EPIDEMIOLOGY OF
Mohamed Badawi
FEMALE SEXUAL CASTRATION
IN CAIRO, EGYPTPresented at The First International Symposium on Circumcision, Anaheim, California, March 1-2, 1989.
INTRODUCTION
In 1985, a group of 350 urban Egyptian women were selected to self-report on their recall of their female sexual castration (FSC) which they experienced as children. Two years of field observations of female genital mutilations in Cairo have resulted in a wealth of quantitative, qualitative and photographic information on the various aspects of female genital mutilations, as observed and practiced through 1985.
The purpose of this pilot study was to provide preliminary baseline information for a future epidemiological study of female genital mutilations and its relationship to female fertility and psychological trauma, particularly psychosexual functioning. This report summarizes selected descriptive findings from the pilot study that was conducted in Cairo, Egypt in 985 and were reported at the First International Symposium on Circumcision held at Anaheim, California (1989). This pilot study has provided some insights into the public health aspects of female genital mutilations; the social-religious factors that compel these practices; age, socio-economic and other factors that place children at risk for FSC; nature and circumstance of genital mutilations; and the personal psychological trauma experienced from these genital mutilations.
METHODOLOGY
A non-random sample of women were selected from various communities and socio-economic sectors in Cairo, Egypt. Participants were not drawn from clinical patient populations. The characteristics of the female participants that were interviewed are summarized as follows:
AGE (Years): <20: 16%; 20-29: 60%; 30-39: 16%; 40-49: 5%; 50+: 3%
RELIGION: Muslim: 94%; Coptic: 6%
MARITAL STATUS: Single: 59%; Married: 37%; Divorced: 2%; Widowed: 2%
EDUCATION: High School: 52%; College: 27%; Elementary: 8%; Illiterate: 2%
WORK: Employed: 46%; Housewife: 27%; Student: 27%
INCOME:
In brief, the female sample studied can be described as young, Muslim, single, educated, employed and of lower incomes in Cairo.
The data was collected during a single interview with each female participant with no follow-up interviews. A three page semi-structured questionnaire developed by the author was used to obtain information in the following areas: a) personal/family data; socio-economic status; conditions and characteristics of the genital mutilation experience; and its effects upon their psychological and psychosexual functioning.
The data collected was coded and edited to protect the privacy of each participant. Computer encoded data included no references to the identity of the participants. 93% of the subjects completed the interview. Women who refused to participate in this study were almost always accompanied by their husbands or a male figure. Women who willingly participated in this study were either alone or accompanied by a younger person of a lesser age or in the presence of another woman.
PREVALENCE OF GENITAL MUTILATION
In this study, a majority of women reported being subjected, at least once, to genital mutilations. Almost 8 out of 10 (81.6%) Egyptian women reported being subjected to genital mutilations. This incidence is in agreement with findings from other investigations that have been made over the past 12 years. The average incidence of FSC in these studies is 80.5% (See Table 1). Although these surveys are not without methodological problems, they are all reasonably consistent in their report of the prevalence of female genital mutilations. A true national survey has yet to be conducted on the incidence and characteristics of female genital mutilations.
TABLE 1.
THE PREVALENCE OF FEMALE CASTRATION IN EGYPT
ABSTRACT OF STUDIES FROM 1977-1985Study Findings Badawi
(1985)Smith (4)
(1980)Assaad (1)
(1979)Baashar (2)
(1979)Saadawy (3)
(1977)Percent* 81.6% 77% 90.8% 70.0% 81.8% Sample Size n=350 n=125 n=54 n=70 n=16 Population General Students Patients Patients Patients Location Cairo Alexandria Cairo Alexandria Cairo *80.5% is the average of female genital mutilation in the above studies
SOCIAL-BEHAVIORAL CHARACTERISTICS OF FEMALE GENITAL MUTILATIONS
The social-behavioral characteristics of female sexual castration in Egypt with respect to age, place, agent and form of genital mutilations are summarized in Table 2. The majority of female genital mutilations occur between 6-11 years of age: 81.2%; 4.5% occur under 6 years of age; and 14.3% occur after age of 11 years. Virtually all genital mutilations occur before the age of menstruation, i.e., it is a pre-menstrual or pre-fertility ritual.
TABLE 2.
