. He is not alone. The physician in Gharbiya, quoted at the beginning of the article, also explains that there are less intrusive kinds of genital cutting, which he does not consider to be circumcision. The research by Gibaly, Aziz and Hussein shows that the practice is largely being reframed by medical practitioners as a cosmetic procedure. 

The reason circumcision rates remain so high is that state, NGO and social efforts to combat it continue to speak around the issue rather than about it. Rather than disputing the belief that a woman’s sexuality should be controlled, these efforts have focused on tackling its short term physical risks and trauma, avoided discussing long term sexual complications and have passed on authority to decide when the practice is “necessary” to medical practitioners.

Anti-circumcision campaigns have also failed to keep up with the medicalization of circumcision and continue to represent it as bloody and traumatic in an immediate sense. Their efforts miss the point, addressing a practice that has, in the minds of many, ceased to exist. 

Pain-free, safe circumcision 

“The doctor has experience and has been educated. A daya is fine, but education is good. A daya would spray an anesthetic, but a doctor gives an injection of anesthesia in the side, and the girl feels nothing but can see.” — A mother in Cairo*

An ad campaign entitled “Stop FGM/C”, launched by UNFPA and UNICEF in cooperation with the National Population Council was aired on national TV in 2015. The advertisement begins with the image of a father cutting himself while shaving, after which his daughter sees the blood on his cheek and covers it with a band-aid. The father then takes the young girl to a dimly lit clinic where a nurse pulls the screaming daughter away from the father in order to circumcise her. A narrator comments that the chastity of daughters cannot be achieved through circumcision but through proper upbringing. A narrator then asks: “Will you have the heart to put her in danger?” The father, at the last minute, decides not to go through with the procedure. 

This advertisement is actually considered one of the milder representations of the practice. Media representations of circumcision often rely on dramatic, bloody and violent representations of the procedure, with focus on the trauma and the short-term physical risks to scare people away. There are two problems with this. First, these portrayals are increasingly irrelevant and outdated, as doctors often provide anesthesia to make the procedure less traumatic in the immediate sense. The focus on danger, which is one of the main messages of the advertisement, does not speak to the current form of the practice, which is perceived to be safe(r) when performed by medical practitioners. (That is not to say that the practice is necessarily safer.)

“We cut her. What’s the problem? There are no problems with circumcision now. Bring your daughter today ,and, if needed, I will cut her immediately tomorrow. We can cut a small part just for her mother-in-law” — A male physician in Gharbiya*

Second, it further entrenches the idea that the issue is not the practice in itself but with how it is being performed. Focusing only on the short-term physical risks, it ignores the long-term sexual repercussions and does not challenge the belief that drives the practice to begin with. 

“In villages, they say the uncircumcised girl would have much more sexual desire, would like to talk to men all the time instead of girls and would play mainly with boys. So, her behavior would not be good.” — A mother from Assiut*

The message in the advertisement, as in many other campaigns, is that chastity should be disassociated with circumcision. Yet, by suggesting that it should instead be accomplished through proper upbringing, the concept that a woman’s sexuality needs to be controlled by her family remains validated. Female sexuality remains, in itself, a taboo, and this is the core reason that girls continue to be circumcised at such high rates.  

Medical justification: Passing on the question of necessity

The idea that the problem with circumcision is not in the practice in itself but in how it is carried out has been around for decades. While the current law, passed in 2016, criminalizes all forms of circumcision regardless of who performs it or where it is done, the history of how different religious and state authorities have dealt with circumcision tells a different story. 

Egypt has a long legislative history of attempting to regulate the practice through ensuring that it is carried out in a particular format rather than banning it altogether. This is because of the persistence of the idea that circumcision may be necessary in some cases and unnecessary in others.

1959 marks the first attempt by the Ministry of Health to regulate the practice of circumcision. A 15-member committee made up of Muslim religious scholars and medical practitioners drafted a decree that forbade type III circumcision, in which the vaginal opening is narrowed by being sealed yet allowed for partial circumcision, which can include cutting off parts of the clitoris, labia minora and labia majora. According to the decree, the practice was only to be performed in private hospitals by trained medical practitioners.

