FGM/C is perceived to be entrenched in custom and tradition
As expected in the study context, respondents considered FGM/C an important cultural obligation. Across the board, the compulsion to adhere to community customs and traditions was revealed to be mothers’, particularly those who were older, most important motivation for cutting their daughters. Findings from the IDIs and FGDs suggest that mothers see FGM/C as an essential practice and therefore end up cutting their daughters without critically assessing their decision to do so. Pressure from female family members and other community members may further reinforce the practice. These views are highlighted in the following quotes;
“We grew up finding our grandmothers, mothers and all people circumcising; [it is] a tradition that you have to do.” Mother, Cairo
“Circumcision has no advantages, but we grew up and found our folks that way.” Mother, Cairo
“I circumcised my daughters [so] that my conscience would be in peace, to be like all other people.” Nurse, Assiut
As further testament to the extent of social pressure faced by mothers, many participants were not particular about the type or extent of the cut. They accepted the removal of just a tiny part of the external genitalia for their daughters to be considered “cut” as illustrated in the following quote;
“I brought the doctor to my home and he said ‘no need’, so I replied saying ‘just for the people here, take a tiny scrap for the talks.” Nurse, Assiut
The mystery client exercise unearthed similar findings, as demonstrated by this quote from a male physician in Al Gharbeya;
“We cut her. What’s the problem? There are no problems from circumcision now, bring your daughter today and if needed I will cut her immediately tomorrow. We can cut a small part just for her mother-in-law.”
Narratives from study participants suggest that health practitioners are not immune to the societal pressure to perform FGM/C on their clients. This pressure is brought about by the perceived entrenchment of this customary practice. In rural areas in particular, refusal to perform FGM/C by health providers (especially recent graduates) was reported to pose reputational risk and was said to result in a loss of community trust. Physicians who refuse to perform FGM/C were reported to have lower client loads and, therefore, reduced income. As a male physician in Cairo explained;
“Doctors in the villages practice a lot (of circumcision) because if he does not do it, the people will be upset with him and no one will come to him, even for a cough. He will be marked.”
Beyond reputational risk, health practitioners pointed out that they were also members of the communities in which they practiced. This reality posed challenges for maintaining professional distance from the customary entrenchment of FGM/C. Despite having a medical education, physicians themselves, especially those who were from rural areas, were also affected by the prevailing cultural norms and beliefs of their community. The pressure to conform to cultural norms sometimes meant that they performed FGM/C although they were aware about the medical risks involved. The following quotes from health providers illustrate these points;
“Doctors are part of the people, part of society and people who are convinced do it in particular because we didn’t come across it in our medical education.” Male physician, Cairo
“When my daughter was 12, I know that this is not good, but I have fears for her and people would talk [gossip]. I refused to inspect her, so I told her I am going to take you to a colleague of mine just to have a look. She was crying all the way from home until we went to the doctor and asked me, “Mama, what are the advantages of circumcision?” Look, I am going to tell you something. Sometimes you know that this thing is wrong, but you do it out of fear. Do you understand?” Female physician, Cairo
Performing FGM/C has financial benefits for providers
According to some physicians, financial benefits were the most important motivator for physicians to perform FGM/C. The narratives from physicians suggested that those who performed the practice due to the financial benefit may understand its hazards and illegality, but still perform it in secrecy. These views are articulated in the following quotations;
“More than 50 percent of the doctors in the rural areas do these things for several reasons. First for financial gains and trust of people that he [the doctor] responded to their needs and they will come to him for other matters. And if he does not do it he will be stigmatized.” Male physician, Cairo
“Believe me, FGM/C in Egypt is not because people ask for it, but it is driven by physicians and nurses. I swear if it wasn’t for the financial benefits out of it, no girl would have been circumcised in Egypt. People get easily convinced by health care providers.” Female physician, Al Gharbeya
When mystery clients asked about the cost and the charges for FGM/C they were given varying amounts ranging from 250 Egyptian Pounds (LE) (US$14) to 1500 LE (US$85). The requested charges were higher for older girls. Physicians noted that they ask for high prices because of the cost of the anesthesia and hospital fees, when performed in a private hospital. As illustrated in the following quote from a male physician in Al Gharbeya, the costs were also reportedly affected by how extensive the procedure was, “When I see her (examine her) and I know how much I will remove, I will tell you how much I will take”.
Some providers view the performance of FGM/C as their religious duty
Providers noted that in some cases, providers’ religious convictions around FGM/C influenced their decision to perform FGM/C. They noted that, in some cases, physicians who are convinced about its importance may perform it for women during delivery, even without being requested to do so.
