The World Health Organization (WHO) defines Female Genital Mutilation as a practice of altering or harming the female genitalia for non-medical reasons. FGM is classified into 4 main types, of which type IV generally includes all procedures that do not fall under the first 3 types (partial or total removal of the clitoral gland, excision of small or large labia and infibulation) for example: puncture , piercing, incision, scarification and cauterization. In addition, other types of female genital alteration, for non-medical reasons, are currently not recognized by WHO as FGM (eg, labia stretching).
FGM IV is often less well known than other types because it is the subject of less research and reports. As a result, practitioners may find it difficult to identify and understand the different forms and complexities of these practices.
In the recent debate on Female Genital Mutilation Type IV and other forms of female genital alteration, we asked the following question :
Do you have information on female genital mutilation type IV and / or (undocumented) types of female genital alterations, practiced in the communities where you live / work or research about it?
You will find a summary of the contributions in this section.
The thematic note addressed different types IV FGM recognized by WHO:
- genital piercing
- vaginal incisions, scrapes, hymenotomies, including:
- Dangouria / Haabize, Angurya and Gishiri in Niger and Nigeria« removal of warts » (southieutes) in Senegal
- incisions to introduce herbs in South Africa
As well as other types of female genital alterations not currently included in the WHO typology:
- Elongation, stretching of the labia
- vaginal drying
- clitoral massage
- cosmetic genital surgeries
- What are the types of undocumented female genital alterations practiced in the communities where you live / work?
- What can be done to raise public awareness about FGM Type IV and other types of harmful genital alterations and prevent them?
- What do you think of the position of the international community on the different types of genital alterations and female genital mutilation type IV? Should other practices be covered by the typology?
- In your opinion and according to your experience, are all types of genital alterations harmful to women and should be considered as FGM? Can certain types of genital alterations have positive effects for women who experience them?
We were able to focus on different practices, with the help of experts, including the practice of « removal of southieutes », with Fatou Kebe, Senegalese sociologist, and labia stretching/elongation, with Emma Claudine Ntirenganya, Rwandan journalist.
Angurya et Gishiri
A member from Nigeria provided information on two types of FGM IV practiced in Nigeria: angurya and gishiri.
Technically, gishiri cuts are not made on external female genitalia, but are classified as FGM by stakeholders in Nigeria. Gishiri is a surgical cut performed on the anterior or posterior vaginal wall using a razor blade or knife. It is said to be mainly used to treat various conditions, including the obstruction of a woman in labor, infertility, amenorrhea (absence of menstruation) and vulvar itching. Angurya cuts are an excision of the hymen (hymenectomy or scraping of the tissue surrounding the vaginal opening) when it is considered too thick. It is generally practical for baby girls shortly after birth and is thought to facilitate penetration when a husband and wife consume their marriage (this is based on the cultural expectation that a woman would have her first sexual intercourse wedding). The majority of the cases of angurya described are « treatment » of girls who are victims of child marriage and women forced to have sex or physical / sexual violence by their husbands.
« Removal of sothieutes », Senegal
Fatou Kebe, sociologist, has just conducted an exploratory study on a practice that has always existed in Senegal of cutting into the vagina of girls who have just married and are having difficulties having sex with their husband. The cut is justified by a supposed « removal of genital warts » or (Sothieutes in Wolof). It is often practiced by the Wolofs but also by the Soces, in Dakar. Most female practitioners (or cutters) are members of this ethnic group. The latest ANSD surveys (National Agency for Statistics and Demography) have shown that Wolofs practicing FGM are estimated at (- 1%).
Health professionals deny the existence of « sothieutes » on the scientific plane, the practitioners on the other hand persist and confirm their existence or the interest of doing a much more in-depth study with a larger sample and diversity to triangulate.
