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The dilemma of worldwide typology and terminology of FGM--with special reference to Sudan.

Abstract

The objective of this article is the development of pertinent FGM typology, through using the local languages and / or dialects that are comprehensible to and culturally accepted by the individuals of different societies.

WHO (1996) typology and the recently (2007) proposed modified WHO one have been criticized. Alternatives for FGM used typology and terminology have been suggested.

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Introduction:

Of all problems traceable to traditional beliefs, and which adversely affect the health and lives of girls and women in Africa today, those arising from FGM are by far the most serious. Original, professional, and pioneer reporting on the health hazards (including fatality) of FGM practice in the Sudan had early been documented by Bredie, et al (1945); Shandal (1967); El Dareer (1983); Rushwan et al (1983, 1994). More recent inputs on the health consequences and gynecological complications have been recorded by El Fadil (2000). The negative psychological impacts were reported by Baasher (19[TEXT NOT REPRODUCIBLE IN ASCII]). Moreover, the negative psychosexual impact of FGM on women has been investigated by Abdel Magied and Musa (2002). Therefore, within the preceding context, it would seem logical to consider FGM as a synonym of endemic fatal disease and type of slavery specific to girls and women, whenever and wherever it is prevalent and/or practiced (Abdel Magied, 1998).

Nonetheless, in the Sudan the practice has been perpetuating for many generations. As such, the practice has been institutionalized as a habit or a custom that became an integral part of the social system. Nevertheless, the reasons behind perpetuation of the practice are complex and should be visualized, considered, evaluated and addressed through a multidimensional scientific approach. The latter should give full consideration to its inter-related culture, health, socio-economic, religious, official and legal perspectives (Abdel Magied, 2001, 2007).

However, of the 28 identified African countries (Rahman and Toubia, 2000) known to practice FGM, Sudan is one of the cases that are worthy of special attention. This is because of the extra prevalence of the unique practice of cosmetic "re-infibulation" or "re-circumcision" by Sudanese women. This is practiced after delivery, but also cosmetically for up to three times a year to have a tighter vagina. The practice is claimed mainly for the pleasure of the male spouse (Abdel Magied et al, 2000). This is in addition to a spread of FGM practice (due to negative acculturation influence) among communities (e.g. Southern tribes) where FGM was not part of their culture (Abdel Magied, 2001 and 2007).

Historical Developments of Previously Practiced Types of FGM in Sudan:

According to Bridie (1945), the operation involves removal of the clitoris and a large part of labia majora and the paring of the latter. This would strictly be the so called Pharaonic circumcision or infibulation which was the only type practiced in Sudan by then.

The age at which the operation of FGM is performed varies from one culture to another. According to El Dareer (1983), 18% of girls were circumcised at five years of age including those aged from seven days to four years. The minimum age of circumcision is seven to forty days and this habitual practice is only found among Beja and Beni Amir tribes of Eastern Sudan. However, the age at which girls are generally circumcised ranges between 5-9 years old (Department of Statistics, Ministry of Economic and National Planning, Khartoum-Sudan, 1991).

Shandall (1967) reported four types of circumcision that have been practiced in different Muslim and Arab countries, Australia, and Somalia. These types were classified as:

Circumcision: this is analogous to that of the male. It consists of removal of the prepuce of the clitoris only, preserving the clitoris itself and the posterior large parts of the labia minora. It is called "Sunna circumcision".

Excision: this consists of removal of prepuce and glans of clitoris, together with the adjacent part of the labia minora or the whole of it without including the labia majora and without closure of the vulva.

Infibulation: this is really excision plus infibulation. It is the commonest type in Sudan where it is known as "Pharaonic circumcision".

Introcision: this is most drastic operation of all of them. At puberty the vaginal orifice is enlarged by tearing it downwards with three fingers bound around with opossum string. The operator is usually an old man trained for the job This is followed by compulsory sexual intercourse with a number of young men and sometimes with the older men of the tribe.

