Dalya, an eighteen-year-old student from Halabja, was cut by her neighbor. “I remember that there was a lot of blood and a large fear,” she told me. “This has consequences now during my period. I have emotional and physical pain and fear from the time when I saw the blood. I don’t even go to school when I have my periods because there’s too much pain.… My family supports me but sometimes I feel like killing myself because of the [menstrual] pain.”
Dalya told me that she is to this day still fearful of her neighbor. Her mother never wants to discuss this with her. “When she sees me this way, my mother feels regret because she circumcised me,” Dalya told me.
Dalya’s story represents the experiences of countless young girls and women whose families still force them to undergo female genital mutilation (FGM), an unnecessary procedure that is harmful to their health in many ways. To me, one of the most astonishing aspects of my research in Iraqi Kurdistan on this subject was the vivid detail with which adult women described their pain and trauma years and even decades after being subjected to FGM. The more I listened to them, the more it became clear how confused they still were about the reasons for this practice.
In 2009, I met seventeen-year-old Gola in Sarkapkan, a small village in the rural area of Ranya in Iraqi Kurdistan. Dressed in a long blue gown, Gola came to a neighbor’s house with her mother and younger sisters to speak to me. Before meeting her, I believed that women would have a difficult time speaking frankly about female genital mutilation, especially because of Iraqi Kurdistan’s socially conservative culture. But much to my surprise, Gola was confident and adamant about sharing her experience with this painful procedure as a young girl.
Gola told me, “I remember my mom and her sister-in-law took us two girls, and there were four other girls. We went to Sarkapkan for the procedure. They put us in the bathroom and held our legs open, and cut something. They did it one by one with no anesthetics. I was afraid but endured the pain. There was nothing they did for us to soothe the pain.”
Some of the women and girls I interviewed thought FGM was a religious duty, while others saw it as a traditional practice, performed because it is the norm in the community. Regardless of the reasons, girls and women felt especially betrayed by the women who made the decision to cut them, most often their mothers.
The World Health Organization (WHO) defines FGM as the partial or total removal of external female genitalia for non-medical purposes. The WHO classifies four types of FGM ranging from least to most severe. Type I, also known as clitoridectomy, refers to the partial or total removal of the clitoris, prepuce, or both. This is the least severe procedure, and the most common type of FGM practiced in Iraqi Kurdistan. Other types of FGM are more invasive and include the partial or total removal of the clitoris and the labia minora, or cutting and then stitching the labia minora, majora, or both with or without excision of the clitoris, otherwise known as infibulation.
Globally, FGM is typically carried out on young girls, from infants to adolescents as old as fifteen. Occasionally, it is carried out on adult women. While it is difficult to obtain accurate data on the magnitude of this practice, the WHO estimates that between 100 and 140 million girls and women around the world have undergone some form of the procedure. More than 3 million girls in Africa alone are annually at risk of FGM.
In Kurdistan, there are no official statistics on the prevalence of this practice. Government ministers I met in Arbil, the capital of Iraqi Kurdistan, assured me that “there are a few cases, here and there … but the issue is not that big.” After Human Rights Watch issued its report on the human rights abuses of FGM in 2010,1 though, the Kurdistan Ministry of Health undertook a statistical study and found that 48 percent of their sample study of five thousand girls and women had undergone the practice.
FGM is practiced for various sociocultural reasons. The simplest is that it is rooted in local culture, and has often been passed from one generation to another. The practice serves as a means of preserving cultural identity by requiring girls and women to undergo this procedure to be accepted socially in Kurdish society.
Another factor is the gender inequality within some societies that view women as the gatekeepers of family honor. Such cultures believe that girls’ sexual desires must be controlled early on to preserve their virginity and prevent immorality. In some communities, this practice is seen as necessary to ensure marital fidelity and to prevent deviant sexual behavior. Other societies practice FGM on young girls because they believe it can enhance sexual pleasure for men.
FGM is also performed ostensibly for hygienic and aesthetic reasons. In some cultures, as in Sudan, many believe that female genitalia are dirty and consider an “uncircumcised” girl to be unclean. This belief may reduce a girl’s chances to get married if she is not circumcised. FGM is also considered to make girls more attractive. Infibulation, for instance, is thought to achieve smoothness—viewed as beautiful—around the genital area.
