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Abstract

Female genital mutilation is a traditional practice affecting girls when their genitals are cut for social, cultural or other non-medical reasons. It is estimated that 3 million girls undergo the procedure every year, mainly in areas in Africa and Asia where it is traditionally practised, but owing to migration patterns, girls living in other parts of the world are also at risk. This article describes the practice of female genital mutilation in a changing world and outlines some aspects in relation to female genital mutilation in girls and women that health staff, teachers, social workers and others should pay attention to. Knowledge regarding complications is important for healthcare, but when complications have been used as arguments against the practice this has had limited effect. Information regarding health risks has to be integrated into culturally sensitive approaches based on human rights and improving the situation for girls and women in order to reach a point where genital mutilation of girls will be generally abandoned.

Keywords

complications culture female circumcision female genital cutting female genital mutilation healthcare prevention

Female genital mutilation (FGM) entails different procedures where parts of the external genitals in girls are removed for social, cultural, religious or other nonmedical reasons. The age at which FGM is performed varies greatly between different ethnic groups. It can be performed from infancy to late adolescence, but is predominantly performed on girls between 4 and 14 years of age [1].

Motives & justifications

Motives and justifications for performing FGM vary between countries and cultures. Generally, in north-east Africa motives related to family honour dominate, while motives related to transition into womanhood dominates in west Africa. Those who practice FGM can usually give numerous motives for letting girls undergo the procedure. Female identity, tradition, hygiene and increased fertility [2], or future marriage [3 –5] are often mentioned as motives for FGM. It has been stated that, in most regions where FGM is practised, men may refuse to marry a woman who has not undergone FGM [6]. FGM is here often seen as evidence of virginity and dignity. Consequently, girls and women in these settings who have not undergone FGM are often considered to be ‘loose women’ prone to have pre- or extra-marital sex. It is often believed that men prefer marrying women who have undergone FGM because the women would then not be sexually overactive and unfaithful [7]. When men have been asked directly, however, many actually prefer to marry women without FGM in order to enjoy sex more and avoid complications for their wife and themselves [8]. In Sudan men have been described as playing a passive role in the decision regarding their daughters' FGM [9,10], but some studies have actually identified the fathers as the main source of objection against FGM in girls when it has not been performed [8,10].

In some cultures in west Africa FGM is an initiation rite into female secret societies. However, in most settings FGM is a transition rite from girlhood into womanhood. It is not until the girl has undergone the operation that she is considered to be a woman, and by that able to share the knowledge and secrets of adult women, and able to marry. It is the women, often older women, who carry on the tradition, and make sure girls in their family undergo the procedure. The practice is often considered to be a female tradition, in the sphere of female dominion, outside male decision-making. This is one of the few areas in which women actually have the power to decide, the power to control something that also affects men. One can hypothesise whether this is one of the reasons why women are often strong proponents of the practise. Lack of communication and understanding between the sexes in relation to FGM is problematic, men and women sometimes blaming each other for the persistence of the practice [11]. However, the practice would most likely not exist in societies where women and men were equal. FGM is ultimately a sign of female subordination and dependency on men, and this perception is internalized by both men and women as they grow up. Basically, whatever motives or justifications are given for performing FGM, the practice seems to express the perceived need to control women's sexuality.

Forms of female genital mutilation

A WHO classification recognises four degrees of FGM ( Table 1 ) [3]. This classification may give the false impression of anatomically distinct forms. In reality, the practice varies widely, not only regionally, but also locally between different practicians. The WHO classification is a way to categorise these practices, not a comprehensive description of what is actually taking place. Figures 1 & 2 show examples of how different forms of FGM may look.

Table 1.

The WHO classification of female genital mutilation [3].

Type I*	Excision of the prepuce, with or without excision of part or all of the clitoris
Type II	Excision of the clitoris with partial or total excision of the labia minora
Type III‡	Excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation)
Type IV	Pricking, piercing, incision, stretching, scraping or other harming procedures on clitoris and or labia

Excision of only the prepuce probably does not exist as a form of its own [12,17,72]

‡

Distinction should, when possible, be made between infibulation of labia minora and majora, respectively [12].