Abu-Bakr (1982) described three types of female circumcision practiced in Sudan:

Sunna Circumcision: this consists of the removal of the prepuce and glans clitoris. The rest of the clitoris is preserved together with posterior large parts of the labia minora.

Excision: Removal of prepuce and glans of clitoris together with the adjacent part or whole of labia minora without including the labia majora and without closure of vulva.

Infibulation: Excision plus infibulation. The second name for it is Pharaonic circumcision. It consists of removal of the whole clitoris, the labia minora and the medial part of the labia majora.

Modawi (1982) described three different types of female circumcision practiced in Sudan:

Classic Pharaonic circumcision or infibulation: is also known in Egypt as the Sudanese circumcision.

Sunna or clitrodectomy: the glans clitoris only is removed.

Re-infibulation or Re-circumcision: This is sometimes done by midwives to close the patulous vagina after giving birth.

According to Rushwan, et al (1983), there ate three types of female circumcision practiced in Sudan:

Pharaonic Circumcision (Infibulation): This form represents classic infibulation or classic Pharaonic circumcision. The process includes: Removal of clitories, labia minora, and part of the labia majora. Labia majora are joined together, leaving an opening for the passage of urine and menstrual discharge.

Intermediate circumcision: Is slightly less severe from infibulation: The clitoris and part or all labia minora are usually removed and the vaginal introitus is narrowed, most of the time by stitching.

Sunna: the term embraces both excision and circumcision proper.

Sudan Demographic Health Survey, SDHS (Ministry of Economic and National Planning, Department of Statistics, Khartoum, Sudan, 1991) used the same classification of typology that has been used by Rushwan etal (1983).

Nevertheless, there are clues in old and recent published and unpublished literature that indicate a shift of the practice in the Sudan from the severe form of infibulation to the milder form of clitoridectomy and non-circumcision. (Abdel Magied, 2007, 2008a and 2008b). However, the latter typology terms, together with others, in addition to some controversial terminologies create the present worldwide dilemma of typology and terminology.

Justification:

Neither WHO (1996) used typology, nor the recently (2007) proposed one would resolve the worldwide dilemma of FGM typology and terminology.

Objectives:

Developing a compromising simple FGM typology and culturally accepted terminology and using the local language and/or dialects that are suitable for and comprehensible by individuals of different societies with different cultures, norms and practices of FGM.

Methodology:

This article is cross sectional, involving critical analysis and development of some secondary data. The latter is obtained from published articles, statements and whatever thought useful and relevant of professional reports and unpublished researches carried out by the coworkers of the author of this article.

Results and Discussion:

Recent Practiced Types and Forros of FGM in Sudan:

In the Sudan, FGM is inflicted on the victimized girl child without her mature consent at an age normally between 5 and 9, and rarely at 10. At this age the development of the prepuce (hood) of the clitoris is only vestigial, and removing it would need a dexterous surgeon and with sophisticated surgical equipment. Accordingly, clitoridectomies which ate normally done by TBAs and midwives in the Sudan would involve at least excision of the glans clitoris and the vestigial prepuce or hood (Abdel Magied, et al, 2003).

Several ambiguous forms of FGM have recently been introduced in Sudan. However, the most common form of infibulation, which is practiced in urban communities, is known as "Sandwich Circumcision". The latter is said to be gradually replacing the classical type of Pharaonic Circumcision or Infibulation (Abdel Magied, 1998). It consists of: a) Excision of the prepuce and glans clitoris, b) This is followed by a longitudinal medial incision or trimming of the margins of the upper (anterior) two thirds of the labia minora, c) The remaining part of the clitoris then becomes sandwiched between the incised or trimmed aspects of the labia minora, d) The two sides of the wound then become stitched to cover the remaining part of the clitoris. An aperture varying from the head of a match stick to the tip of finger is left for passage of urine and menstrual discharge.