Other societies link FGM to religion, but the practice is not particular to any religious faith, and it predates both Christianity and Islam. FGM has been practiced by adherents to Islam, Christianity, and Judaism. It is also practiced among animists.
The association of FGM with Islam has been refuted by many Muslim scholars and theologians, who say that FGM is not prescribed in the Koran, the Muslim holy text, and indeed is contradictory to the teachings of Islam. In 2006, the late Muhammad Sayyed Tantawi, Grand Sheikh of Al-Azhar University, the most respected Islamic university among Sunni Muslims, said that FGM is not an Islamic practice and it is not mentioned in “Sharia, in the Quran, in the prophetic Sunnah [an act performed to strengthen one’s religion].” He stated that “circumcising girls is just a cultural tradition in some countries that has nothing to do with the traditions of Islam.” In 2007, the Al-Azhar Supreme Council of Islamic Research issued a statement that FGM has “no basis in Islamic law or any of its partial provisions and that it is harmful and should not be practiced.”
In Iraqi Kurdistan, I found that many women are perplexed about the reasons for this practice. Some women I spoke to insisted that FGM is a Kurdish tradition, a practice that has been around for generations. Other women said that FGM used to be a fad but is now less prevalent. Some referred to the practice as sunnah, giving FGM a religious significance. Most Iraqi Kurds are Sunni Muslims and adherents to the Shafi’i school of Islamic jurisprudence.
A mullah I interviewed in Germian, a rural area in Iraqi Kurdistan, contended that a girl goes through puberty faster in warmer climates and that therefore FGM is practiced to “allow girls not to show bad behavior.” Other interviewees explained that if a girl does not undergo FGM, she may become very sexually active, and this will tarnish her reputation. Given the importance of chastity in Muslim societies, the reference to FGM as sunnah and a mandate by Islam strongly reinforces the justification for its continuation in the Muslim societies where it is practiced.
Nawal el-Saadawi, a well known Egyptian physician and feminist scholar, has pointed out that, “behind circumcision lies the belief that, by removing parts of girls’ external genital organs, sexual desire is minimized.” One can therefore argue that the ultimate reason for FGM in places like Iraqi Kurdistan is fear of women’s sexuality. Regardless of its devastating health effects for women and girls, FGM continues to be referred to as sunnah, and remains shrouded under the cloak of religion.
One reason FGM proves intractable is that even doctors tasked with caring for the health of women and girls are not fighting to end the practice. “Circumcision is nothing,” a respected gynecologist and obstetrician in Arbil, Dr. Atia al-Salihy, told Human Rights Watch. She added that the type of FGM practiced in Iraqi Kurdistan does not have any harmful health effects. Even after we issued our report extensively documenting serious harm to girls from FGM, female physicians at the Sulaimaniya Maternity Hospital claimed during a visit in November 2010 that Type I FGM doesn’t have any adverse consequences—because, they said, only the tip of the clitoris is cut. They repudiated our findings and said that what we called FGM is what is practiced in places like Egypt and other parts of Africa, not in Iraqi Kurdistan.
According to the World Health Organization, though, all types of FGM have numerous acute and chronic physical health consequences, including implications for reproductive health. The most immediate consequences include death and the risk of death from hemorrhaging and shock from the pain and level of violence that may accompany the procedure. Heavy bleeding can be life threatening in a context of limited access to emergency health care. Serious sepsis may also occur, especially when unsterile cutting instruments such as razor blades are used. The risk of infection may increase when the same instrument is used to cut several girls. Acute urinary retention may also result from swelling and inflammation around the wound.
Long-term complications also include anemia, the formation of cysts, painful sexual intercourse, sexual dysfunction, and hypersensitivity to the genital area. Infibulation or Type III, the most severe form of FGM, may cause severe scarring, difficulty passing urine, menstrual disorders, recurrent urinary tract infections, fistula, prolonged labor, and infertility.
The World Health Organization confirms that women who have experienced any type of FGM, including clitoridectomy, run a greater risk of complications during childbirth. Pregnant women who have experienced FGM are more likely to need a Caesarean section or an episiotomy and may suffer from postpartum hemorrhage. All types of FGM also have detrimental health effects on fetuses and cause the risk of a stillbirth. Newborn babies may risk early neonatal death and may have lower birth weight. Obstetric complications may arise, depending on the extensiveness of the procedure.2
FGM also has severe consequences for a woman’s sexual and psychosexual health. Both the clitoris and the labia minora include large sensory nerve receptors, which are often damaged in the course of a clitoridectomy or any other form of FGM, thereby impairing female sexual response.