Type III includes reinfibulation

Figure 1.

Example how the female genitals may look in female genital mutilation type II.

Figure 2.

Infibulation, female genital mutilation type III.

There is controversy as to whether excision of the prepuce of the clitoris exists as a form of FGM at all. This form has not been found in any study. On the contrary, it has been shown that other more severe forms of FGM, even type III, have been performed when excision of the prepuce has been reported [12]. Under traditional circumstances we doubt that excision of only the prepuce takes place. There is an increasing medicalization going on, but this does not lead to milder forms being performed [13]. There has not been any evidence of forms of FGM where only the prepuce has been removed, even when the girl allegedly underwent the procedure by a doctor [13].

The WHO classification defines all forms where the sides are stitched together, be it the remnants of labia minora or majora, and regardless of the extent of stitching, as type III, infibulation. Thus, it is not possible to judge the anatomical extent of the FGM operation from the WHO classification, which is important to consider when carrying out research regarding health complications. Research regarding FGM should relate effects not only to the WHO classification, but also to the anatomical extent of cutting.

A secondary form of FGM is reinfibulation, performed on infibulated women who have given birth, are widowed or divorced. In reinfibulation the two sides are restitched together to recreate the narrow vulva of a virgin [14 –16]. Women who have undergone infibulation have to be deinfibulated (cut open) to allow childbirth. After deinfibulation the raw, bleeding edges must be secured in some way. Two options are available [17]. The first, a circular stitching around the remnants of the labia majora, leaves the vulval area open, allowing the free flow of urine and menstrual blood. The second option is the one traditionally performed and is considered a reinfibulation. The raw edges are sewn back together to restructure the hood of skin covering the urethra and vaginal introitus. This is a medically unnecessary and potentially dangerous practice. The definition of ‘reinfibulation’ is not always clear. It should, however, be distinguished from episiotomy repair, aiming at reconstructing a normal vulva anatomy postpartum. The perceived need for a more extensive tightening beyond episiotomy repair is the basis of the reinfibulation practice and its potentially adverse health effects.

Terminology

There is controversy concerning the terminology of the practice. The term ‘mutilation’ is medically correct, since it comprises the removal of normal, healthy organs without any medical indication. However, this term also carries a condemnatory attitude, which is possibly offensive to some groups, including women who have undergone the procedure. ‘Female circumcision’, the term that was traditionally used to describe the practices, is still in common use. However, this term is problematic from many perspectives. It implies an analogy with male circumcision, which is wrong both from anatomical and religious aspects. Lately the term ‘female genital cutting’ (FGC) has appeared in the literature. While it avoids the problematic aspects of the other terms, it still fails to recognise the extent of what is actually taking place. The ‘cutting’ taking place in infibulation would in males anatomically correspond to the removal of the glans, most of the penile tissue and the scrotal skin.

Many communities use local terms for the practice. The word ‘sunna’ is sometimes used in some Muslim settings across Africa to describe what are thought to be less extensive forms of FGM, for instance removal of the prepuce and parts or the entire clitoris, that is, WHO type I. However, research findings show that the word ‘sunna’ is used for any form of FGM, even the most severe ones [12]. The word ‘sunna’ refers to what the prophet Mohamed has said or done. By using this term the practice is associated with Islam and given a religious value. Thus, one possible reason for the widespread use of ‘sunna’ to describe FGM could be to justify the practice by referring it to a religious term. It is, however, important to note that FGM is not a religious practice since it predates the arrival of both Christianity and Islam in Africa [18,19], and FGM is not known in many Muslim countries [19]. Motives for performing FGM are sometimes expressed as religious, although neither the Koran nor the Bible mentions it [9,20,21].