There are several recognized forms of FGM which have recently been described by midwives and traditional birth attendants, TBA's (Abdel/ Magied et al, 2003). They reported two forms of pharaonic circumcision (Infibulation): i) Al Tagleed(; which includes the process of removal of clitoris from the base, removal of the.labia minora, removal of the labia majora, and then both sides of the skin are brought together and sutured in zigzag(VVVV). This type of suturing is described by Arabic adopted numbers as" Sabaa/Tamania" (1), leaving only small hole, about the size of the head of a match stick or a little bit more. This form of infibulation is practiced in western Sudan in Dar Fur and Kordoufan. ii) The second form is called Al Kurbage; this includes removal of the clitoris from the base, labia minora, and labia majora. The two sides of the skin of the labia majora are then sutured by thorns, leaving a hole about the size of the root of the feather of the pigeon's wing. This type is practiced in Eastern Sudan by the Hadandwa and other Biga tribes.

There are also two modifications of clitoridectomic genital mutilation which include two types; i) Al Makjour ([TEXT NOT REPRODUCIBLE IN ASCII]); which includes a process of cutting the head of the clitoris with the prepuce, splitting the rest of the clitoris longitudinally and introducing insulating material between the split surfaces of the clitoris until healing, ii) Al Ma'akouf ([TEXT NOT REPRODUCIBLE IN ASCII]); includes either cutting of the head of clitoris with the prepuce or leaving it as it is, then splitting the clitoris longitudinally, and then making ah incision in one of the labia minora, stitching one of the edges of one of the spilt sides of the clitoris with the incision in one of the labia minora. All these two forms are done at the level of clitoris.

Modification of the previously called Intermediate genital mutilation includes two forms of infibulation: i) Al Nus ([TEXT NOT REPRODUCIBLE IN ASCII]): the process includes removal of the upper half of the clitoris, removal of small portion of the upper parts of the labia minora, removal of upper parts of labia majora, sutring the wounds up to the vaginal orifice, ii) AL Masnad ([TEXT NOT REPRODUCIBLE IN ASCII]): it includes two processes: a) removal of clitoris from the base and suturing to stop hemorrhage, making incision in the upper parts of the labia minora and suturing, making longitudinal incisions along the labia majora from the lower parts till half way and suturing the wound till after the vaginal opening, leaving a small hole midway above the vaginal opening, b) removal of the clitoris from the base and suturing the wound, leaving the labia minora intact, and removal of the labia majora and then suturing leaving a small opening in the middle of the vulva.

Dilemma of Typology and Terminology

Typology:

WHO(1996) recognizes four degrees of FGM which are classified into four types:

Type I Excision of the prepuce, with or without excision of part or the entire clitoris.

Type II Excision of the clitoris with partial or total excision of the labia minora.

Type III Excision of part or all of the external genitalia and titching/narrowing of the vaginal opening (infibulation)

Type IV Pricking, piercing or incising of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue; scraping of tissue surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri cuts); introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it; and any other procedure that falls under the definition given above.

This classification (WHO, 1996), as well as WHO (2007) classification and the suggested typology seem non-specific, ambiguous and confusing when trying to fit in the types and forms of FGM practiced in Sudan. To begin with and for argument sake, let us agree that FGM includes any intended permanent damage to part/parts or all the external female genitalia, with particular emphasis on the girl child for non therapeutic purposes.

In the Sudan, some of the recent forms of clitoridectomies practiced in the Sudan might fit in WHO (1996 and 2007) Type I FGM. However, one alternative of Al Maakouf ([TEXT NOT REPRODUCIBLE IN ASCII]) form which does not involve excision, but longitudinal splitting of the whole clitoris (Abdel Magied et al, 2003), neither fits in Type I nor in Type IV. Type II is not practiced in the Sudan; hence none of the types and forms of FGM practiced in Sudan would fit in WHO (1996 and 2007) Type II. On the other hand the claimed Pharaonic ([TEXT NOT REPRODUCIBLE IN ASCII]) and intermediate ([TEXT NOT REPRODUCIBLE IN ASCII]) FGM practiced in Sudan, with all their forms, very well fit in Type III (infibulation). On the other hand, damages inflicted on different parts of the genitalia, mentioned under Type IV, are not practiced in the Sudan. Moreover, introduction of substances or herbs to tighten the vagina are only temporary cosmetic applications by adult women on themselves; hence should not be considered under FGM (Abdel Magied, 1998). "Introduction of harmful substances" as in type IV of WHO (2007) is ambiguous. Moreover, the re-infibulation or re-circumcision practiced in the Sudan is not catered for in both WHO classifications (WHO 1996 and WHO 2007). Consequently, the following classification of typology is suggested:

Type I (Clitoridectomy \[TEXT NOT REPRODUCIBLE IN ASCII.]): This includes all degrees of excision or damage inflicted on the clitoris. The nature and degree of excision of damage of the clitoris to be given the local name as "form" of clitoridectomy.

Type II (Infibulation \[TEXT NOT REPRODUCIBLE IN ASCII.]): This includes all degrees of excision of the genitalia beyond clitoridectomy to include other part/parts of the external genitalia, followed by suturing of not. The nature of the degree of damage of the genitalia to be given the local name as a "form" of infibulation.

Type III (Re-infibulation or Re-circumcision \[TEXT NOT REPRODUCIBLE IN ASCII.]): This includes de-circumcision and re-circumcision of an already infibulated woman and suturing as in original infibulations, after delivery or for cosmetic reasons.

Type IV (Unclassified): This includes all degrees of damage of part/parts of the genitalia that do not fall under Types I, II and III. The nature of and the degree of damage on the genitalia to be given the local name as a "form" of unclassified type IV FGM. Nonetheless, Elmusharaf et al, (2006) based on self reporting and clinical investigation of mutilated women and girls also challenged the validity of WHO (1996) classification and recommended revision of WHO typology.

Terminology:

Abdel Magied (1998) criticized some of the terminologies used in FGM literature and suggested the use of alternatives:

Mutilation and Female Circumcision:

The term "Female Genital Mutilation [TEXT NOT REPRODUCIBLE IN ASCII.]" (FGM) would be most appropriate to describe the state of a circumcised female irrespective of the degree of excision of the genitalia. The term "Female Circumcision [TEXT NOT REPRODUCIBLE IN ASCII.]" may also be used only when necessary.

Sunna circumcision:

The term "Sunna" implies linking FGM with Islamic religion. Therefore, the habitual use of the term "Sunna" when used in connection with FGM, especially in Muslim countries, implies recognition and perpetuation of the type as an Islamic practice. Therefore, the term "Sunna circumcision [TEXT NOT REPRODUCIBLE IN ASCII.]" should be abolished from the future FGM literature, except

when rectifying a situation." The suggested alternative term is "Clitoridectomic Circumcision" or synonymously "Clitoridectomy /[TEXT NOT REPRODUCIBLE IN ASCII.] [TEXT NOT REPRODUCIBLE IN ASCII.]. This would also be consistent with the typology which has been suggested earlier.

Infibulation versus Pharaonic Circumcision:

Since the origin of the practice is still controversial and to avoid unnecessary confusion, the term "Pharaonic Circumcision \[TEXT NOT REPRODUCIBLE IN ASCII.]"

should be abolished from future FGM literature. The alternative relevant term would be "Infibulation/[TEXT NOT REPRODUCIBLE IN ASCII.].

Abolition versus Eradication:

The word "eradication\[TEXT NOT REPRODUCIBLE IN ASCII.]" (extermination) implies a forceful physical act, while the word abolition deals with a holistic concept. Abolition on its own has always been used in connection with abolishment of slavery. Doubtless, FGM is a type of slavery specific to the female gender. It is, therefore, suggested that the term "Eradication" becomes excluded from future FGM literature and be replaced by the term "Abolition\[TEXT NOT REPRODUCIBLE IN ASCII.]". Consequently, the following suggested terminology would become relevant:

Abolition of FGM ([TEXT NOT REPRODUCIBLE IN ASCII.]) instead of Eradication of FGM ([TEXT NOT REPRODUCIBLE IN ASCII.]) : FGM Abolition Campaigns([TEXT NOT REPRODUCIBLE IN ASCII.]) instead of FGM Eradication Campaigns([TEXT NOT REPRODUCIBLE IN ASCII.]).