Studies documenting the sexual health consequences of FGM show that when women undergo such a procedure, they may experience physical pain during intercourse and lack physical pleasure during sex. “The missing structures and tissue of a woman’s sexual organs have negative effects on a woman’s sexual desire, arousal, sexual pleasure and satisfaction,” say Padmini Murthy and Clyde Lanford Smith in their book, Women’s Global Health and Human Rights.3 Cutting the glans clitoris makes it difficult for women to achieve orgasm. Such sexual difficulties may be more common in women who have undergone FGM either after a period of adolescent sexual activity or before childbirth. Nahid Toubia, a Sudanese surgeon and human rights activist, explains that “FGM removes the woman’s sexual organ and leaves her reproductive organs intact.”4
Infections and inadequate penetration during sexual intercourse may also affect the ability of a woman who has undergone FGM to become pregnant. In communities where fertility and childbirth constitute major roles for women, the failure to produce children is most often blamed on women and may lead to rejection by the husband and his family.
Regardless of the type of FGM performed in any given country, health care professionals should act as primary sources for reliable information about this practice. They should also exercise their ethical responsibility to ensure that women and girls have access to accurate information on the health consequences. And they should provide medical treatment to girls or women who have undergone the procedure, in addition to providing counseling, and making referrals for victims who experience emotional distress.
While only a few studies have tackled the effects of FGM on girls’ and women’s mental and emotional health, psychological consequences may involve a loss of trust or a sense of betrayal by a close family member. Girls are often accompanied to the midwife’s home by their mothers, aunts, or grandmothers—without any prior knowledge about where they are going and why. In other instances, close female relatives or neighbors, instead of traditional midwives, carry out the procedure on girls in their own families. Girls may grow to fear the female members of their families because of the experience, and sometimes mothers feel a sense of regret for forcing their daughters to undergo a harmful procedure. Halima Q., a twenty-eight-year-old mother told me, “My daughter is circumcised and I regret it. I feel pain for her because I saw blood coming out from cutting this part.”
Mental health disorders associated with FGM may include depression, anxiety, phobias, post-traumatic stress disorder, psychosexual problems, and other mental health problems. The prevalence of post-traumatic stress is likely to be higher in girls and women who undergo more severe forms of FGM. The risk of post-traumatic stress may also increase if the girl or woman suffered severe complications as a result of the procedure or when she has flashbacks triggered by reminders of the procedure. These memory triggers may occur during sexual intercourse, during gynecological exams, and even during childbirth and delivery. A female obstetrics and gynecology specialist in Arbil who denied that Type I FGM has any health consequences, did concede that women who undergo FGM suffer psychologically. She said that when they marry, women may begin to remember the assault on their bodies when they were children, with severe consequences for sexual and mental health.
Chronic pain in women who undergo FGM is often the result of either trauma or physical complications they may have experienced while undergoing the procedure. Complications may include infections or painful menstrual periods. Chronic pain also causes girls and women to experience distress and feelings of sadness. Their social isolation, sense of worthlessness and feelings of guilt may also increase as a result.
The recognition of FGM as a human rights violation has contributed to the development of global, rights-based strategies to combat the practice. International human rights frameworks have addressed FGM both as a health issue and as a form of violence against children and women. This has helped governments and institutions evaluate and map out strategies, including legislation and various programs, to address the issue at the national and local levels.
UN monitoring bodies have called on numerous countries to adopt laws to ban FGM. They have highlighted the importance of raising awareness and educating communities about harmful practices. These agencies have addressed the fact that FGM awareness campaigns need to address families, and entire communities, to convince them to abandon this practice. These agencies have also identified key stakeholders in elimination efforts such as religious leaders, health professionals, and traditional midwives.
While the elimination of any practice that has been entrenched as “cultural” or religious is complex, it is clear that the underlying factors perpetuating the practice must be addressed for eradication efforts to be effective. The criminalization of FGM alone is not an effective strategy to combat the practice and must be balanced with other protective measures. Unless accompanied by other measures, penalties on practitioners and family members who practice FGM may drive them underground and place the lives of girls and women at even greater risk. For instance, those who perform the cutting as a profession must be given information about the harmful consequences of FGM and be offered employable skills, and an alternative source of income. Above all, efforts must be made to integrate traditional midwives in FGM elimination efforts.
