Female genital mutilation/cutting and issues of sexuality in Egypt.THE 2008 Demographic and Health Survey (DHS) in Egypt found that 91% of women of reproductive age have undergone female genital mutilation/cutting (FGM/C), (1) down from 97O/o in 2000. (2) Recent studies suggest that the prevalence is falling even more among the younger generation, (3,4) which is believed to be a result of many years of broad work against the practice.
Gifts in Egypt usually undergo the procedure prior to or around puberty. The most common forms fit into two of the four types classified by the World Health Organization (WHO): Type I (removal of part or all of the clitoris) and Type II (removal of the labia minora and part or all of the clitoris). (5) In 1996, Type I and Type 1I accounted for 84% of all cases examined in a large study, with Type III, the most severe, accounting for 9%, while 7% had not undergone the procedure. (6)
In 1999, a study among 500 doctors working in the Ministry of Health and teaching hospitals showed that just over half of them were in favour of FGM/C for at least some, if not all, women. (7) Medicalization of the practice poses serious ethical questions and concerns, with arguments that the procedure violates the basic principles of medical ethics. (8,9) However, according to the 2008 DHS, doctors in Egypt carry out a large majority (72%) of circumcisions in gifts under 17 years of age, and dayas (traditional birth attendants) 2l%, as reported by girls' mothers. (1)
The main motivation reported in 2003 for the practice in Egypt is to maintain the tradition and adhere to what people think is a religious requirement, as well as husband's preference for circumcised wives, and to prevent illicit sexual behaviour in women, particularly premarital and extra-marital sex. (10)
Prominent Muslim religious leaders including the late Grand Sheikh of A1-Azhar, have spoken out strongly against FGM/C on several occasions, defining it as a socio-cultural belief rather than a religious requirement. (11-13) The Egyptian Orthodox church has also spoken against the practice.
Efforts to combat the practice in Egypt date back to the 1920s, beginning mostly with individual initiatives. The first conference to publicly address the issue was held in 1979 by the Cairo Family Planning Association, a leading non-governmental organization (NG0). Since then, more NG0s have added the issue to their agendas, and community efforts have expanded to combat it. The National Task Force against FGM/C, consisting mainly of NG0s, was established immediately after the International Conference on Population and Development in Cairo in 1994. The Task Force succeeded in placing FGM/C on Egypt's agenda and created a dialogue between the different stakeholders. (14) In 1989 the National Council for Childhood and Motherhood was established and is currently administered under the Ministry of Family and Population, established in 2009. The Council played a leading role in the fight against FGM/C and had pioneered a nationwide project entitled "Female Genital Mutilation Free Village Model" in 2003. The project is currently present in 120 villages in different Egyptian governorates. (14) This project succeeded in engaging all stakeholders and has mobilized public declarations against the practice.
In 2007, the news of two girls who died as a result of circumcision was widely publicized. After the death of a 13-year-old girl, Bedour, following a circumcision performed by a medical doctor, the Ministry of Health issued a decree banning doctors and nurses from performing FGM/C. (15) The doctor responsible was sentenced to one year's imprisonment and fined LE 1000 (around US$200). In 2008, with the help of the National Council for Childhood and Motherhood, a law was passed in Parliament, criminalizing FGM/C and imposing harsh penalties on practitioners. 16 As of this writing, there had been only one documented case of a daya and a mother being fined and imprisoned for FGM/C. However, several other cases have been reported and are currently being investigated by district attorneys in several governorates (Fouad, National Council for Childhood and Motherhood, Personal communication, 2010).
Relationship between female genital mutilation/cutting and sexuality
Controlling the sexuality of women is often stated as a key motivation in the literature on FGM/C. In Egypt, concerns over the consequences of the practice for women's sexuality have been mentioned in articles and books by Egyptian feminists, such as Nawal El-Sadawi. (17) However, none of this literature has attempted to explore what is meant by the consequences for sexuality in the country. We set out to do so.
