There are an estimated ninety to a hundred million women and girls living today in African countries that have had some form of female circumcision (Lane and Rubinstein 1996). Recent articles in the media have reported the growing practice of female circumcision in the US and Europe, among immigrants from countries where it is part of the culture. Circumcision occurs for a number of cultural reasons, such as religion, tradition, preserving virginity, and cultural identification. However, the practice of severe forms of female circumcision is now proven to be a great health risk, and the women of the societies that still practice female circumcision risk severe health problems. This paper reviews the practice of female circumcision and proposes a plan to reduce the use of harmful forms of circumcision, and consequently, the helth problems associated with it.

The Issues

There are different forms of female circumcision. A form of female circumcision called excision involves the removal of all or part of the clitoris, and in some cases other external genitalia. In the most extreme form of circumcision, called infibulation, the clitoris and both labia are removed and the two sides of the vulva are sewn together- except for a small opening for urine and menstrual blood to go through (Heise 1993). Another, less severe form of circumcision involves small incisions in the skin covering the clitoris. Eighty- five percent of worldwide female circumcision involves this less severe form or excision, and fifteen percent includes infibulation. Infibulation and excision cause both immediate and long term health risks. The immediate consequential health risks of infibulation or excision are shock, hemorrhaging, infection, pain, urinary retention, and damage to the urethra (Heise 1993).

In a study performed in Cairo, Egypt, 79.3 percent of genital surgeries happened at home. Only 0.3 percent of the operations were done in hospitals. Most operations are done without anesthesia or sterile instruments which often causes Septicemia, tetanus, or urinary tract infections. Unhygienic salves used to heal the wound also cause infection. Reproductive health risks include a loss of sexual sensation, chronic urinary tract infections, and painful intercourse (Heise 1993). The resulting scar tissue of infibulation also obstructs birth, and the consequential tears and hemorrhaging are "likely contributors to the very high rates of maternal mortality in Sudan and Somalia" (Lane and Rubinstein 1996). Pelvic inflammatory disease caused by chronic infection and/ or scar tissue blocking the fallopian tubes causes sterility, which has extremely high rates in areas that practice infibulation.

Women and girls are not informed of these health risks. In a study performed in Egypt, survey data shows ninety- nine percent of the respondants were not informed of the severe health risks (Gallo 1996). Another study in Nigeria, with survey data from over 400 women, also indicates a need for educational reform. Only 30 percent realized there was a risk of infection, 17 percent realized the risks of birth complications, and 5 percent realized the risk of extreme blood loss (Ebong 1997).

Religion is also correlated with female circumcision. A large percentage of circumcised women are of the Islamic faith, although circumcision is not mentioned in the Islamic holy book, the Koran. Circumcision is seen as a sign of purity and a way of retaining virginity by protecting women's sexuality (Lane and Rubinstein 1996). Also, as these cultures modernize and girls are sent away to school or work, infibulation is seen as a way to control sexuality. A large proportion of circumcised women are from rural areas, where uncircumcised women are not socially accepted. Respectable men would never marry an uncircumcised woman, as she would be seen as impure.

Immigration of cultures that practice female circumcision to cultures that do not practice female circumcision has also raised questions in countries such as France, Italy, Netherlands, the United Kingdom, Canada and the US. France banned the practice when an immigrant father performed the operation on his infant daughter resulting in her death. Canada established a policy prohibiting doctors from performing female circumcisions in Ontario, and the Netherlands Ministry of Health published a report allowing for only one kind of non mutilating form of circumcision (Kool 1994). In the United States, Representative Patricia Schroder introduced a bill in 1996 proposing abolishion of female circumcision in the US. (Lane and Rubinstein 1996).

There have been policies banning the practice in Kenya, Egypt, and parts of Europe. The United Nations has also become involved in attempting to ban the practice. Social, religious, and traditional reasons for female circumcision have been questioned as the health risks of infibulation and excision are more widely understood.

Explaining Female Circumcision

Symbolic interactionism argues that individuals and societies develop the meanings attached to symbols through social interactions. Individual's interactions involve an exchange of information from individuals to other individuals. This pattern of informational exchange continues, involving a whole society.

1P>>2P>>4P>>8P>>16P>>

One person may exchange information with two people, and those two people may exchange information with two other people, continuing the exchange of information to include many people. Meanings attached to symbols are passed on this way and learned.