FGM Abolitionists ([TEXT NOT REPRODUCIBLE IN ASCII.]) to be adopted synonymously for Anti-FGM Campaigners and their supporters (Abdel Magied, 1998). State of Circumcision ([TEXT NOT REPRODUCIBLE IN ASCII.]):

When describing a female's status of circumcision, the term "Uncircumcised" should be one of three alternatives:

Uncircumcised ([TEXT NOT REPRODUCIBLE IN ASCII.]).

Clitoridectomised ([TEXT NOT REPRODUCIBLE IN ASCII.]).

Infibulated ([TEXT NOT REPRODUCIBLE IN ASCII.]).

Classifying the uncircumcised as one of the states of circumcision of a female, serves establishing a purposive definition. First, it will serve the purpose of recognition of her circumcision situation as the ideal state of circumcision of a female, worth of defending, protection and campaigning for. Second, it will help lifting the negative psychological stigma, resulting from the societal inferiorating attitude towards the uncircumcised female (Abdel Magied and Omran, 1999).

Conclusions:

Up to 1983, three described types of circumcision were practiced in Sudan. Those were namely: Pharaonic circumcision (infibulation), intermediate circumcision and Sunna circumcision (clitoridectomy). Recent forms of FGM introduced by traditional birth attendants (TBAs) and midisives include:

Forms of infibulation:

Al Tagleed.

Al Kurbag.

Sandwitch circumcision.

Al Nus circumcision.

Al Masnad circumcision.

Forms of clitoridectomy include:

Al Makjour.

Al Ma'akouf.

WHO (1996) typology has been criticized and challenged by Abdel Magied since 1998. Moreover, recently Al Musharf et al (2006) also challenged the validly of WHO (1996) typology for Sudan case. Accordingly, those authors recommended revision of WHO (1996) typology.

Nonetheless, the present article criticizes WHO (1996) and the recently (2007) proposed typology. Nonetheless, the article suggests a pertinent typology that suits Sudan case in particular and perhaps other cases.

The present article was also critical about some used FGM terminologies and hence suggested pertinent alternatives for the negative ones and recommended keeping the positive terminologies,

Arabic terms were designated for the different types and forms of FGM practiced in Sudan. Also suitable Arabic terms were designated for alternatives of negative terminologies as well as for the positive ones.

References:

Abdel Magied, Ahmed; El Balah, A. Sulima; Dawood, M. Kawther (2000): Re-Circumcision: The Hidden Devil of FGM in Sudan--Case Study on Sudanese Men of Different Socio-economic Status. The Ahfad Journal, Vol. 17, No. 2.

Abdel-Magied, A. (2008a).The Shift from Infibualtion to Clitrodectomy to Non-circumcision in Sudan. The Ahfad Journal, Vol 25, No. 1

Abdel Magied, Ahmed(2008b): Female Genital Mutilation in Sudan--A Human Rights Issue (Unpublished book).

Abdel-Magied, A. (1998). Some FGM Terminology Between the Negative and Positive Impacts. The Ahfad Journal, Vol. 15, No. 2.

Abdel-Magied, A. (2001). Overview and Assessment of Anti-FGM Efforts in Sudan. Khartoum Sudan: In Collaboration with UNICEF.

Abdel-Magied, A. (2007). Social Determinants and Developments in Policies and Practices Connected with Abolition of FGM in Sudan, in Collaboration with Social Research Center, American University, Cairo, Egypt (December, 2007)

Abdel-Magied, A., Al-Musharf, H., & Adam, I. (2003). Midwives, Traditional Birth Attendants (TBAs) and the Perpetuation of Female Genital Mutilation (FGM) in the Sudan. The Ahfad Journal, Vol 20, No. 2.

Abdel-Magied, A., Balah, S. A. E., & Dawood, K. M. (2000). Re-circumcision: The Hidden Devil of FGM in Sudan.--Case Study on Sudanese Women of Different Socio-economic Status. The Ahfad Journal, Vol. 17, No. I.