The practice is explained in this video that the CoP FGM created with Fatou Kébé as part of the FGM IV discussion
Pressure on the clitoris, Nigeria and West Africa
A member told us that in Nigeria clitoral massage or « pressing » is sometimes performed as a « tarnsition » from cutting (FGM I or II). This massage is usually done with warm water or Vaseline. This pressing/massage is done for the same reasons as cutting e.g. decrease sensitivity to reduce sexual urge and prevent promiscuity/extra marital or pre-marital sex and for aesthetics (prevent clitoris/labia minora from growing and protruding out of the labia majora). Some health workers were reported to encourage this transition as a non-harmful alternative to cutting. Anti-MGF/C advocates (from the government and civil society) describe it as Type IV MGF and strongly discourage this practice, while some obstetricians and gynaecologists, have challenged them stating that it is benign, has no physical effect and cannot be classified as type IV FGM/C.
During the discussion, another member of the CoP informed us about the use of Alum stone in West Africa to press on the vulva. The stone causes a momentary contraction of the vagina, which can give the appearance of virginity to a woman who has already had sex. It is claimed that if a woman regularly uses alum stone, the walls of the vagina become rigid and can tear when giving birth. This stone destroys the vaginal flora that helps protect women against sexually transmitted diseases. Moreover, as the powder of the stone has the consistency of sand, it inevitably causes irritation that can lead to severe cases of vaginitis.
The piercing of the clitoris or surrounding tissues, the pricking, is a procedure in which the skin is pricked with a sharp object. Blood may flow but no tissue is removed and no sewing is done. The practice is classified by the WHO as Type IV FGM. (WHO, 2008)
« Pricking » is practiced as a form that can replace a more extensive excision – and is thus sometimes promoted as a « risk reduction strategy », for example in Somalia, Guinea …
A participant in the discussion told us that Stop FGM Middle East & Asia is bringing together activists from several countries where pricking is practiced. According to his experience, when one refers to pricking to define a practice, this is usually not the case. An Indonesian study has shown that pricking occurs only in 3% of cases.
A Somali member explained that it is difficult to measure pricking, since there are a very large number of different definitions of what a « light » cut would imply. Some people think that it is a « light form » as soon as there is no suture. Some practitioners perform the infibulations by joining the labia. It is in this way that the activist herself has suffered a mutilation with infibulation considered as a « light form » by her family.
Harmful practices in the MENA region
Isma Benboulerbah, Programme officer at END FGM Eu Network, shared information on procedures aiming at a partagé les procédures visent à modifier les organes génitaux des femmes et à contrôler leur sexualité dans la région MENA, en focalisant principalement sur l’Algérie, le Maroc et la Tunisie.
As mentioned in the COP document, the hymenoplasty is classified as a “aesthetical genital surgeries and procedures” (p.16) and defined as “reconstruction of the hymen”. However, I would like to raise this practise as a controversial and potentially dangerous surgical procedure on women’s lives based on ethical, social and cultural point of views.
In several communities, virginity and marriage are tied to each other. Virginity is key to a successful, blessed, honorific and socially well-approved marriage. Marriage is the main objective and greatest achievement for young girls to be accepted and treated as a respected woman within the family and at a larger scale, the community.
These social norms don’t prevent young women and women from having sexual intercourses outside of marriage. However, when they decide to marry they quickly realise the pressure they are facing, and that they must save their “honour” by bleeding on their wedding night. – The misconception that several communities share to the next generation on the sheets stained with blood must be discussed in a separated conversation, that’s why I’ll only focus on the hymenoplasty. –
More and more women are forced by their families (and sometimes mothers – sisters – cousins) to have the surgery done or hide from their relatives to have the surgery done. The surgery isn’t easy, and it isn’t a secret for Arab women that this secret is a matter of life of death with communities. I personally know a woman who had the surgery done even if she was a virgin. She needed the visual proof of her virginity and had to modify her vulva to let appear a “fake” hymen. The most controversial part is for women who decide to have an hymenoplasty after being raped. Hymenoplasty isn’t only an aesthetical surgery, it is a tool to control women’s sexuality and their identity as sexual being. Their decisions are judged as stupid, dangerous, shameful and they must turn the page and feel guilty about their choices.