In the context of changing practice, one should be even more attentive to the meaning of traditional terms used. In a study on Somali immigrants in Sweden the respondents claimed to have stopped ‘circumcision’. When the interviewers probed more into this, it turned out that the reason for this statement was that they stopped the practice as they were used to it in their home country (infibulation). Instead they practiced ‘sunna’, which they defined as removing the forbidden (Haram) part [22]. This probably corresponds to clitoridectomy, WHO type I. As outlined above, forms described as ‘sunna’ could in reality be any form, and often the most severe ones. It is important to be aware of this low reliability of reported form when conducting studies based on interviews. If the respondents are not asked to describe what they mean by the different words, the results could hardly be interpreted at all [12].

Where & why

FGM is practised in more than 30 countries, mainly in a belt reaching from east to west Africa north of the equator, but also in southern parts of the Arabian peninsula, along the Persian Gulf, and among some migrants from these areas to Europe, North America and Australia [1]. The fact that FGM is also common in South-east Asia, for instance in Malaysia [23] and Indonesia [24], has often been neglected. These countries are not included in the estimate of 132 million girls and women subjected to the practice [1]. It is estimated that approximately 3 million girls undergo genital mutilation every year in Africa alone [25].

The most extensive forms are predominantly practised in north-east Africa, but also exist in some areas in western Africa [1]. Types I and II account for 80–85% of all FGM in Africa [26]. Figure 3 shows the distribution of FGM and its different forms in Africa.

Figure 3.

The prevalence of female genital mutilation and its different forms in Africa.

There are great variations in practice, not only amongst different countries, but also within individual countries. Both in east Africa, for instance Sudan, and in west Africa, for instance Sierra Leone, there are tribes that practice FGM to almost 100% and tribes that do not practice it at all. Those who change and turn against the practice are generally young and/or well educated [9,13]. In fact, female education is one of the single most important determinants for the practice. The more education the mother has, the less risk that her daughters will undergo FGM [14,27 –30].

Parental education and socioeconomic level are significant determinants for the practice of FGM, but social pressure from outside the family might also have a strong influence. Peer pressure on the parents, and also on the girls, influences the decision to perform FGM [13,14,22]. Girls who have not undergone the operation might be under considerable pressure from their female friends. To avoid this and associated bullying, girls sometimes ask for the operation to be done, even when their parents decided not to do it [22,31].

Considering the strong positive social and cultural meanings of FGM, it is not strange that FGM continues to be practised after migration. Even though many re-evaluate and abandon the practice in exile [32], there is evidence that it continues. More than 40% of Somali girls growing up in London have been subjected to genital mutilation after moving from their home country. Many had the procedure done on vacations to the Middle East or Somalia, but several cases, including the most severe form, had been performed in England [33]. In France, there have been documented cases both in the healthcare [27] and the legal systems [19] (families from west Africa). The results from several studies indicate that FGM is practiced on girls residing in Sweden [22,34,35], and in 2006 there were two cases brought to court, and parents sentenced to prison for letting their daughters undergo FGM. In both cases the actual operation took place in Somalia.

In spite of many decades of campaigns and legislation, FGM is still highly prevalent in the areas where it has traditionally been practised and, to some extent, in girls from these areas residing in other parts of the world. Legislation and campaigns against FGM based on complications are not enough. Sudan was the first country in the world to criminalize the practice in 1946, and research and campaigning started to gain momentum in the 1960s and 70s. In Khartoum, the capital, the prevalence has dropped from more than 95% 40 years ago to an estimated 70% of girls today [13]. Before all underwent type III, but now approximately two-thirds undergo this severe form. For some groups in Nigeria there was a drop in the prevalence from 65% in 1933 to 26% in 2003 [30]. Sweden was the first country in the west to enact a law criminalizing FGM in 1982. In addition to this there are strong child protection laws that have proved to be effective in other forms of child abuse. Still, it was not until 2006 that cases of FGM were brought to court. One reason for this discrepancy might be that social workers, health professionals and others working with children do not have the necessary knowledge to recognize girls at risk [36].