In regards to female circumcision, symbolic interactionalism would argue that girls learn meanings attached to symbols through interactions with other women and girls. As individuals learn meanings attached to symbols through interactions with society, they may develop a sense of themselves based on the social standards that are set for them. If women are circumcised, they may see themselves as pure and beautiful because these are the meanings associated with circumcision that were learned through interactions with others. Symbolic interactionism states that an individual's behavior in society is based on her perception of symbols and the meanings associated with those symbols. In the course of interactions with other girls, the positive meanings associated with circumcisions are learned. The positive meanings associated with circumcision may include womanhood, purity, fertility, and beauty.

The idea of the Looking Glass self argues that individuals develop a sense of themselves as they believe others see them. When a young girl is about to be circumcised, her mother or other women and girls in her society will tell her that she is becoming a woman, that this will help her stay pure, and she will be beautiful. Everyone in that society will see her as these positive symbols. The young girl will then see herself as all these symbols when she is circumcised.

Research supporting the explanation

"When girls of my age were looking after the lambs, they would talk among themselves about their circumcision experiences. Every time the other girls talked about their infibulated genitals, I would feel ashamed I was not yet circumcised. Whenever I touched infibulated girls, they would tell me not to touch them since I was [still] "unclean."... One day I could not stand it anymore. I took a razor blade and went to an isolated place. I tied my clitoris with a thread, and while pulling at the thread with one hand I tried to cut part of my clitoris. When I felt the pain and saw the blood coming from the cut I stopped .... I was seven years old." (Abusharaf 1998).

The above account describes an overwhelming urge to conform to socially constructed symbols. Social labels in countries where circumcision is practiced are strong enough to cause a seven- year old to mutilate herself. Where it is practiced, female circumcision is strongly promoted and closely safeguarded; it is regarded as an essential coming-of-age ritual that symbolizes virginity, cleanliness, fertility, and enhances the beauty of a woman's body. These are all symbols girls are taught to associate with circumcision at a very young age (Asali 1995).

Rite of passage
Through interviews of various African women, female circumcision is shown to be symbolic as a rite of passage to womanhood. Girls are showered with gifts and attention after being circumcised. In some societies the experience includes secret ceremonies and instruction in cooking, crafts, child- care, and the use of herbs. After circumcision, adolescent girls are also allowed to be married. By complying, they also please their parents, who can arrange a marriage and gain a high bridal price for a circumcised daughter. Among the Masai of Kenya and Tanzania, girls are circumcised publicly. Then the cutting becomes a test of bravery and a proof that they will be able to endure the pain of childbirth. Circumcision gives girls status in their communities, because they are seen as women after being circumcised instead of as girls (Abusharaf 1998). These examples reinforce the positive meanings associated with circumcision- purity, fertilty, and womanhood.

Uncircumcised women
Mothers who have their daughters circumcised believe they are doing the right thing-because their children would become social outcasts if they did not get circumcised. The consequences of not undergoing the ritual are extreme. Negative meanings attached to symbols are also learned through social interactions. An uncircumcised woman is labeled unclean, impure, and unfit to marry, bear children, or attain respect in old age. Interviews of the Sabiny people of Uganda state that an uncircumcised woman who marries into the community is always lowest in the pecking order of village women, and she is not allowed to perform the public duties of a wife, such as serving elders. Uncut women are called girls, no matter what their age is, and are forbidden to speak at community gatherings. The social pressures are so intense that uncircumcised wives often become circumcised as adults (Abusharaf 1998).

Woman's virginity
Another less common reason given for infibulation or excision is decreasing a woman's sexual desire in order to preserve virginity. Infibulation is intended to dull women's sexual enjoyment, and it appears to be extremely effective. In a survey conducted in Sierra Leone, circumcised women reported feeling little or no sexual responsiveness. The clitoris is always at least partially removed during the operation, and without it orgasm becomes practically impossible. Uncircumcised women are generally assumed to be promiscuous, and man-chasers (Abusharaf 1998). Purity and virginity are closely associated with circumcision. Symbolic interactionism would argue that this concept is learned through interactions of individuals within a society.

Tradition and Folklore
Female circumcision is deeply enmeshed in local traditions and beliefs. Interviews of 21 Bedouin women in southern Israel uncovered several reasons for circumcision. The most common is social pressure to maintain tradition. The second most common is the belief that uncircumcised women are not good bakers or cooks. Many women believe that after circumcision, women are cleaner. The justifications for female circumcision vary. Interviews of ethnic groups in Nigeria believe that if a woman's clitoris is not removed, contact with it will kill a baby during childbirth. Other people believe that without circumcision, the female genitalia will continue to grow. Vaginal secretions, produced by glands that are often removed as part of the surgery, are thought to be unclean and lethal to sperm. These examples of folklore show socially constructed negative symbols towards uncircumcised women. These social symbols are learned through interactions with other women and girls.