In 1994, the ban on the practice in public hospitals was reversed and the state set aside one day a week for girls to be circumcised in order to ensure that the practice is conducted in a safe and hygienic space. This was partly due to pressure from religious authorities, most prominently Sheikh Gad al-Haq, former Grand Imam of Al-Azhar from 1982-1996, who said that parents have a duty to circumcise their children. His successor, Sheikh Muhammad Sayyid Tantawi, on the other hand, argued that the Quran contains nothing on female circumcision and that the sayings of the Prophet Muhammad on this subject are weakly attributed and disputed. But even Sheikh Tantawi, who took the more progressive stance compared to Gad al-Haq, said that people should defer to doctors to decide whether or not a girl should be circumcised.

After a turbulent year, a decree was finally issued in 1996 that banned the practice once again in both private and public hospitals, even when performed by medical practitioners. The decree, however, added that in case of medical necessity permission should be granted by the head of gynecology. A stricter, more consistent stance was finally taken by Dar al-Ifta in 2007, issuing a statement that the practice was prohibited in religion. A similar statement was issued by the Coptic Church, which noted that female circumcision is not mentioned in the Bible. The practice was criminalized in 2008.

From the late 50s until the mid-90s, medical practitioners were given the responsibility to perform the practice safely and encouraged to have a say in whether or not a girl should be circumcised. Even the 1996 decree maintained gynecology departments’ power to authorize the procedure. The current 2016 law still contains a loophole. It states that the practice should not be performed without medical justification, but it does not define what medical justification constitutes.

Over this four-decade span, authority over circumcision was transferred from religious to medical authorities. The undefined idea of medical necessity, both in legislative decrees and in current practice, remains one of the key forces sustaining circumcision.

A case-by-case basis

“Bring her. I’ll take a look (examine her), and then I’ll decide. If it [her genitalia] looks ugly and will affect marriage, we cut it. And if it is okay, we leave it … I just have to see what is there. I haven’t seen anything … I have to see with my own eyes and will do what is necessary for her.” Male physician, Cairo*

In many cases, medical practitioners ask to examine the girl first before deciding whether or not circumcision is necessary. The reasons given are not uniform and what a “normal” vagina should look like is something that is left up to the doctors to decide. Some remove parts of the clitoris if they decide it is too big, while others remove parts of the labia majora or minora. Others say they cut in order to maintain hygiene and to prevent girls from getting infections or ensure that they will not become hypersexual.*

“Look, the normal size is when the labia majora are closed. Nothing is protruding from them. That one does not need it, but if there are protrusions outside the labia majora, there is a need [to cut the girl].” — A female physician in Gharbiya

Some physicians claim that only some forms of circumcision are necessary and acceptable, while others claim that certain cuts are not even considered circumcision. While it is common that the practice is considered only cosmetic as long as the clitoris is not cut, it is still generally unclear what exactly the criteria are for a cut to be considered circumcision.*

Overall, the definition of what circumcision is and what forms of it are acceptable are, for the most part, left up to the doctors to decide on a case-by-case basis. Because medical practitioners are increasingly seen as the most credible source of information, banning the practice on legal and religious grounds can only do so much. 

“There is a woman doctor who told me that many people come to ask for this operation. They say they feel that the labia minora is large, and she does it to them, but she does not come close to the clitoris. I told her that this is circumcision. She said no. People ask for it as a cosmetic need. She considers it cosmetic and not circumcision because it is the labia minora only.” — A female physician in Assiut.

We need, instead, to tackle the reasons why medical practitioners are consulted on the appearance of girls’ genitalia in the first place. We must find ways to spread the idea that there is no correct amount of sexual desire or behavior for a woman and no such thing as wrong-sized genitalia.

What we talk about when we talk about circumcision  

Over the past years, female circumcision has mostly been drawn into public debate when it has caused death, like with Nada’s story last month. The law which is meant to criminalize the procedure in itself has rarely been applied, but, in the very rare cases that it has, it was because of death not because of the practice of female circumcision in itself. 

We need to start focusing not only on what happens when female circumcision goes wrong but also what happens when it goes right — when it is not traumatic, when it is performed by a “civilized,” educated practitioner and when the girl lives. While we need to find more ways of holding doctors accountable, it will take much more than punishment to reverse decades of power and authority. 

Saying no to female circumcision in a context where the practice is not uniformly defined and is changing in its association is not really saying much anymore. We need to start speaking about the “need” for circumcision. Otherwise, girls whose genitalia is a certain size and who are projected to have an appropriate amount of sexual desire may be spared the procedure, but the fates of those who don’t remain bleak. 

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Views or opinions represented in this article are personal and belong solely to the writer and do not necessarily represent those of references cited.

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