Our study aimed to investigate a deconstructed conception of sexuality in relationship to FGM/C, including the many issues assumed to shape women's perception of sexuality, such as marriage-ability, gender roles, and views on masculinity and manhood. We have followed the path of many anthropologists, in that context is considered the main parameter for the construction of sexuality. (18-20)
The existing literature on FGM/C and sexuality, published from 1965 until today, mostly since the early 1990s, (21-38) is conflicting regarding the effects of FGM/C on sexual feelings. Several socio-anthropological studies over the past 20 years have challenged what they call the "western assumption" * that the clitoris is key to female sexual response, and that FGM/C has a negative effect on sexual feelings. (21-28) An extensive literature review, conducted by 0bermeyer et al on FGM/C and sexuality, published in 1999, concluded:
"The existing evidence challenges the assumption that the capacity for sexual enjoyment is dependent on an intact clitoris, and that orgasm is the only measure of 'healthy' sexuality." (29)
It is evident, however, that a fundamental challenge in investigating the sexual consequences of FGM/C lies in both how to measure sexual response itself and in linking it to the type of and extent of excision of the clitoris involved, since much of the clitoris is inside the body and would not be excised. In some cases, frequency of sexual relations has been used by researchers as an indicator, but women may or may not have frequent sex for other reasons too, e.g. depending on whether they are trying to get pregnant, and regardless of whether they experience sexual pleasure or not. (30)
A study in Egypt published in 1996, which included 41 women with FGM/C, found that the majority of women reported no negative impact on their sexual relations with their husbands. (31) Studies in 1965 (32) and 1998, (33) on the other hand, suggested that circumcised Egyptian women were more likely than others to experience loss of sexual desire. A larger study, published in 2001, which examined 250 women attending family planning centres in Egypt, found that 80% of the circumcised women were more likely to report psychosexual difficulties than the uncircumcised women, including reduced frequency of intercourse, fewer orgasms and less enjoyment of sex. (34)
A more elaborate hospital-based study in Egypt, published in 2003, found that women with Type I FGM/C experienced no reduction in sexual desire, while those who had undergone Type II or III experienced several sorts of sexual problems. (35) These findings are in line with a review in the same year that found that dyspareunia (painful intercourse) was experienced by 16-46% of the women with FGM/C compared to 14-32% of the women without it. (36)
In 2007, a survey of 1,000 married women in Egypt, of whom more than 90% were circumcised, found that almost 70% of circumcised women experienced some sort of sexual dysfunction. However, most of them did not associate circumcision with what they were experiencing. Marital disharmony and socio-economic pressures were blamed instead. (37)
Most recently, a systematic review (published on the web in 2010) concluded that the low quality of the body of evidence on the psychological, social and sexual consequences of FGM/C:
"... precludes us from drawing conclusions regarding causality, and the evidence base is insufficient to draw solid conclusions about the psychological and social consequences of FGM/C. However, our results substantiate the proposition that a woman whose genital tissues have been partly removed is more likely to experience increased pain and reduction in sexual satisfaction and desire." (38)
The aim of the qualitative study reported here was to explore Egyptian women's and men's perceptions of the relationship between female genital mutilation/cutting and women's sexuality as a broad construct. Topics discussed included women's experience of FGM[C, marriage experience, sexual life, sexual pleasure, desire and satisfaction, other harmful traditional practices such as virginity testing, and gender-related questions on gifts' education and women's work.
Methods and participants
Our first task was to translate the term "sexuality" into colloquial Arabic. Although Arab feminists use the term genisawaya to refer to sexuality, this usage does not exist beyond academia and intellectual circles. Instead, we found that people used phrases like genss (sex), neck (sexual intercourse), motta'a (pleasure), shahwa (desire), and motta'a gensiya (sexual pleasure).
Data were mainly collected through focus groups and in-depth interviews. To enrich the data set, a total of six case studies, and four inter-generational life histories were conducted; in these interviews we pursued the deeper and personal meaning and experiences of the issues. The findings of the case studies and life histories will be presented elsewhere.
A total of 25 focus group discussions were conducted in the three sites, 13 with women and 12 with men, with 94 women and 93 men. The groups were divided by age in order to see whether a difference in thinking had developed over time. Six groups were with women over 35 years of age, seven with women under 35, six with men over 35 and six with men under 35. Each group included educated and non-educated participants, and mixed Moslems and Christians. The vast majority of the women participating were circumcised. In addition, 31 in-depth interviews were conducted in the three sites: eight with women, six with men, four with community leaders, six with religious leaders, and seven with circumcisers and health providers.