One reason for the persistence of the practice might be that campaigns have failed to approach the fundamental values of it. Previous campaigns focusing on health risks have had limited effect [37]. Using the health risk approach alone has led to problems by overplaying the medical complications. Disbelief about the harmful effects of FGM could arise among women who have undergone the operation without such negative effects [38]. In addition to this, the health approach has tended to medicalize the practice [37,38]. Traditionally, FGM has been performed by lay persons, traditional circumcisers, and the trend towards medicalization is problematic, since health workers become important stakeholders [39,40]. In spite of the problems, the health risk approach is an important component of an integrated approach, also using social, cultural, religious, human rights, legal and women's empowerment approaches. Most of those who oppose the practice in Sudan use medical complications as arguments [9,41 –43]. Figure 4 shows a poster that has been used in Sudan in campaigns against FGM.

Figure 4.

Poster by the Sudan National Committee on Traditional Practices warning about some of the dangers associated with genital mutilation of girls.

It is often neglected in the debate that this ancient tradition also carries positive values for those practising it, and it is only when campaigns manage to address these perceived positive values that they can succeed. Further research is important to better argue against the fundamental motives for FGM and to use correct arguments in campaigns against the practice, avoiding dissonance between people's lived experiences and claims pronounced by eradication campaigns. Information about health risks plays a role, but will not be enough to undermine a practice based on cultural beliefs and perceived need to control a women's sexuality and fertility. However, research regarding health risks related to these aspects of the practice would add relevant information, which would be important for interventions focusing on social change. The WHO has reviewed different preventive intervention programmes and made recommendations based on this [44].

There are very few clinical studies or other systematic research on the primary victim of the practice: the girl child. In the absence of pediatric research on FGM, immediate and long-term complications for girls are basically unknown, as well as their clinical and social picture. Research findings would make it possible to improve health care for girls facing complications of genital mutilation, but might also reveal findings that challenge the perceived positive effects of the operation. For instance, if FGM is performed in order to increase future chances of marriage and ensure fertility, the risk of infections in the girl leading to infertility would be a significant argument against the operation.

Health effects

Complications of FGM have not been well elucidated in research. Findings about complications have mainly been based on self-reported problems by adult women, case reports or theoretical assumptions. There is a lack of clinical studies with control groups. As a result, there is now controversy over the significance of some health effects. The WHO has reviewed the health effects of FGM [45]. This report lists studies reporting complications. However, it does not critically analyze the findings from a scientific point of view, to find out whether methods, results and conclusions are scientifically correct. Other attempts to review research regarding health complications are incomplete [46]. In any case, few studies have been appropriately designed to measure the effect of FGM on health.

Psychological effects

FGM is performed in a sensitive period for the child, when she is developing her sense of identity in relation to others. The psychological and physical effects of genital mutilation in girls are basically unknown [1]. For other forms of trauma in this age, researchers recognise that children's responses to major stress are similar to adults' (re-experiencing the event, avoidance and arousal) and that these responses are not transient. Post-traumatic stress syndrome is the most common psychiatric disorder after traumatic experiences, including physical injuries. There is also evidence of other comorbid conditions, including mood, anxiety, sleep, conduct, learning and attention problems [47]. Child sexual abuse has long-term repercussions for adult mental health, parenting relationships and child adjustment in the succeeding generation [48]. FGM is very different from other forms of traumatic experiences and sexual assault, since it is performed in a setting where there is strong belief in the positive effects of the practice. There are often festivities and the girl receives gifts. In spite of these alleged positive effects, considering the extent of the operation, the pain and other effects many girls face, it is likely that genital mutilation in girls has severe repercussions, not only for physical health, but also psychologically and developmentally. Girls subjected to FGM have been shown to have significantly more post-traumatic stress disorders and other psychiatric syndromes as adults than women without FGM [49].

Physical effects

In the low estrogenic environment of the prepubertal girl, the thin atrophic epithelium of the vagina may be susceptible to bacterial invasion. The genital tissue damage provoked by FGM, with its inherent microbial contamination, creates a risk of vaginal infection. Such infections can be expected to thrive in the prepubertal girl's lack of vaginal acidity [50,51]. In the absence of a protective environment, the infection might ascend to reach the uterus and the fallopian tubes, with risk of ensuing tubal damage and impaired fertility [52].