Vagina whitening – Vagina bleaching
Women are facing more and more pressure when it comes to the aspect, texture, colour of the vulva and vagina area. Darker skin tones are judged as “dirty”, “disgusting” and a “lighter-coloured” vulva is promoted as the norm. The first time I heard about this practice it was in 2018, when 16-17-year-old teenagers told me about this new lightening treatments.
It is practised in different ways: lightening creams or laser (which is supposed to remove permanently darker coloured tissue in the vulva area). The consequences on women’s bodies and health are serious: pain during sexual intercourse, vaginal laxity, vaginal burns, scarring, chronic pain etc. The US Food and drug administration has been warning against the use of “vagina bleaching” – “rejuvenation” product.
Rbat – tasfeh practice
In North Africa, virginity and “social honour” are linked, and women are experiencing social pressure from within their families, communities and even at governmental state to avoid sexual intercourses outside marriage. Hymen is the living symbol of a soon-to-be woman’s purity and is often checked by family members before the wedding night (virginity certificate) or after the wedding night with the traditional “dance with the bleeding sheet” that is a proof of their purity.
Before this possibility of accessing the social rank of a woman, a traditional practise for young girl still exists in Algeria, Morocco and Tunisia: rbat or tesfah, “the closed vagina”. Tesfah is considered a psychological violence against women and girls, but in some cases the young girls are also forced to have several non-medicalised checks of their vaginas to ensure their virginity. Tesfah done on young girls before puberty and is a spiritual practise. Girls are taken to a qabla (traditional midwife) and must repeat 7 times “wald el nas khet wa ana haït” which can be translated as “People’s son is a string and I’m a wall”. This sentence is highly sexualised and symbolises the incapacity for the new marbouta (knotted) – msakra (closed) girl to have sexual intercourses outside of marriage. It can only be undone before the wedding and by saying “wald el nas haït wa an khet” meaning “People’s son is a wall and I’m a string”.
The ritual is practised in different ways, but always leads with the cutting of the young girl: either on the upper part of her right thigh (they put khol on the incisions, so it becomes a tattoo), on her knee or in South of Algeria (with the Reguibet tribe) on the clitoris. The Reguibet practise the Tesfah on young girls: they attach them, legs and arms spread. They cut the clitoris and put henne on it, while repeating the sentence. The marks, the incisions and the ceremony are a symbol of the social pressure the young girls will experience since she is the carrier of the family’s honour.
Harig – Burning the intimate areas
In Algeria, and other countries, families spent lots of time analysing the behaviour of young girls. A list of names exists to classify them and to find adapted remedies.
One of them consists of putting harissa smashed hot pepper or raw hot pepper on the genital area of young girls who are extravert, overreactive or not shy. We say “klatha douda” which literally means that she was eaten by a worn. However, “klatha douda” often means that “the spirit of the devil is in her” and the only way to force her to behave “in a normal way” is to burn her clitoris and to put the fire out. Some women are punished this way several times, and they also had pressure applied on the clitoris while the harissa was put on their clitoris.
Some forms are no longer in the WHO definition of FGM type IV. It was decided to focus on « cutting » because of its obvious consequences.
The reasons were:
1. There was not enough research on the subject and not wanting the supporters of the stretch to destroy the efforts already made, especially in the field of FGM ;
2. Communities such as those in the central and western region have not been sensitized on the issue; and some especially from the central region were very protective of this culture ;
3. The obvious dangerous impact of the cut could be used as a springboard to tackle other practices such as stretching, application of weeds to shrink or dry out the passage and others.
Emma-Claudine Ntirenganya, journalist shared her professional and personal experiences of labia elongation in Rwanda. According to her, the Rwandan society where she grew up educates girls to practice labia stretching for the satisfaction and pleasure of their future husband.
