the removal of the entire clitoris, both prepuce and glans, and may include the removal of the adjacent labia, either minora, majora, or both. Sunna circumcision and excision affect 85 percent of the women who have undergone genital mutilation (World Health Organization, 1994). The most extreme procedure, infibulation, also referred to as pharaonic circumcision, involves the removal of the clitoris, the adjacent labia (minora and majora), and the joining of the sides of the vulva across the vagina, securing them with thorns or with silk or catgut thread. A small opening is left to allow the passage of urine and menstrual blood. The infibulated vagina is forced or cut open to accommodate sexual penetration and childbirth (World Health Organization, 1994).

The immediate health consequences of female genital mutilation can include infection, including tetanus and HIV, septicemia, hemorrhage, injuries to adjacent tissues, urinary retention, shock, and death (World Health Organization, 1994; Howson et al., 1996). Antiseptic techniques and anesthesia are generally not used. The sequelae of infibulation are the most serious (Howson et al., 1996). The sequelae of all procedures may be exacerbated by unsanitary conditions in which women live and give birth and lack of access to routine health care, safe surgery, and antibiotics.

In some countries, nationally representative samples of women have been asked about their experience of female genital mutilation. Circumcision is nearly universal among Egyptian women (El-Zanaty et al., 1996). In the Sudan, "pharaonic circumcision" is the most prevalent type of female genital mutilation, experienced by three-quarters of all women (Department of Statistics, Sudan, 1991). In the Central African Republic, 43 percent of women aged 15-49 reported that they had been circumcised (Nguelebe, 1995).

The long-term effects include loss of sexual sensitivity and sexual frigidity caused by painful intercourse, delayed menarche and cryptomenorrhea or dysmenorrhea, chronic pelvic complications, dysuria, recurrent urinary retention and kidney infection, vaginal stenosis, keloid formation, neuroma, retention cysts, and disfigurement of the external genitalia (Howson et al., 1996). Forcible sexual penetration of an infibulated woman can cause lacerations of the perineum, rectum, and urethra. Obstetric consequences range from sterility due to infection of the uterus and fallopian tubes to exposure of a fetus to infectious diseases, risk of damage to the baby's skull as it passes through the damaged birth canal, and fetal asphyxia or brain damage due to prolonged labor. An infibulated woman must be "opened" to ensure safe delivery of her child, a procedure that poses further risks to the mother and baby (Howson et al., 1996; World Health Organization, 1994).



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