The study was conducted in three sites: one slum area in Cairo, and two villages in Al Minya Governorate around 250 km south of Cairo. The three sites have a mix of Muslim and Christian population and none of the three sites was part of the "Female Genital Mutilation/Cutting Free Village Model" project of the National Council for Childhood and Motherhood. The study locations were selected in consultation with local NGOs. The research team selected three NGOs to assist in the process of site selection and recruitment of the study participants. The NGOs were selected based on their previous and current reputation, diversity of programmes in different communities, relationship with local authorities, and willingness to cooperate with the research team.
The recruited participants were selected from the selected communities by the respective NGOs, based on pre-set criteria such as age, marital status and willingness to participate in the research. Participants in the case studies and inter-generational life histories were random members of the communities who fulfilled the research criteria.
The majority of women participating in the study were either not literate, just able to read and write, or had primary education. The male participants generally had a slightly higher level of education. All the women involved in the study were or had been married at some point, while men were married or non married, it is socially unacceptable to ask women who have never married about their sexual experiences.
All the participants were informed of the objectives of the research, as well as the time that they would be expected to spend with the research team. Verbal consent was obtained prior to all in-depth interviews, focus group discussions, case studies, and intergenerational histories. Tapes and notes were locked in a special compartment with access only for the research team. Because of the sensitivity of the research topics, interviews with women were conducted by a female member of the research team while interviews with men were conducted by a man.
The research team had two doctors who offered to help with any medical problems, questions or concerns the participants might have during the course of the study. Furthermore, those with gynaecological problems were referred for free examination and treatment as required. The study received ethical approval from the World Health Organization and an internal ethical committee of the Cairo Family Planning and Development Association. All data were collected in January and February 2008; the analysis was completed in the first half of 2009.
FGM/C, sexual desire and sexual drive FGM/C was still widely practised among the study participants and was deeply rooted in people's minds in all the study sites. The main reason given for supporting the practice was to reduce and regulate girls' and women's sexual desires and sexual drive. In general, among both women and men over age 35, it was believed that uncircumcised women would be "like a restless bull and demand a man" or would "reach orgasm while walking or even if someone holds their hand".
The clitoris was seen as the site of such strong sexual urges that its presence would make it difficult for women to resist sexual overtures from men. The belief that the clitoris is the seat of sexual desire was the basis of the belief that an intact clitoris created the risk of women losing their virginity before marriage, which is immensely important in Egypt at both a religious and social level.
The focus group discussions also revealed a widespread fear among men that if their wives had not undergone circumcision, the strength of their sexual desire within marriage could also be a risk, that women's sexual demands would be beyond their capacity, with the associated risk that wives might feel the need to engage in extra-marital relations, e.g. if their husbands travel abroad. Exposure to foreign pornographic films, particularly popular among the young men, in which the women in the films were taken to represent western women generally, further strengthened the belief that lack of FGM/C would lead women to be promiscuous due to excessive sexuality.
However, the majority of men and women interviewed said they did not consider the clitoris important for achieving women's sexual satisfaction.
The issue of marriageability has often been cited as the strongest motivation for FGM/C. (39) The expectation is that if a woman is not circumcised in a community where this is the norm, her chances of getting married will be severely reduced, and hence her social status and livelihood endangered. In this study, however, neither men nor women described circumcision as a prerequisite for marriage, nor linked the two directly. However, the importance of premarital virginity and marital faithfulness, and the belief that female genital mutilation]cutting helps to accomplish these, may be understood as indirect support for the assumption in these communities that men prefer to marry women with "good behaviour", and thus women who have been circumcised.
We also found that the circumcision status of the woman appears rarely to be discussed during marriage negotiations, but given the high prevalence of FGM/C it would commonly be assumed that the bride has already undergone the procedure.
Right to sexual pleasure and happiness within marriage
Taking the initiative to have sex is often used as an expression of the extent of women's sexual desire. Hence, measurement of this is believed to say something about women desire for and pleasure in sex. (27,35,40) However studies have also shown that women's motives for engaging in and initiating sex go far beyond sexual desire, and include both emotional and practical aspects as well, including duty, desire for children, and the hope that sexual favours may result in material benefits from the husband. (41) Our study also found that local sociocultural gender norms also had a strong influence on whether women could initiate sex, and the ways in which they could do so. It was generally considered unacceptable for women to make direct overtures, instead the man was expected to do this, and even to beg for it. It became clear in these conversations that while men are encouraged to express and celebrate their sexual pleasure through physical parameters, women are not.