« I practiced it myself, and I also received various questions as part of my work from the women in my audience. «
Emma-Claudine considers that labia stretching should not be encouraged, because several women suffer in their marriage, either because they did not do it, and in some cases because they have it made. Moreover, it is not a practice that girls practice because they are happy and proud to do, but because society puts pressure on them to do it at all costs. « Is not it appropriate that girls and women have the right to their bodies and do what they want to do without being judged, » she asked.
« If you talk to Rwandan women, some will tell you that the practice of stretching your labia was fun and acceptable, while others will tell you that it was difficult, imposed and disgusting. The latter will add that they have done so only to ensure that they are not rejected by their future husbands. Few Rwandan women have not done this practice. And with the new generation of Rwandan girls now in college and university, most of them did not do it because they did not have anyone to educate them and others think it was is one of the outdated cultural practices. «
Main concerns about labia stretching:
• Stretching lips is not something you do for a day or two, a week or two. It is a practice that can take years to achieve the desired results. In fact, it’s a burden!
• Use of various plants as well as cow butter for fast results. The small lips become irritating and it hurts.
• Risks of STI transmission when girls practice « gukurakuza » (touch their labia).
• When girls are educated to stretch the labia, they are told that if they do not do it their husbands will reject them, it is a matter of pleasure for men.
• At the same time, sexuality in Rwanda is very much based on the fact that women have pleasure and reach female ejaculation. Women are told that they can not achieve this ejaculation if they have not stretched their lips and that, if they do not reach female ejaculation, their husbands could cheat them with other women who they did this practice.
• With the new generation, most Rwandan boys still want to marry a girl who has stretched their labia, while most girls their age have not done so and do not even want to do it. This is one of the sources of couple conflict that may occur in the near future.
• Many women who have not stretched their labia are harassed by their husbands who ask them to do so even if they have been married for years and have had children
• There are also some cases of women stretching their labia, but after their marriage, their husbands asked them to have their lips cut.
According to Emma-Claudine the « benefits » attributed to the stretching of the labia would rather be « the result of female hormones, the result of love in the couple, desire and satisfaction of the partner, experience and abilities the partner, as well as a healthy mental health, ready to engage in a loving relationship including making love. «
Difficulties with identification of type IV FGM, UK and Australia
Two members, from the UK and from Australia, shared examples of ongoing court cases regarding « pricking » or other type IV FGM.
In the UK an ongoing trial concerns a possible type IV FGM in a small girl. The case highlights the difficulties that the court has had in definining whether FGM took place and whether significant harm was caused to the child. Several medical experts undertook examinations but did not agree on whether or not the child had been cut or what type of FGM itw as.
“Pediatricians seeing children for suspected or alleged sexual abuse are experienced in genital examination but may be unfamiliar with the different types of FGM particularly where physical signs are minimal or absent. Obstetricians, gynaecologists and midwives are expected to be more familiar with the health implications of FGM although this is not always the case. In addition, as adult clinicians, they are not generally trained in the examination of children and are less used to working with social care or the police.
A lack of rigorous UK research combined with secrecy surrounding the procedure means there is scant knowledge about the health implications of FGM in children. Little is known on attitudes to or prevalence of FGM type IV among diaspora communities in the UK and the impact of a referral on the family as mandated is unknown.
FGM referrals to the children’s safeguarding clinic and paediatric gynaecology services had increased over recent years. As a result, the UK’s first and still only paediatric FGM service was established in 2014 comprising a monthly multidisciplinary clinic with input from child psychotherapy and specialist nursing.
In the UK type IV FGM is heavily under-researched and reported; practitioners also find it difficult to identify and understand the different forms and complexities around type IV FGM. Although much work has been done to raise awareness of FGM, the focus on type IV procedures is limited and there needs to be much more research to interrogate the different forms of type IV FGM.”
Similarly, in Australia a case against a mother and a religious leader charged with having FGM type IV performed on two girls then aged 6-7 was brought to the High Court as an obstetrician who examined the girls could not detect any evidence of cutting. The High Court agreed that the law banning FGM encompasses all types including “someone simply cutting or nicking a girl’s clitoris.”
