Description of the different types of female genital mutilation

Female genital mutilation is usually performed by traditional practitioners, generally elderly women in the community specially designated for this task, or traditional birth attendants. In some countries, health professionals trained midwives and physicians are increasingly performing female genital mutilation. In Egypt, for example, preliminary results from the 1995 Demographic and Health Survey indicate that the proportion of women who reported having been circumcised by a doctor was 13%. In contrast, among their most recently circumcised daughters, 46% had been circumcised by a doctor.

The procedures employed in each type of female genital mutilation are described below.

Type I

In the commonest form of this procedure the clitoris is held between the thumb and index finger, pulled out and amputated with one stroke of a sharp object. Bleeding is usually stopped by packing the wound with gauzes or other substances and applying a pressure bandage. Modern trained practitioners may insert one or two stitches around the clitoral artery to stop the bleeding.

Type II

The degree of severity of cutting varies considerably in this type. Commonly the clitoris is amputated as described above and the labia minora are partially or totally removed, often with the same stroke. Bleeding is stopped with packing and bandages or by a few circular stitches which may or may not cover the urethra and part of the vaginal opening. There are reported cases of extensive excisions which heal with fusion of the raw surfaces, resulting in pseudo-infibulation even though there has been no stitching. Types I and II generally account for 80-85% of all female genital mutilation, although the proportion may vary greatly from country to country.

Type III

The amount of tissue removed is extensive. The most extreme form involves the complete removal of the clitoris and labia minora, together with the inner surface of the labia majora. The raw edges of the labia majora are brought together to fuse, using thorns, poultices or stitching to hold them in place, and the legs are tied together for 2-6 weeks. The healed scar creates a hood of skin which covers the urethra and part or most of the vagina, and which acts as a physical barrier to intercourse. A small opening is left at the back to allow for the flow of urine and menstrual blood. The opening is surrounded by skin and scar tissue and is usually 2-3 cm in diameter but may be as small as the head of a matchstick.

If after infibulation the posterior opening is large enough, sexual intercourse can take place after gradual dilatation, which may take weeks, months or, in some recorded cases, as long as two years. If the opening is too small to start the dilatation, recutting (defibulation) before intercourse is traditionally undertaken by the husband or one of his female relatives using a sharp knife or a piece of glass. Modern couples may seek the assistance of a trained health professional, although this is done in secrecy, possibly because it might undermine the social image of the man's virility.

In almost all cases of infibulation and in many cases of severe excision, defibulation must also be performed during childbirth to allow exit of the fetal head without tearing the surrounding scar tissue. If no experienced birth attendant is available to perform defibulation, fetal and/or maternal complications may occur because of obstructed labour or perineal tears. Traditionally, "re-infibulation" is performed after the woman gives birth. The raw edges are stitched together again to create a small posterior opening, often the same size as that which existed before marriage. This is done to create the illusion of virginity, since a tight vaginal opening is culturally perceived as more pleasurable to the man. Because of the extent of both the initial and repeated cutting and suturing, the physical, sexual and psychological effects of infibulation are greater and longer-lasting than for other types of female genital mutilation.

Although only an estimated 15-20% of all women who experience genital mutilation undergo type III, in certain countries such as Djibouti, Somalia and Sudan the proportion is 80-90%. Infibulation is practised on a smaller scale in parts of Egypt, Eritrea, Ethiopia, Gambia, Kenya and Mali, and may occur in other communities where information is lacking or still incomplete.

Type IV

Type IV female genital mutilation encompasses a variety of procedures, most of which are self-explanatory. Two procedures are described here.

The term "angurya cuts" describes the scraping of the tissue around the vaginal opening. "Gishiri cuts" are posterior (or backward) cuts from the vagina into the perineum as an attempt to increase the vaginal outlet to relieve obstructed labour. They often result in vesicovaginal fistulae and damage to the anal sphincter.

There is no mention of removing only the clitoral hood as described by Dr. Nowa Omoigui.

While the clitoris is the analogue of the glans penis, it should not be assumed that it is innervated in the same way. The evidence is that the glans clitoris is far more sensitive than the glans penis, and that the nearest analogue to the clitoris in sensitivity is the male foreskin.

Among the Bedouins of Israel none of the 37 women examined was mutilated. They all had only small scars on the prepuce of the clitoris and/or the upper 1 cm of the labia minora near the clitoral prepuce.

Asali A, Khamaysi N, Aburabia Y, Letzer S, Halihal B, Sadovsky M, et al.
Ritual female genital surgery among Bedouin in Israel.
Arch Sex Behav 1995;24:571-5.

Upon physical examination of the other group, Ethiopian Jews, which resides now in Israel and performed female genital mutilation in Ethiopia, 63% of the women, who all claimed to have been circumcised, did not even have a scar! 20% had scars, in 7%, one square centimeter of the labia minora was removed from beneath the clitoris and only 10% demonstrated a real and severe form of female genital mutilation, total amputation of the clitoris.

Grisaru N, Letzer S, Belmaker RH.
Ritual Female Genital Surgery Among Ethiopian Jews.
Arch Sex Behav 1997;26:211-5.

This does not speak about the severity of FGM in any other community, and it does not in any way mitigate the human rights abuse of FGM.