“There are people who do it (FGM/C) and are strongly convinced about it, people who are (I don’t want to classify them) Muslim Brotherhood, Sunni, especially the Sunnis, those with beards, and those religiously fanatic, these ones do it out of religious conviction, even if they do not take money. The one who does it for money can cut ten people and the one who does it for religion, can cut a hundred.” Male physician, Al Gharbeya
Some physicians in Assiut and Al Gharbeya believed that performing FGM/C was a religious obligation despite being condemned by Al-Azhar (Highest Muslim Religious Authority). Other physicians considered FGM/C as “Sunna” – that is, not mandatory, while others refuted a religious basis for FGM/C. Physicians based in Assiut and Al Gharbeya were more likely to believe that there were religious indications for performing FGM/C than physicians based in the other study sites, which may reflect the more conservative culture in Upper Egypt.
“If it [circumcision] were forbidden, why was it done originally? Okay, why was it done in many Islamic countries? If it was forbidden and haram [religiously wrong], why was it done from the time of my grandmother and your grandmother before us?” Female physician, Al Gharbeya
As illustrated by the following quotes, some physicians and nurses also believed that “Sunna circumcision” is of the first degree and did not have any negative consequences on marital sexual relations.
“I may perform FGM/C when needed for the girl, and to avoid the problems which would happen if she was not cut. The Muslim Prophet, when asked about female circumcision, said shorten but don’t over-excise, which means performing a minor cut for the cosmetic appearance.” Female physician, Al Gharbeya
“It is okay to cut a small part, just for beautifying the clitoris, and the Prophet said shorten but don’t over-excise, which means that we shouldn’t cut much.” Nurse, Assiut
FGM/C is not included in the medical training of health care providers
Despite the high prevalence of FGM/C in Egypt, physicians indicated that FGM/C did not feature in their medical school curriculum or training. Almost all of them mentioned that they only studied the anatomy of the female genital system. Only a few physicians stated they had some exposure to the prevalence of FGM/C in Egypt in the public health curriculum or the reproductive health postgraduate curriculum. As intimated by a male physician in Assiut, “I never took anything deep about FGM/C. We took the anatomy of the female system. That is the information I have”.
Given the lack of medical training for performing FGM/C, providers who perform it mentioned that they learned about the practice from their colleagues. They also mentioned that physicians used different techniques because they had no reference. As a male physician in Assiut noted, “Nothing in medicine taught us how to [perform FGM/C], and I didn’t study it during my years of education. Whether cutting from the right or from the left, it is personal”.
Most physicians and nurses further indicated that except for training on the anatomy and physiology of the female genital organs, they had received no training on sexual health. Their knowledge about sexual health was limited to what they had learned from self-reading and internet searches. These views are illustrated in the following quotes from health care providers;
“We had obstetrics/gynecology in the fourth year of medical school and it was one lecture on sex and that year this lecture was removed for political reasons.” Male physician, Assiut
“We took physiology and histology but not sexuality. In Assiut University, they talked about the science of orgasm and functions but not sexuality.” Male physician, Assiut
“What I know about sexual health comes from the time I was in secondary school when the ‘Always’ (sanitary pads) company came and gave us a brochure on periods, the body, the monthly ova and drawing of the uterus. That is it. I still have a copy [of the brochure].” Nurse, Al Gharbeya
Few physicians had correct knowledge that sexual health is a broad term encompassing physical and psychosexual aspects, while most providers mentioned incorrect definitions of sexual health. Most of them stated that sexual health only encompasses “sexual intercourse”. Unsurprisingly, therefore, some physicians referred erroneously to the presence of smegma between labia minora and labia majora as an indication for FGM/C (i.e., cutting the labia minora), as it could be a predisposing factor for cancer. In line with this gap in sexual health training, physicians felt ill-equipped to provide counseling on sexuality and sexual health despite the admitted demand for it from their patients. Physicians spoke of their experiences handling clients with sexual health problems. Some stated that they were too embarrassed to discuss sexual health issues with their clients, mentioning that they usually used medical management and failed to provide any counseling.
“We are not prepared at all. Really, we are asked a lot and we are being exposed to many situations as gynecologists. For example, patients with sexual dysfunction come and say this happens with me and this does not. I am not prepared to respond but it is a basic part of our practice.” Male physician, Assiut
“If a newly married woman came seeking my consultation, I can’t tell her anything, not because of embarrassment, just because I don’t know, and I tell her to ask someone else better than me.” Female physician, Assiut
“Sexual health? I don’t know what that means. We treat medical issues, but we don’t know how to do sexual health consultations.” Female physician, Assiut
“Sexual health consultation is a doctor’s own effort. None of us learned it. Everyone learns by himself. Patients come to us to ask us about sexual health. I tell them, you tell me.” Female physician, Al Gharbeya
Some physicians also felt that providing sexual health counseling could be unacceptable to the community, especially when provided by an unmarried female physician.