The external genitals have a dense nerve distribution and rich blood supply, especially through the clitoral artery that is most often cut in FGM, independent of which form. Consequently, FGM carries risks of immediate complications, such as shock due to pain and/or haemorrhage; difficulty in passing urine; wound infection, septicaemia, and damage to surrounding tissues [1,53,54]. There are often stories about girls dying from complications of the procedure, but research in this area is difficult. However, there is one study from Somalia that shows excess female child mortality in the age group 5–15 years, which is when FGM is performed [55].

In regard to long-term complications, the increased risk of repeated urinary tract infections is well documented both in girls and adult women [53,54,56 –58]. The association between FGM and infertility has been shown both in epidemiological and clinical studies [52,59,60]. Dribbling of urine is common in infibulated women [56,61,62], probably both due to difficulties in completely emptying the bladder [63] and stagnant urine under the hood of scar tissue. Several case studies describe inclusion cysts; calculus formation and keloid formation as a result of all different forms of FGM [1]. Women with FGM are significantly more likely than those without FGM to have adverse obstetric outcomes, for instance hemorrhage and cesarean section [64]. FGM is estimated to cause an extra 1–2 perinatal deaths per 100 deliveries [64]. Risks seem to be greater with more extensive FGM, but also type I leads to increased risk [64].

Some alleged complications have been used in campaigns against FGM without any scientific evidence of any association, for instance vesicovaginal and rectovaginal fistulae and HIV. Although there might be valid hypotheses based on theoretical assumptions and clinical experience, there is no published evidence on these associations. There results of several studies indicate there is no association between FGM and sexually transmitted infections [65 –67].

Men can also experience complications owing of female genital mutilation, for instance impotence and other sexual problems, probably due to pain and lack of sexual response [8]. When the woman has been infibulated the tight introitus can cause wounds on the penis [8]. It is true that these complications are only minor ones compared to the suffering women have to face because of FGM, but the fact that they exist opens possible new ways to work against the practice, especially since marriageability and male satisfaction are often mentioned by women as motives for performing FGM.

The effect of FGM on sexuality is poorly understood. Naturally the response to sexual stimuli is altered since sensitive tissue has been removed, but it seems that not only the extent of operation is important. Some women with a particular type of mutilation (also type III) may experience sexual pleasure while others do not. Psychological aspects and memories from the operation are probably very important for the outcome.

The importance of recognising genital mutilation in girls

There is reason to believe that FGM contributes significantly to morbidity already in childhood. However, a large share of this does not come to medical attention. Many of the complications are probably treated by those performing the operation. Only a small proportion of problems reach the healthcare system, but even then there is a great risk they will be missed. This is partly because symptoms are under-reported, the girl or the guardian being too shy or afraid to describe the problem, but there is also a risk that the problem will not be taken into account by the doctor. There is an alarming nonrecognition of the entity of FGM as genital trauma within the field of pediatrics.

Due to lack of scientific studies on how FGM affects girls there is scant knowledge of which signs, symptoms and disease entities relate to FGM. Symptoms from the urogenital tract are often under-reported [53]. Therefore, it is important to ask specific questions relating to this area, to routinely perform urinalysis for girls coming from ethnic groups traditionally practising FGM, irrespective of complaints, and to inspect genitalia on more liberal grounds. Even though genital inspection should be a part of the routine examination of pediatric patients, such inspection is, according to our observations, rarely done. This reluctance to ask about symptoms of the genital tract and to inspect the genitalia implies a failed diagnosis with inappropriate treatment, which in turn might increase the risk of further complications.