SOCIAL-BEHAVIORAL CHARACTERISTICS OF
FEMALE SEXUAL CASTRATION IN EGYPT:
AGE, PLACE, AGENT AND FORM OF GENITAL MUTILATIONS- PERCENTAGE- Age 6 Years 6-8 Years 9-11 Years 12 years + Percent 4.5% 38.7% 42.5% 14.3% Place Home Clinics Street Booths Hospitals Percent 79.3% 13.5% 4.1% 3.0% Agent Midwife Physicians Barbers Percent 60.9% 22.9% 16.2% Genital
MutilationsClitoral
CircumcisionClitoral
RemovalLabial
RemovalInfibulation Percent None 100% 100% None
The home of the girl is the primary place for genital mutilations where 79.3% of genital mutilations occur; 13.5% occur in clinics; 4.1% in street booths, and 3.0% in hospitals.
The primary person that inflicts the genital mutilations is the midwife--Daya (60.9%); followed by physicians (22.9%); and then barbers (16.2%). It must be emphasized that physicians who perform these genital mutilations are not following medical procedures that are taught in the medical schools; and that they are violating their medical oath and ethics that prohibit unnecessary medical practices. These physicians have abused and exploited their medical knowledge and skills to compete with traditional healers for the people's limited money.
NATURE OF FEMALE GENITAL MUTILATIONS
I have personally observed over 100 completed female genital mutilations with photographic documentation. The genital mutilation technique almost always involves the removal of the clitoris and labia minora and to a lesser extent slashing the labia majora when it is bulky and protruding. In practice there is a wide range of technical variation of genital mutilations which differ within the same practitioner across time, instrumentation used, and with the socio-economic status, age, location, traditionalism, and ethnicity of the child and her family. This issue of variation of degrees of genital mutilations has yet to be systematically studied and documented.
INFORMED CONSENT
The majority of children (77.4%) subjected to genital mutilations were never informed as to what they were being subjected to, let alone given the opportunity to give informed consent. The women reported that they were deceived, assaulted, chased an violently immobilized to be forced to have their genitals mutilated. The remaining percentage of women (22.6%) reported that they were deceived, misinformed, and misled as to the imminent danger of physical violence and genital mutilation. Their "consent" was not "informed" in any legal sense of the word.
PERSONAL RESPONSES TO FEMALE GENITAL MUTILATION
The following personal comments were recorded from the women who were interviewed:
"I was terrified to say No."
"I dare not say NO"
"I wasn't fully comprehending what was happening to me. I wanted someone very much to explain what was being done to me in vain."
"I was shocked and never was I able to comprehend until it was over."
"Please don't make me remember what happened, I am trying to forget."
"I cried and screamed for help and no one helped."
"I cried like mad, shouting `You all cheated me.'" (Then the respondent wept silently with a choking voice.)
"They told me: `You must be purified like the rest of your sisters, you are no exception.'"
"They attacked me by surprise."
"I saw the Daya holding a razor, then she hurt me."
"I couldn't believe my mother was with them; they all attacked me one early morning while I was still sleeping."
The above are some of their emotional recalls of what had happened to them. The intensity of their recall, as I remember very well, was very strong and vivid and commonly associated with weeping and remembered pain and humiliation. The lifelong psychological effects of these genital mutilations needs to be systematically studied.
EFFECTS OF GENITAL MUTILATION UPON PSYCHOSEXUAL FUNCTIONING
The effects of genital mutilations upon responses to sexual stimulation was examined in a subset of FSC women compared to non-mutilated (normal) women. There were 133 FSC women and 26 normal women who were compared with respect to sexual excitement in response to stimulation of the clitoris or clitoral area; stimulation of the labia areas; and intercourse.
It was found that 7.7 times as many normal women experienced sexual excitement to stimulation of the clitoris/clitoral area than did the genitally mutilated women. Masturbation (involving labia as well as clitoral areas) was the method of choice for sexual satisfaction that was 2.2 times more frequent in normal women than in the genitally mutilated women. Manual stimulation of the clitoris/clitoral area resulted in the experience of orgasm in 50% of the normal women and in 25% of the genitally mutilated women.
There are two notable findings from this preliminary survey. The first is that only 50% of normal (non-mutilated) women experienced orgasm with manual stimulation of the clitoris; and as much as 25% of the genitally mutilated women were able to experience orgasm in response to stimulation of the clitoral area. The extent to which orgasmic potential in the mutilated women is related to the nature and degree of genital mutilation is a subject for future research.