To succeed, FGM eradication programs must be implemented in institutions at all levels: national, regional, and local. A strong political commitment to abandon FGM through the development of policies and laws, adequately supported by resources, is essential. Coordination between governmental and nongovernmental agencies is equally critical.
An effective strategy also entails the mainstreaming of FGM prevention into policies and programs that seek to promote reproductive health and literacy. The medical community must play a primary role in disseminating accurate information on the health effects of the practice, while learning to manage complications resulting from FGM.
In Iraqi Kurdistan, efforts to curb FGM are under way. Awareness-raising programs, especially in rural areas, discuss the damaging health effects of this practice on girls and women. Some education programs even include participation by religious leaders, who travel to towns and villages to tell families about the health consequences of this practice and that it should not be carried out in the name of Islam. Similar efforts are being undertaken in certain African countries like Senegal, where the efforts of the NGO Tostan (“breakthrough” in the Wolof dialect) have successfully led to the abandonment of the practice in thousands of villages.5
Shortly after Human Rights Watch’s report on FGM was published in July 2010, the High Committee for Issuing Fatwas at the Kurdistan Islamic Scholars Union, the highest Muslim religious authority in Iraqi Kurdistan, issued a fatwa, a religious edict or pronouncement, attesting that FGM is not an Islamic practice. This was a major step forward. Religious leaders in Iraqi Kurdistan, and especially in rural areas, have tremendous influence over people, and this fatwa was an exceptionally important pronouncement. The fatwa was not a complete solution, as it did not expressly denounce the practice, and left the decision to parents whether to mutilate their girls.
While the announcement of the fatwa in Iraqi Kurdistan was one vital piece of the puzzle of eradicating this harmful practice, the primary responsibility for protecting girls from FGM rests with the government. The Kurdistan parliament’s adoption in June 2011 of a family violence bill, including two provisions on FGM, constituted another major milestone on the road to ending FGM. I and other rights activists had lobbied vigorously for the Kurdistan government to finally ban FGM as a show of political will that harmful traditional practices will no longer be tolerated in Kurdish society. For me, this was a deeply satisfying moment, as I recalled the harrowing testimonies of women and girls I interviewed in the course of my research.
What this teaches us is that FGM eradication efforts require a multifaceted approach—one that works with numerous key actors at the same time, including victims, their families, religious leaders, health care professionals, teachers, and community leaders. Debate and discussions are essential to encourage a community affirmation to stop the mutilation of girls. In every country where FGM exists, government authorities can follow the example of Iraqi Kurdistan and make a public commitment by sending out a clear message that this harmful practice has no place in their society. In fact, they should ban the practice. Any law to accomplish that goal should provide a clear definition of FGM, explicitly state that it is prohibited, and identify perpetrators and penalties—though sanctions alone will not suffice. Legal steps must always be paired with social outreach, otherwise criminalization could be counterproductive unless measures are taken to ensure the practice is not driven underground.
Global experience shows that a commitment to end FGM depends on a society’s willingness and a government’s commitment to safeguard the rights of girls and women. There are clear precedents for eradicating a harmful traditional or religious practice. At the beginning of the last century, girls across China had their feet bound to make them more attractive to men. Today, that harmful, traditional, and literally crippling practice is forever ended.
I hope that girls like Gola and Dalya, who so vividly recalled their own painful experiences and are still confused about the reasons for undergoing this harmful practice, will be at the forefront of the battle to end FGM. Parents and grandparents should learn more about the damage that this practice does to the health of their daughters and granddaughters. Above all, I hope that female genital mutilation and other harmful traditional practices will cease to be justified under the name of any religion, and that along with government leaders, religious figures will take the lead to eliminate it forever.
Nadya Khalife, women’s rights researcher for the Middle East and North Africa for Human Rights Watch, is the author of Human Rights Watch’s 2010 report on female genital mutilation in Iraqi Kurdistan titled “They Took Me and Told Me Nothing.” Prior to joining Human Rights Watch, she worked on a number of development projects following the 2006 Lebanon war. She has also conducted research for a European Union project on economic opportunities for women, contributed to work of human rights groups in the Great Lakes region of Africa, and worked on US-sponsored post-9/11 projects.