The Male Role
Men are emphatically not involved in female circumcision, according to all informants (Asali 1995). Fathers are not aware of whether daughters have had circumcision. Women, not men, are the custodians of the ritual- in fact, a Sudanese man recently made headlines by filing a criminal lawsuit against his wife for having their two daughters circumcised while he was out of the country. Why do women subject their daughters to what they know firsthand to be a wrenchingly painful ordeal? Many are simply being practical. "I think that it is very important for the virginity of women to be protected if they want to get husbands who respect them," a fifty-five-year-old Sudanese mother of five girls reports (Abusharaf 1998). Getting married and having children is a survival strategy in a society plagued by poverty, disease and illiteracy. Conflict theorists would argue that the socioeconomic dependence of women on men affects their attitude toward circumcision. Women are more likely to get married to wealthier men if they are circumcised. Symbolic interactionism would argue that socially learned meanings associated with circumcision-purity, fertility, beauty, and womanhood- are appealing to men.Uncircumcised women are less likely to be married. They are seen as impure, bad cooks, infertile, and promiscuous.

Religion
Although female circumcision is practiced by Africans of different religions, a higher percentage of circumcised women are Islamic. Many Muslims believe the ritual is a religious obligation. However, female circumcision is not even mentioned in the Koran, and it is unknown in predominantly Muslim countries outside of Africa, such as Saudi Arabia and Iraq. What seems likely is that when Islam came to Africa, its emphasis on purity became associated with the existing practice of female circumcision (Abusharaf 1998). Through interactions in societies that practice female circumcision, the social label of purity became associated with female circumcision.

Cultural Identity
Advocates of female circumcision charge the increasingly vocal opponents of the practice with trying to undermine African culture (Barrie 1996). European colonialism tried to abolish female circumcision in the first half of this century, but local people adamantly rejected the interference of invading foreign cultures and held onto their own traditions as a backlash. They began to associate female circumcision with their own identity and cultural traditions. Female circumcision became symbolic of holding on to their own traditions, and not adapting to a new culture that tried to impose its own social norms onto another culture through colonialism.

Solution

The health risks caused by infibulation and excision are of major concern for African women. The high infant mortality rate and high maternal death rate associated with infibulation prove this fact (Bimal- Kanti 1993). There are, however, solutions to this problem that have been proven to work. In the Netherlands, a conflict arose because immigrants from areas practicing infibulation wanted to continue the tradition. However, doctors refused to practice infibulation because of health risks and human rights based on their own cultural morality. In the Netherlands culture, female circumcision is considered unethical. In response to immigrants' desire to practice their cultural rights, the Netherlands made a law allowing a specific kind of female circumcision that had no long term effects, and was not a health risk. This type of circumcision involves a small incision made in the skin covering the clitoris. This was accepted by the immigrants and the doctors, as the immigrants felt they were still able to practice their cultural traditions, and doctors did not feel unethical because this kind of circumcision has no long term effects. The symbols of beauty, fertility, womanhood, and virginity were still associated with circumcision. In Africa, governmental laws should be changed allowing for this type of circumcision. The success this had in the Netherlands could also be found in Africa. Cultures following these laws would find a lower infant mortality rate, as well as a lower death rate for young girls and mothers.

Results from a study in the Nigerian state of Akwa Ibom, involving survey data from over 400 women, indicate a need for educational reform. Only 30 percent of the women realized there was a risk of infection, 17.5 percent the risk of birth complications, 5 percent the risk of extreme blood loss (Ebong 1997). This shows that many women are ignorant of the health risks involved in infibulation and excision.

An African women's group started education campaigns in the Sudan against the harsher, widespread form of circumcision, called infibulation. Women were informed of the health risks, including risks to unborn children (Asali 1995). The same form of circumcision allowed in the Netherlands was introduced in the Sudan. These women could uphold their cultural traditions without posing any risk to themselves or their babies. The result was favorable, some women in societies practicing infibulation reformed to the form of circumcision practiced by Bedouin women and in the Netherlands. The circumcisions practiced in Bedouin culture are the same as those allowed by the government in the Netherlands. In interviews of twenty- one Bedouin women, none report any ill effects from this type of circumcision (Asali 1995). This type of circumcision was also found favorable by some groups in the Sudan. If such educational campaigns could be brought to other countries in Africa and in rural areas, there could be massive reform, as the Netherlands study and the Sudan study suggest.