However, it was considered acceptable, and even desirable, for women to express their availability or interest in sex in a subtle manner, thereby encouraging their husbands to initiate sex. Men and women mentioned various ways in which a woman could entice her husband or show her availability. Activities such as having a shower, preparing a good meal, dressing in special clothes, or walking in a special way were all understood as means women could use.
At the same time, it was not considered appropriate for a woman to refuse sex when their husbands requested it. Both men and women in general considered complying with men's desire for sex as a woman's duty, and in line with Islamic teaching. Some focus groups of men aged over 35 noted that women refusing to have sex without physical reason is not accepted and a woman could be beaten for it.
In contrast, neither women nor most men expected FGM/C to have a negative effect on their sexual pleasure. In response to our questions on sexual pleasure, men, especially younger men, directly connected sexual pleasure to the sexual act itself (intercourse) and saw sexual pleasure as a cornerstone of their marital happiness. For the men, an important reason for marrying was for sex, and being sexually happy meant they were happy in marriage.
Some of the men expressed ambivalence about female genital mutilation/cutting. While they wanted their wives to have undergone the procedure for its perceived beneficial effects on women's sexual morality, they perceived and lamented a negative effect on sexual pleasure. For, in contrast to the women, some of the men, particularly the younger ones, did believe this occurred.
However, those men, mostly young, who did express worries about negative sexual consequences of FGM/C focused in the discussions on how it would affect them. The concern was that it might reduce wives' sexual desire and ability to be sexually engaged, i.e. respond to the husband's overtures and take an active role sexually, which could then have a negative effect on the husband's pleasure.
In contrast to the men, the women generally defined sexual pleasure, satisfaction and happiness within a broader social context such as having a caring and kind husband, happy children and economic needs
fulfilled, and in close relation to men's sexual satisfaction. Though the women frequently mentioned that they "felt cold during sexual relations", "had no satisfaction out of sex" or "had pain during sex" both in the interviews and focus groups, they did not indicate that this distressed them. Rather, they said they bore with this as a marital duty and fulfilment of religious obligations. Some also said their husbands had said they might take another wife if they did not have sex with them.
Views of religious leaders
In fact, almost all the men in the focus group discussions and the religious leaders stated that women have as much right to enjoy sex as men, when the issue is placed in a religious framework
"The holy book gives the right to enjoy sex to both the man and the woman. And the book says do not steal each other's right. A woman has the right to desire her husband." (Priest, interview)
The views of religious leaders on the sexual effects of female genital mutilation/cutting on women differed and not all supported the common cultural understanding that it reduces women's desire.
"Circumcision is not the main factor in sexual desire. A woman could be circumcised but have a very strong sexual desire; or, she could be uncircumcised and have no desire. This needs a medical study." (Sheikh, interview)
Religious leaders also differed in their perceptions of whether FGM/C affects sexual relationships for couples. For those who considered that it reduces women's sexual pleasure, this conflicted with their religious ideals of a mutual right to enjoy sexual relations within the marital union.
"'There is a Prophet's saying that says that a man should not end the act until his wife reaches the peak. "" (Sheikh, interview)
However, while most Muslim religious leaders shared the common understanding that FGM/C may reduce desire but not pleasure, one of the local priests had a more complex understanding of the interplay between sexual desire and sexual pleasure:
"Family problems exist a lot in our area, the woman does not respond to her man. When site has the desire, she does not get satisfied. In these cases, I talk to the man and ask him to cope with the situation and advise him that circumcision is wrong and he has to accept his wife as she is." (Priest, interview)
Views of health care providers
All the formally trained health care providers had experience of couples coming to see them with sexual problems which, in some instances, they considered to be related to female genital mutilation/cutting:
"A woman came to me a month after marriage with depression saying they had circumcised her six or seven months before; she felt insulted (her pride was insulted by cutting a piece of her flesh). Another comes complaining that her sexual life with her husband is cold, she is afraid he might take another wife. Another asks me for medicines to increase her sexual feeling. This causes problems between the couple." (Physician, interview)
"There is a general thought that circumcision is important for marriage, men think so, and yet they come afterwards complaining." (Physician, interview)
However, the doctors and other trained health providers feared that banning the practice and subjecting the practitioner to harsh penalties might drive it underground, thereby increasing surgical complications from the operation.
