JEDDAH, 20 March 2005 — Female circumcision is a very sensitive issue that is rarely discussed in Saudi Arabia because it is not practiced by the majority of the population. It is known, however, to be common in the Southern Region.
Doctors in all the hospitals and clinics around the country are mostly aware of the practice and the health problems associated with it, but there are neither statistics nor research into the phenomenon and very little effort at educating those involved.
Although it is a practice that predates Islam and continues as a tradition among Muslims and non-Muslims — including Christians and Jews — there is the false impression that it is endorsed by Islam. The ritual cutting and alteration of the genitalia of female infants, girls and adolescents today persists primarily in 28 African countries and in small communities in Asia and the Middle East as well as in North America and Latin America.
“We have to be careful in approaching this subject because of the different religious stands and interpretations,” said Dr. Nasr Khabbaz, pediatric surgeon at the Children and Maternity Hospital in Jeddah. Muslim scholars have differed on whether female circumcision is required, recommended or optional based on two controversial sayings by the Prophet (peace be upon him). They are regarded as having little credibility or authenticity and are in contradiction to the Holy Qur’an.
“We have to differentiate between ‘Islamic circumcision,’” which does not hurt women because Islam would not allow something that is hurtful, and the types that are mutilating,” said Dr. Khabbaz. There are variations of this genital procedure frequently termed female genital mutilation (FGM), referring to the removal of all or part of the external parts of the female genitalia.
The Sunnah circumcision, the variety supposedly allowed by Islam, consists of the removal of the prepuce (retractable fold of skin or hood) and/or the tip of the clitoris. “This is the simplest type and what is most commonly performed here,” said Dr. Khabbaz.
The other type is clitoridectomy or excision, which consists of the removal of the entire clitoris and the removal of the adjacent labia. The severest type is infibulation, the removal of the clitoris, the adjacent labia minora and labia majora, and the joining of the scraped sides of the vulva across the vagina, leaving a small opening to allow passage of urine and menstrual blood.
Even if the words attributed to the Prophet were actually spoken by him, one can say that infibulation goes far beyond the description given and so the Hadith cannot be used to justify the more severe forms of mutilation. In Africa 85 percent of FGM cases consist of clitoridectomy and 15 percent are infibulation. In some cases only the hood is removed.
According to research done in countries where circumcision is prevalent, the age at which the procedure is carried out varies from just after birth to some time during the first pregnancy; most cases occur between the ages of four and eight. Dr. Khabbaz recently had to treat a baby less than a month old who was bleeding with part of labia minora removed.
The procedure is rare in regions other than the south of Saudi Arabia but people from that region or from countries that perform it who are living in Saudi Arabia find the people and the place to perform it on their daughters, even though it is not allowed in hospitals and clinics. In the past five years, Dr. Khabbaz has seen three cases of girls with a clitoral cist after the procedure; the oldest was eight years old. “They don’t realize what was done to them but it is painful and psychologically damaging.”
Most often this procedure is done without the care of medically trained people and the use of anesthesia is rare. The girl is held down by older women to prevent her from moving around. The instruments used by the midwife will vary and could include broken glass, a tin lid, razor blades, knives, scissors or any other sharp object. These items usually are not sterilized before or after usage and often the same instrument is used on several girls at the same time. Once the genital area for removal is gone, the child is stitched up and her legs are bound for up to 40 days.
This procedure can cause various side-effects and, in extreme cases, death. Some of the results of this procedure are serious infections, abscesses and small benign tumors, hemorrhages, shock and clitoral cysts.
A family physician at a public hospital told Arab News that a Saudi mother presented her six-year-old daughter because she was in pain; on examination, doctors found a benign tumor due to recent cutting. When she asked the mother where she had this done to her daughter, the mother said at a small clinic in their village.
The long-term effects of these procedures may also include kidney stones, sterility, sexual dysfunction, depression, various urinary tract infections, and gynecological and obstetric problems. In order to have sexual intercourse the women have to be opened up in some fashion and in some cases cutting is necessary. After childbirth some women are re-infibulated to make them tight. Many obstetricians perform this procedure everyday in our hospitals on mainly African women who request them to do it.
Because of the large number of cases of FGM and the deaths it has caused, FGM is now outlawed in some European countries, the United States and some African countries such as Egypt, Kenya and Senegal. Even though it is illegal in many countries in Africa and the Middle East, this has not reduced the number of the girls that are mutilated every year.
The governments of these countries have no way of monitoring the spread and practice of FGM. The UN, UNICEF and the WHO have considered FGM to be a violation of human rights and have made recommendations to eradicate it. However, trying to fight FGM on legal terms is ineffective since those who practice it oftentimes do not report it.
“The girls here who had the procedure had it at home and not by a doctor. Whoever recognizes the dangers of inappropriate tools and dangers of cutting would not perform it. It is most likely someone who is not licensed or knowledgeable,” said Dr. Khabbaz. However, the hospital does not report for investigation the person who performed the operation. The people who perform this procedure are neither regulated nor questioned.
FGM is also widely practiced in villages and remote places where the government does not have an easy access. A better and more effective approach would be cooperation on the national as well as international levels. The UN and the WHO have already taken the first step in abolishing these practices. Countries also need to have rigid laws that deal with FGM cases.
This is also insufficient by itself. Researchers recommend that anthropologists, educators, social scientists and activists have to go into these villages and areas and educate the practitioners of the dangers of FGM. It can only be abolished by a grassroots approach, which would take into consideration all aspects of a particular culture and try to work within that system of beliefs to eradicate this no less than torturous practice.
“Muslims who perform the non-Islamic circumcision lack understanding. Our awareness campaign should focus on eradicating the wrong type of female circumcision,” said Dr. Khabbaz.
Medicalizing FGM by performing it in hospitals with appropriate surgical techniques will not eliminate all of the complications associated with this practice and thus cannot be considered a solution that reduces the health risks. Current estimates by the WHO state that over 100 million women and girls have been affected by some form of genital cutting with four million being cut every day.
In a society practicing FGM, a girl cannot be considered to be an adult until she has undergone this procedure. In most of those cultures a women cannot marry without FGM. Family honor, cleanliness, ensuring virginity and fidelity to the husband are sometimes used as excuses for the practice of FGM. It is mostly a culture identity practice.
“I have interviewed some women who were circumcised and all of them were against it because most of it is non-Islamic. Many of them refuse to perform it on their daughters and curse their fathers for doing it to them. But it is not easy for them to convince the fathers not to do it,” said Dr. Khabbaz.
He suggests treating it as a medical malpractice but it remains a sensitive issue because of traditions. In several countries it is considered child abuse.
“In Islamic countries, theoretically it can be considered child abuse, but in practical terms, you can’t punish a whole nation. This issue needs awareness gradually over many years and if the numbers decrease that is a success,” he said.
The awareness campaign should include people from different specialties including religious leaders who understand the motives and reasons for eliminating it as a practice.