Institutional solutions, such as laws allowing for a non- harmful form of circumcision, should be enforced throughout Africa. Symbolic interactionism would argue that these laws would allow the people to keep the meanings associated with circumcision that define their culture. Educational programs and campaigns aimed at stopping infibulation and promoting non- harmful circumcision should also be funded and enforced by the governments throughout Africa. The people would not have to change their way of life, or the symbols attached to circumcision. The symbols would just be transferred to a different form of circumcision. With these solutions, there would be a higher life expectancy, a lower infant mortality rate, and liberation of African women from the painful side effects caused by infibulation.

Implementation of the solution

My goal is to have educational campaigns in all areas where infibulation is most rampant. These areas would include Sudan, Egypt, and Nigeria.

In urban areas, the educational programs would offer courses to women's groups, in schools, religious centers, and workplaces dominated by women. Their goals would be to:

1. Educate the women on the harmful health risks caused by infibulation
2. Introduce the non- harmful form of circumcision

For tribal or rural areas, educational campaigns would focus on the midwives of each respective cultural group. The midwives would:

• Be educated on the health risks of infibulation and excision
• Be trained on the sterilization of surgical instruments
• Be trained on how to perform the proposed form of circumcision.

Evaluation

To evaluate the success of the proposed action, surveys and interviews would be completed yearly throughout the targeted areas, Sudan, Egypt, and Nigeria. The surveys would include women ages six to twenty, as these are the ages most common for circumcision. The respondents would be chosen randomly from the targeted areas. These surveys would estimate:

• Women's' knowledge of the health risks involved in infibulation
• the number of women still being circumcised yearly
• the type of circumcision practiced
• the feelings associated with both forms of circumcision.

Time Line

1. In January, 1999, surveys performed by government funded educational campaigns of women and girls ages six to twenty would establish the percentage of women and girls being circumcised, the type of circumcisions, feelings associated with the different types of circumcisions, awareness of the health risks, and would also include other information that describes the population in terms of economic status, age, ethnicity, and health. Sudan would be the targeted area. The sample of 200 respondents would be chosen randomly from the targeted areas.

2. In March, 1999, educational campaigns would target the above mentioned countries and inform women and girls of the health risks associated with infibulation, and introduce the other non- harmful form of circumcision. These educational campaigns would be established in the schools, women's groups, and religious centers in urban areas. In rural areas, midwives would also be specially trained, educated, and would assist the campaigns.

3. Using the same respondents as before, the same survey data would be collected in March 2000, and yearly after that. If the numbers of infibulated women have decreased, knowledge of health risks increased, and negative feelings about infibulation have increased, this would evaluate the success of the program.

References

Abusharaf, Rogaia Mustafa "Unmasking tradition: a Sudanese anthropologist confronts
female "circumcision" and its terrible tenacity." The Sciences, March-April 1998 v38
n2 p22(6)

Asali, Abed; Khamaysi, Naif; Aburabia, Yunis; Letzer, Simha; Halihal, Buteinha;
Sadovsky, Moshe; Maoz, Benjamin; Belmaker, R.H. "Ritual female genital surgery
among Bedouin in Israel." Archives of Sexual Behavior, Oct 1995 v24 n5 p571(5)

Barrie Essence, May 1996 p95-97

Bell, Heather "Midwifery training and female circumcision in the inter-war Anglo-
Egyptian Sudan." The Journal of African History, July 1998 v39 n2 p293(20)

. Bimal- Kanti, Paul "Maternal Mortality in Africa:1980-87." Social Science and
Medicine; 1993, 37, 6, Sept, 745-752.

Ebong, R.D. "Female Circumcision and Its Health Implications: A Study of the Uruan
Local Government Area of Akwa Ibom State, Nigeria."
Journal of the Royal Society of Health; 1997, 117, 2, Apr, 95-99.

Gallo "Epidemology of Female Sexual Castration in Cairo, Egypt" Proceedings of the 2-4
International Symposium on Circumcision- Internet.

Heise, Lori "Reproductive Freedom and Violence Against Women: Where are the
Intersections?" Journal of Law, Medicine, and Ethics; 1993, 21, 2, summer
206-216.

Kool, Martin "Female Circumcision in the Netherlands as a Moral Problem" Amsterdam
Sociology; 1994, 21, 2, Oct, 71-85.

Lane, Sandra; Rubinstein, Robert "Judging the Other: Responding to Traditional Female
Genital Surgeries" Hastings Center Report; 1996, 26, 3, May- June, 31-40.