"There should be a special place affiliated to the Ministry of Health where female circumcision could be safely done when needed instead of going to a nurse or a daya." (Doctor, interview)
The new regulations against FGM/C and women' status
There was widespread resistance expressed to official "interference in family affairs", which was how the decree was seen, and they doubted its efficacy in stopping the practice. Some younger men said they would still "have it done at home". On the other hand, the younger respondents seemed to be opposed to several harmful traditional practices affecting women, including dokhla baladi (virginity testing), and expressed more support than the older respondents for girls' education and women's work.
Discussion and recommendations
This study points to certain key issues that need to be taken into consideration in future interventions, starting with the gendered way in which sexuality is constructed by both women and men, and influenced not only by their personal experience, but also by their socioeconomic situation. In a 2007 study in Egypt, (37) women related their sexual problems most often to socioeconomic circumstances. Like the women in our study, many reported that they engaged in sexual activity for marital commitment, religious and financial reasons, and to reduce the risk of husbands engaging in extramarital relationships.
Some of the men in our study, especially the younger ones, perceived that FGM/C could have negative effects on women's sexual response; this was not unexpected since many tended to equate sexual pleasure with the physical aspects of sexual relations. They are then more likely to blame "the missing parts" for any sexual dysfunction women might be experiencing. Men are thus in a quite equivocal position--on the one hand concerned that women's pleasure in sex is reduced, thus hindering their own pleasure, and on the other hand worried that uncircumcised women will be too sexually demanding, endangering their control over the sexual relationship.
The expressions of resistance to political interventions imply that, although important, the newly introduced legislation alone may not be able to stop the practice. As people consider female genital mutilation/cutting to be key to women's sexual morality, educational measures will also be needed. Experience from interventions in both Egypt and other countries suggest that political commitment must be combined by strong advocacy and education programmes at both national and community levels, within a package of education and training to eliminate other harmful traditional practices, such as early marriage and domestic violence.3<37 A developmental approach is also needed within this, in which women are empowered and their position in the family is improved.
Most Egyptians are avid TV watchers, and keen on movies and drama. TV, radio, newspapers, drama and soap operas could well be used for educational messages against female genital mutilation/cutting. Information that could counteract the association between the clitoris, sexual desire and "immoral" behaviour in women could have an important effect.
It seems paramount also to include these perspectives in the training of health care providers and those involved in interventions against the practice in Egyptian communities. Health care providers should also be trained in sexuality counselling, so as to be able to deal with sexual problems that may or may not be related to female genital mutilation/cutting. In addition, those personnel expected to enforce the law, such as police, attorneys and social workers, need to be made aware of these issues.
We recognize however, that the inclusion of these perspectives on FGM/C and sexuality must be handled with care, as this is a quite sensitive subject in Egypt.
The changes we found among the younger generation of our respondents in opposing several harmful traditional practices, and their greater support for girls' education and women's work, indicate a more favourable environment for empowering women and consequently some hope for the abandonment of female genital mutilation/cutting in the future.
This study was supported by the UNDP/UNFPA/ WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction, World Health Organization. Many thanks to R Elise B Johansen, whose editorial support was invaluable. Thanks are also due to all the NGOs the team has worked with: The Cairo Family Planning and Development Association, Al-Khashaba Association for Development, St Mark for Development Association, and the Association for the Development and Enhancement of Women. The Cairo Family Planning and Development Association managed the financial and administrative parts of the study. The research team is indebted to the two research assistants who helped tremendously with collecting the data and the process of transcription: Mrs Naglaa Fathy and Mr Mohamed Darwish. Many thanks also to Dr Shereen El Feki for valuable remarks and assistance and editing the final report.
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Amel Fahmy, [a] Mawaheb T EI-Mouelhy, [b] Ahmed R Ragab [c]
[a] Programme Officer, UNFPA-Egypt, Cairo, Egypt
[b] Principal Investigator, Independent Consultant in Population and Reproductive Health, Cairo, Egypt. E-mail: email@example.com
[c] Professor of Reproductive Health. International Islamic Centre for Population Research and Studies, Al-Azhar University, Cairo, Egypt