In health or social care, people working with children should have some basic knowledge regarding FGM and how it might affect girls. This statement is true not only for Africa but, due to recent migration patterns, almost all over the world. Girls and women with FGM living in exile often experience being different and vulnerable and feel exposed in the encounter with the health carer [68]. It might be difficult to know when a girl is at risk of having FGM, or to interpret signs and symptoms indicating that it has been done. As stated above, there has not been much research regarding this, but there are some symptoms or facts that should lead the thought in that direction ( Box 1 ). Professionals also need to have knowledge regarding and understanding of the tradition, concerning its social meaning and context, in order to be able to respond to arguments, have a relevant discussion with parents and give proper care [69]. Knowledge regarding which ethnic groups practice FGM is important to address the right persons. To respect the individuals and their culture is essential to be able to meet in any discussion. It might be better to use less value-laden words, such as ‘the tradition’ rather than ‘genital mutilation’ or ‘genital cutting’. To show that one is aware that FGM is common in their ethnic group, but that some have also abandoned the tradition, might be a good opening for a fruitful discussion. For healthcare workers it is important to ask direct questions about symptoms from the genitals and micturition as a routine part of history, and to inspect the genitals on liberal grounds. This might give valuable clinical information, but also shows the girl and her parents that it is legitimate to talk about such things.

Box 1.

Factors that might be associated with genital mutilation of girls (from ethnic groups traditionally practicing female genital mutilation).

When should you suspect that there is risk that genital mutilation will take place?

The girl has a sister who underwent female genital mutilation

The girl tells that she will take part in a ceremony or that her family will celebrate her specially

When should you suspect that genital mutilation has taken place?

Physical complications:

Genital infections

Genital wounds

Genital bleeding

Pain

Cysts in vulva

Repeated urinary tract infections

Problems passing urine

Painful menstruations

Psychological complications:

Fear, anxiety, anger, sorrow, confusion

Psychosomatic problems (e.g., unexplained abdominal pain, backache)

Depressive behavior

Rapid weight loss

Nightmares and sleeping problems

Feeling of guilt

School absence or dropout

Adapted from Lockhat (2004) [18].

Conclusion & future perspective

FGM is a very sensitive and complex subject. Medical, psychological, sexual, religious, cultural, social, economic, gender and human rights aspects, to mention a few, intertwine to a web that is difficult to understand and dissolve. Most previous research about FGM has concerned adult women, which means that the clinical symptoms of FGM and its consequences during childhood are essentially unknown.

Legislation and campaigns based on health risks have had a small effect on the practice, and will not be enough to make people generally abandon the tradition. In spite of this, further research regarding health complications, especially in girls, is needed. We need to know better how girls are affected in order to discover their needs and be able to help them. Pediatricians and others working with children need to recognise the entity of FGM as genital trauma and be attentive to girls at risk of genital mutilation.

The health risk approach will not be enough to abolish FGM, but it will be an important component in campaigns also in the future. Health risks are neutral to discuss, can provide the entry point into practising communities and catalyze an ongoing change. Information regarding health risks may only reach a few receptive and well-educated people, but these early converters are important in any social change [70,71]. The coming steps would be different in different communities. In some places religious arguments against the practice are important, in others it is possible to use a human rights approach focusing on the rights of the child, and in some communities it would be possible to bring up the situation of women and female empowerment. The latter ones are probably the most important for a sustainable change. FGM would not exist in societies where men and women are equal and there is no need to control female sexuality.

Executive summary

Female genital mutilation (FGM) entails different procedures where parts of the external genitals in girls are removed for social, cultural, religious or other non-medical reasons.

Motives & justifications

Numerous motives/justifications are given for letting girls undergo the procedure, such as female identity, tradition, hygiene, fertility or future marriage. However, basically, the practice expresses the perceived need to control women's sexuality.

Forms of female genital mutilation

A WHO classification recognises four degrees of FGM. This classification may give the false impression of anatomically distinct forms, but in reality the practice varies widely between different practitioners.

It is not possible to judge the anatomical extent of the FGM operation from the WHO classification, which is very important to consider when doing research about health complications.

Terminology

The terms ‘female circumcision’, ‘female genital cutting’ and ‘female genital mutilation’ are used interchangeably to describe the same practice.

In the context of changing practice one should be aware that traditional terms and words for the practice might have changed meaning.

The reliability of reported forms of FGM might be very low.