SUMMARY
In overview, the majority of women with genital mutilations came from modest and low socio-economic family status (SES); illiterate and partially educated parents (although the majority of daughters who were subjected to genital mutilation had a high school or college education (79%); and came from rural regions, particularly southern communities. Girls of urban/rural areas (living in urban areas but raised in rural areas) remain at a higher risk for genital mutilation than urban/urban girls. Girls of rural/rural families remain at the highest risk for genital mutilation. Regional factors involving peer and ancestral pressures influence the family's decision to have their daughter's genitals mutilated.
Mothers are directly responsible for arranging the genital mutliation of their daughters. However, without a male authority (marital dissolution, separation, sickness, labor migration and death), mothers are likely to have second thoughts about subjecting their daughters to genital mutilation. Also, daughters of financially independent mothers are seldom exposed to genital mutilation, as a mother's financial independence seems to allow her parity in family decision-making.
Religious beliefs are a strong predisposing factor for female genital mutilations. A large percentage of women whose genitals are mutilated are affiliated with the Islamic religion despite the fact that female genital mutliation is not prescribed by the Islamic religion. Female genital mutliation is a pre-Islamic religious practice with its roots in the officially banned African faiths and practices which dominated Egypt for thousands of years in pre-historic times.
In the dawn of monotheism -- Judaism, Coptism and Islam -- many Egyptians who converted to monotheism have assimilated their predominant tradition (African) beliefs and practices with their chosen monotheism. To a keen observer, many features of "Muslim" Egyptian faith lifestyle and religious practices (such as ancestral worship, Zar cults, circumcision and many other forms of blood and flesh sacrifices) meet earlier African faith standards and no current monotheistic beliefs (except for Judaic male circumcision).
By understanding African religions and faith practices many of the traditional religious behaviors of "monotheistic" Egyptians become meaningful. For example, women located in the Southern regions of Egypt (upper Egypt which is closer to African cultures), whether Muslim or Coptic, are at a higher risk for genital mutilations than are Muslim or Coptic women located in the Northern or coastal regions of the country (lower Egypt). Finally, there is no clear and definite statement in the Koran, the principal religious authority of Islam, that supports the practice of female genital mutilations.
CONCLUSIONS
Female genital mutilation is a common and popular practice throughout Egypt where every day thousands of young girls are subjected to this torture and mutilation. Religious institutions and ancient social customs are primarily responsible for the genital mutilation of female children. The full social and psychological consequences of mutilating the genitals of female children have yet to be evaluated. Preliminary evidence, however, suggest that the psychological consequences of female genital mutilation is very similar to that of rape victims.
What can be done to bring an end to female genital mutilation in Egypt and other countries? The use of force would only drive it underground and increase the resistance to cultural change. Educational programs that are directed to Egyptian families; the agents that perform the genital mutilations (midwives, doctors, barbers); and the social-political and religious leaders on the harmful and devastating effects that these procedures have upon women will contribute significantly to the elimination of female genital mutilations. Specific attention must be given to the effects of genital mutilations upon reproductive processes, the birth of the child and the marital sexual relationships. Men need to understand that their marital sexual relationships and happiness will be significantly enhanced when the female genitals are not mutilated. Finally, the education of women must be accelerated if these objects are to be realized.
REFERENCES
Assad, M. (1980) Female cirumcision in Egypt. Studies in Family Planning, January 11 (1): 3-6.
Baasher, T. (1982) Psycho-social apsects of female circumcision. In: Baasher, T. Bannerman, R., Rushwan, H., Sharaf, I. (Eds). Traditional Health Practices Affecting the Health of Women and Children. WHO Regional Office for the Eastern Mediterranean. EHO EMRO Technical Publication. 2(2):162-180.
Psychological Aspects of Female Circumcision, WHO East Mediterranean Regional Office, Alexandria (1977).
El-Saadawi, N. (1977): Women and Sex. Madbouly Publishers.
Smith, E. (1980) Female Circumcision in Egypt. Higher Institute for Nursing (Unpublished).
BIOGRAPHICAL NOTE
Mohamed Badawi, M.D., M.P.H., is a graduate of Cairo University, School of Medicine (1973); a graduate of the University of Michigan, School of Public Health (1981); a graduate of Al-Azhar University School of Medicine, Cairo (1985); and is currently completing a doctoral program at the Johns Hopkins University School of Public Health. This pilot study was supported by the personal funds of Dr. Badawi.
This paper was later published in the Truth Seeker, Volume 1 Number 3, Pages 31-34. (July/August 1989).
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