in addition to posing a risk to the survival of mother and infant, can also cause severe perineal lacerations or damage to vaginal tissue, often resulting in vasicovaginal fistulae, a serious medical problem wherein a passage is created between the vagina and the urinary bladder or other parts of the body cavity, including the rectum (see Shandall 1967, Mudawi 1977, Verzin 1975). For some women the result is a most embarrassing condition rendering her unable to retain urine and producing constant leakage. In rural areas where pads or absorbent cotton are not available in the market or are beyond the means of a family, the woman may be unable to preserve basic hygiene and may suffer the consequence of social avoidance, ostracism, or divorce (El Dareer 1982:38).
Infibulation is also related to an apparently high prevalence of urinary tract and other chronic pelvic infections. If urine cannot be passed easily and there is only a single pinhole-sized opening for both bladder and vagina, some women experience the backing up of urine into the vagina, which is particularly dangerous during pregnancy. One can easily imagine how a woman with such a condition—or any woman who finds it difficult, slow, or painful to pass urine—might be tempted to cut down on her fluids, drinking too little for good health in a hot climate. In many rural areas, latrines are nonexistent and hidden places, as well as opportunities, for uninterrupted urination may be few. When traveling by bus or truck, the lack of facilities at stops may force women to hide under their long veils and urinate in the open; many prefer the discomfort of holding their urine for many hours.
Such conditions and inadequate fluid intake could be contributing factors to the high rates of urinary tract infections reported: Shandall has reported a prevalence rate of 28 percent of northern Sudanese women affected by urinary tract infections (1967, see also Boddy 1998a:53).
The limited epidemiological information available on maternal mortality, stillbirths, and neonatal mortality in the countries affected by female circumcision practices gives cause for concern, though clear demonstrations of the relationship of these results to incidence of female circumcision await better data. Nevertheless, there is every reason to believe that reduction of the incidence and severity of female circumcision could contribute to improvement of the health and survival of women and children. (For more on medical consequences, see Abdalla 1982; Boddy 1982, 1989, 1998; Cook 1976; Dorkenoo and Elworthy 1992; Dorkenoo 1994; El Dareer 1982; Verzin 1975; Rushwan et al. 1983; Shandall 1967; Toubia 1993, 1994; Van der Kwaak 1992).
Psychological risks have also been discussed by some writers and depicted in fiction (e.g., Walker 1992, El Saadawi 1980a, Abdalla 1982). Abdalla states that psychological reactions range from “temporary trauma and permanent frigidity to psychoses,” and she hypothesizes an effect on the personality development of the young girls, a “totally neglected” topic (1982:27). There have been a few studies of mental health sequelae and the issue is being addressed in the literature (e.g., Baashar et al. 1979; Grotberg 1990, Toubia 1993). Baashir notes that the physical complications often produce psychological effects, for example, the “toxic confusional states” resulting from shock or tetanus, and there are also longer-term psychiatric sequelae to the physical complications, which can lead to “chronic irritability, anxiety reactions, depressive episodes and even frank psychosis” (quoted in Abdalla 1982:27). More research would be useful on female circumcision trauma in relation to later depression, fear of intimacy, and sexual dysfunction. Psychological consequences clearly can be expected to vary considerably, depending on cultural meanings that are taught and whether girls are prepared for the operations.
Reviewing the horrendous health risks, one can understand the intense outpouring of condemnation that ensued when the practices became more widely known by people outside the societies involved. That they have been nevertheless strongly defended and variously interpreted is the source of the intense controversy.
The Extent of Female Circumcision Practices
Various writers estimate that there are more than 100 million women and girls whose bodies have been altered by some form of female circumcision. Toubia estimates 114.3 million (1993:25). About 2 million are considered at risk for undergoing the procedure each year. Some form of female genital cutting is practiced in about twenty-eight countries in Africa.
But the procedure is not limited to Africa. Many more countries need to be concerned, as medical practitioners and social services providers find themselves dealing with circumcised women of immigrant populations now living in North America, Europe, South America, and Australia. Although new cases among immigrants are believed to be few, public health education of immigrants is needed and caregivers need preparation. Circumcision may also spread as people come to believe, however erroneously, that it is required by their religion, as in the case of Muslim populations in South Asia and Indonesia that have adopted circumcision. Several countries of Europe, south and southeast Asia, and North America, together with Brazil and Australia are said to have practicing populations that are “less than 1 percent” (Toubia 1993:34).
In Africa, statistics on prevalence of circumcision, its types, and the rates of new cases have been difficult to determine, as data are uneven (see Toubia 1993, 1995; Amnesty International 1997; Hosken 1978, 1982, 1998). According to data drawn from national surveys, small studies, country reports in WIN News, and anecdotal information, the affected countries have prevalence rates (i.e., the percentage of cases in the appropriate female age groups) that range from as high as 98 percent to as low as 5 percent. Some countries have none. The moderate rates of some countries may reflect an average of high prevalence in one area (perhaps certain ethnic groups) with low prevalence in another.
The countries with the highest total estimated prevalence are Somalia (98 percent), Djibouti (95–98 percent), Egypt (97 percent), Mali (90–94 percent), Sierra Leone (90 percent), Ethiopia (90 percent), Eritrea (90 percent), Sudan (89 percent for the northern two-thirds of the country), Guinea (70–90 percent), Burkina Faso (70 percent), Chad (60 percent), Cote d’Ivoire (60 percent), Gambia (60 percent), and Liberia (60 percent). Also very high, with estimates of 50 percent each, are Benin, Central African Republic, Guinea Bissau, Kenya, and Nigeria. Countries where fewer than one-third of women and girls are affected include Mauritania (25 percent), Ghana (15–30 percent), Niger (20 percent), Senegal (20 percent), Togo (12 percent), Tanzania (10 percent), Uganda (5 percent), and Zaire (5 percent). The remaining countries of northern Africa and southern Africa are considered “nonpracticing countries.” (See Map 1.)
Nearly a third of the cases in Africa are in Nigeria, not because of high prevalence but because of its large population; the country accounts for 30.6 million of the 114.3 million cases for Africa as a whole, according to Toubia (1993:25). Just seven countries of northeast Africa (Egypt, Sudan, Eritrea, Ethiopia, Djibouti, Somalia, and Kenya) contain half of the circumcised women and girls in Africa.
Infibulation, the most severe form of female circumcision, is most common in that same region of northeast Africa, including Somalia, Djibouti, eastern Chad, central and northern Sudan, southern Egypt, and parts of Ethiopia and Eritrea (see also Hicks 1993). The people of Djibouti have practiced infibulation almost exclusively. For Somalia, circumcision is virtually universal, and at least 80 percent are infibulated. For the northern two-thirds of Sudan, where El Dareer’s research team conducted interviews, 98 percent had circumcisions, but only 2.5 percent were sunna, while 12 percent were intermediate and 83 percent were infibulated. At the time of the interviews in 1979 and 1980, only 1.2 percent reported no circumcisions (El Dareer 1982:1). In Egypt the prevalence of infibulation is high mostly in the south near Sudan. Similarly, the areas of Eritrea and Ethiopia where infibulation is found are those near Sudan, Somalia, and Djibouti, where infibulation is predominant.
Although the amount of information is growing, mapping the areas where the various forms are practiced today and indicating prevalence is challenging, given the unevenness of data. Unfortunately, some of the maps that are being used in publications draw upon earlier efforts that incorporated anecdotal accounts that, at least for the areas of Sudan with which I am familiar, are not fully supported by ethnographic