The term ‘sunna circumcision’ has been shown to be used for any form of FGM, including the most severe ones.

Where & why

FGM is mainly practised in Africa, but also in some countries in Asia and among migrants from these areas to other parts of the world.

In spite of many decades of campaigns and legislation, FGM is still highly prevalent in the areas where it has traditionally been practised.

There is evidence FGM continues to be practised among migrants from Africa to Europe, but to a lesser extent than in their home country.

Traditionally, FGM has been performed by lay persons, but it is increasingly common that it is performed by medically trained people. This is problematic, since health workers become stakeholders and justify the practice by their participation.

Female education is one of the most important determinants of FGM. The more education the mother has, the less risk that her daughters will undergo FGM.

Health effects

There are few clinical studies or other systematic research on complications to FGM.

There are both psychological and physical short- and long-term effects of FGM.

Urinary tract infections, infertility and some obstetric complications are among the few well documented consequences.

Importance of recognizing genital mutilation in girls

Most previous research on FGM has concerned adult women, which means that the clinical symptoms of FGM and its consequences during childhood are essentially unknown.

There is reason to believe that FGM contributes significantly to morbidity even in childhood. It is important that professionals working with children have knowledge regarding FGM and how it might affect girls, to be able to identify children in need of medical or other help.

Conclusion & future perspective

Professionals working with children need to recognise the entity of FGM as genital trauma and be attentive to girls at risk of genital mutilation.

There are very few studies on how FGM affects the girl child. This under-researched area should be given much more attention in future research and interventions.

Previously, campaigns against FGM have been based on information regarding health risks, supported by laws criminalizing the practice. This has had some effect, but in order to abolish FGM there need to be more culturally sensitive approaches, preferably taking into account human rights and the situation of girls and women.

References

Papers of special note have been highlighted as either of interest (•) or of considerable interest (••) to readers.

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World Health Organization: Female Genital Mutilation Report of a WHO Technical Working Group, Geneva, 17–19 July 1995. World Health Organization, Geneva, Switzerland (1996).

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: Female circumcision: obstetric issues. Am. J. Obstet. Gynecol. 169(6), 1616–1618 (1993).

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12.

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: Being victims or beneficiaries? Perspectives on female genital cutting and reinfibulation in Sudan. Afr. J. Reprod. Health 10(2), 24–36 (2006).

13.

Important paper that provides understanding on the persistence of female genital mutilation (FGM) in an African country.

14.

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: Reliability of self reported form of female genital mutilation and WHO classification: cross sectional study. BMJ 333(7559), 124–127 (2006).

15.

Important report making recommendations on how to classify FGM when conducting research.

16.

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: Prevalence and determinants of the practice of genital mutilation of girls in Khartoum, Sudan. Ann. Trop. Paediatr. 26(4), 303–310 (2006).

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20.

Toubia

: Female circumcision as a public health issue. N. Engl. J. Med. 331(11), 712–716 (1994).

21.

Classic paper that attracted much attention to the subject.

22.

Lockhat

: Female genital mutilation : treating the tears. Middlesex University Press, London, UK (2004).

23.

Rahman

Toubia

: Female genital mutilation: a guide to laws and policies worldwide. Zed, London (2000).

24.

Excellent and detailed review of the general situation of FGM in most countries in the world.

25.

Abu-Sahlieh

: To mutilate in the name of Jehovah or Allah: legitimization of male and female circumcision. Med. Law 13(7–8), 575–622 (1994).

26.

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27.

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28.

Important paper that adds to the understanding of the continuation of FGM after migration.

29.

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34.

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35.

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38.

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39.

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40.

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41.

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42.

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43.

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44.

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45.

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51.

Important report to consider before planning or evaluating interventions.

52.

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56.

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Landmark prospective multicenter study.

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80.

Izett

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Genital Mutilation of Girls

Abstract

Keywords

Motives & justifications

Forms of female genital mutilation

Terminology

Where & why

Health effects

Psychological effects

Physical effects

The importance of recognising genital mutilation in girls

Conclusion & future perspective

References