Abdel-Magied, A., & Omran, M. (1999) The Uncircumcised Female in an Ideal State of Circumcision. The Ahfad Journal, Vol. 16 No. 2.

Abdel-Magied, A., & Musa, S. (2002). Sexual Experiences and Psychosexual Effect of Female Genital Mutilation (FGM) or Female Circumcision (FC) on Sudanese Women. The Ahfad Journal, Vol. 19, No. 1.

Abu-Bakr, S. (1982). Circumcision and Infibulation in The Sudan. No. 2 Volume 2, 162-178. In T. Baasher, R. H. O. Bannerman, H. Rashwan & I. Sharaf (Eds.), Traditional Practices Affecting the Health of Women and Children (Vol. 2, pp. 18-144). Alexendria: WHO\EMRO Technical Publication

Baasher, T. (1982).. Psycho-social Aspects of Female Circumcision, WHO Seminar on Traditional Practices Affecting the Health of Women and Children. In T. Baasher, R. H. O. Bannerman, H. Rushwan & I. Sharaf (Eds.), Traditional Practices Affecting the Health of Women and Children (Vol. 2, pp. 162-178.). Alexandria: WHO\EMRO Technical Publication

Bridie, E. D.; Lorenzen, A. E.; Cruickshank, A.; Hovell, J. S.; MacDonald, D. R.; Ali Bedri.; Abdel Haleem Mohamed;al Tigany AlMahi and Abd Allah Abu Shamma. (1945). Female Circumcision in Anglo-Egyptain Sudan: McCorcodale Printing Press S.G. 1185CS. 5000.6\51. Department of Statistics, Ministry of Economic and National Planning, Khartoum-Sudan (1991): Sudan Demographic and Health Survey(SDHS).

El-Dareer, A. (1983). Women, Why do you weep? Circumcision and its Consequences. Zed Press, London.

El Fadil, Saad (2000): Gynecological Complications of Female Genital Mutilation (FGM). Proceedings of the World Congress Obstetrics and Gynecology. Washington D.C. (September, 2000).

Elmusharaf, S., Elhadi, N., & Almorth, L. (2006). Reliability of self reported form of female genital mutilation and WHO classification: cross sectional study. British Medical Journal, 333(7559), 124-127.

Modawi, S. (1982). The Obstetrical and Gynecological Aspects of Female Circumcision in the Sudan. In Baasher, T.; Bannerman. R. H. O., Rushwan H. & Sharaf. I (Eds.), Traditional Practices Affecting the Health of Women and Children (Vol. 2, pp. 335-341). ALexandria: World Health Organization, Regional Office for the Eastern Mditerranean.

Rahman, A., & Toubia, N. (2000). Female Genital Mutilation Aguide to Laws and Policies World Wide. Zed Books, London and New York.

Rushwan, H., Slot, C., Dareer, A. E., & Bushra, N. (1983). Female Circumcision in the Sudan; Prevalence, Complications, Attitudes and Changes: Faculty of Medicine, University of Khartoum.

Rushwan, H. (1994). The Health Consequences of Female Genital Mutilation from a Health Providers Perspective. Paper presented at the 47th World Health Assembly. The Briefing Session on Female Genital Mutilation, Geneva.

Shandall, A. A. (1967). Circumcision and Infibulation of Females; Ageneral Consideration of the Problem and A Clinical Study of the Complications in Sudanese Women. Sudan Medical Journal S.M.J, Vol 5 No. 4. 178-212.

WHO, (1996). Female Genital Mutilation. A Joint Statement WHOUNICEF\ UNFPA. WHO Publications, 3.

WHO (2007): WHO FGM Modified Typology--Notes on the Classification of FGM.

(1) Sabaa = seven in Arabic / Tamania = eight in Arabic

Abdel Magied Ahmed (School of Health Sciences, Ahfad University for Women)
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Author:Ahmed, Abdel Magied
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Date:Jun 1, 2008
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