FGM, consent, aesthetical genital surgeries
An increasing number of adult women undergo genital surgery, which could be regarded Type IV and sometimes Type I FGM. Anne-Marie Middelburg was invited to speak at a conference organized by plastic surgeons and gynecologists in Germany. In the program were included six plastic surgery sessions to watch live. The hearing witnessed a reduction in the foreskin clitoris, a tightening of the vagina and some lip reductions. While the surgeon operated these women, the public could follow the operation live on large screens and could even ask him questions. « FGM of all kinds, including type IV, is considered a violation of human rights and is criminalized. Even ‘pricking’ is considered FGM. But these types of genital surgery (some of which were quite serious) are not considered a violation of human rights, are not criminalized and occur on a large scale. «
Some women in Liberia, Sierra Leone, The Gambia and Kenya are also campaigning for adult FGM / C. According to them, once a girl is over 18, she should have the right to undergo (a « light » form) FGM.
RESSOURCES – shared by members
Tasfia, vaginal bleaching
“FDA Warns Against Use of Energy-Based Devices to Perform Vaginal ‘Rejuvenation’ or Vaginal Cosmetic Procedures: FDA Safety Communication”, 30 July 2018, Available online: https://www.fda.gov/medical-devices/safety-communications/fda-warns-against-use-energy-based-devices-perform-vaginal-rejuvenation-or-vaginal-cosmetic
Federal Register, “Skin bleaching drug products for over-the-counter Human use; Proposed rule”, Vol. 71, No. 167, 29 August 2006, Available online: https://www.govinfo.gov/content/pkg/FR-2006-08-29/pdf/E6-14263.pdf
FERHATI Berkahoum, « Les clôtures symboliques des Algériennes : la virginité ou l’honneur social en question », Clio, p. 169-180, Available online : https://journals.openedition.org/clio/6452.
BEN Dridi Ibtissem, « « Est-ce que ça marche ? », A propos du tasfih, rituel protecteur de la virginité des jeunes filles tunisiennes », L’année du Maghreb, p. 99-122, Available online : https://journals.openedition.org/anneemaghreb/826asfe
Aesthetical genital surgeries
Runacres, S. A., & Wood, P. L. (2016). Cosmeticlabiaplastyin an adolescent population. Journal of pediatricand adolescent gynecology, 29(3), 218-222.
Shaw, D., Lefebvre, G., Bouchard, C., Shapiro, J., Blake, J., Allen, L., … & Awadalla, A. (2013). Chirurgie esthétique génitale chez la femme. Journal of Obstetricsand GynaecologyCanada, 35(12), 1113-1114.
Smarrito, S. (2017). Classification of labiaminora hypertrophy: A retrospectivestudyof 100 patient cases. JPRAS Open, 13, 81-91.
Yurteri-Kaplan, L. A., Miranne, J. M., & Iglesia, C. B. (2014). Vulvaranatomyand labiaminoraplasty. International urogynecologyjournal, 25(6), 841-843.
Oranges, CM, Sisti, A. et Sisti, G. (2015). Techniques de réduction de la Labiaminora: une revue complète de la littérature. Journal de chirurgie esthétique , 35 (4), 419-431.
Ouar, N., Guillier, D., Moris, V., Revol, M., Francois, C., & Cristofari, S. (2017). Complications postopératoires des nymphoplastiesde réduction. Étude comparative rétrospective entre résections longitudinale et cunéiforme. Annales de Chirurgie Plastique Esthétique, 62 (3), 219-223.
Obstetrical genital violence – The “husband stitch”, Canada
LE POINT DU MARI: DES MÈRES QUÉBÉCOISES SE FONT-ELLES RECOUDRE SANS LEUR CONSENTEMENT ? https://urbania.ca/article/le-point-du-mari-des-meres-quebecoises-se-font-elles-recoudre-sans-leur-consentement/?fbclid=IwAR3DZzLVtGPHawnTJnM-9ImZmCgy1ScmoTbb0FCQyN8o6yb5XdK09leVdgs