“There is no sexual education and the society disapproves of that, and what we know is from our own personal effort, but we didn’t learn it [in medical school].” Female physician, Assiut
“If she is single [a virgin], even if she is a doctor, they will not accept her consultation. In other words, doctor [X] will be accepted but I won’t be. They would say it is “disgraceful”, it is unacceptable for a girl to talk about sexual health, even if she is a doctor.” Female physician, Assiut
This gap in training and knowledge arguably helps sustain the practice of FGM/C. If providers do not recognize sexual health as a fundamental part of overall health, and if they do not make the possible connections between poor sexual health and FGM/C, then they are less likely to work towards the abandonment of the practice.
Mothers, on the other hand, are unaware of health care providers’ lack of knowledge and training on FGM/C and underscored their preference to have their daughter cut by health providers rather than dayas. They stated that health providers were a trusted source of health care and highlighted the clean environment in health facilities and the use of sterile equipment. Mothers also reported that health care providers were better trained, cut less tissue, used anesthesia and followed up with patients. Having the procedure performed by trained practitioners, and preferably in a clinic or a hospital, was thought to minimize the health risks, pain, and, even, marital sexual problems, while sustaining the practice to meet cultural norms.
“The doctor has experience and has been educated. A daya is fine but education is good, a daya would spray an anesthetic but a doctor gives an injection of anesthesia in the side and the girl feels nothing but can see.” Mother, Cairo
“Women who have problems with their husbands because they were circumcised by a daya. If it were a doctor, it would be different. I have been circumcised by a doctor. My sisters by a daya. They have problems and I don’t.” Mother, Assiut
Social construction of girls’ well-being makes FGM/C a perceived necessity
Further analysis of respondents’ narratives suggests that the practice of FGM/C is driven by the social construction of girls’ well-being in the study setting. Participants’ narratives reveal various concerns that mothers have for their daughters’ health and happiness, and comfort in Egyptian society. The narratives demonstrate that girls’ well-being is constructed around how they are viewed by others in the community. Attributes such as propriety and bodily beauty afford a girl respect from the community. These attributes also increase a girl’s marriageability, particularly in the rural areas. A lack of such characteristics is associated with being uncut a status that is stigmatized. Understandably, therefore, mothers have a shared goal of ensuring their daughters meet community standards (and therefore undergo FGM/C), thus attaining better life chances in general.
Sexual purity, for instance, was a key construct that participants referred to in their conceptualization of girls’ well-being. When referred to, sexual purity for girls was often framed in terms of low (or a total lack of) libido, which was also viewed as evidence of ‘good behavior.’ Respondents in Cairo and Al Gharbeya were more likely than their Assiut peers to express these opinions. These views are illustrated in the following quotes from mothers;
“She would have more sexual desire than her husband if left uncircumcised that is why they say circumcision is good for girls.” Mother, Assiut
“In villages, they say the uncircumcised girl would have much more sexual desire, would like to talk to men all the time instead of girls and would play mainly with boys. So, her behavior would not be good.” Mother, Assiut
“I had a daughter her body was ‘hot’ [sexually excited]. When I circumcised her, she calmed down. I used to tell her you are agitated, but she became good and came back to her mind when I circumcised her. My mother-in-law told me to circumcise her. I sent her to Fayoum because my sister-in-law is a nurse at a doctor’s clinic and she circumcised her.” Mother, Cairo
Some mothers, physicians, and nurses disputed any associations between FGM/C and girls’ sexual excitement and behavior, however, contending that sexual arousal is a complex biological and neurological process, or pointing out the effect of environmental and relational factors on sexual behavior.
Interviews and discussions with study participants demonstrate that girls’ well-being is also linked to their bodily beauty in the study context. Indeed, most mothers in Assiut, for example, did not link FGM/C to sexual behavior, but rather to genital hygiene and cosmoses. Most of them reportedly cut their girls to ensure that they did not have a protruded clitoris that would be erect during sexual intercourse, which they considered unacceptable. Uncut girls were considered to have similar organs to men, which was considered unfeminine and unattractive. These perceptions are illustrated in the following quotes;
“They say a girl if left uncircumcised would be like a man. We have to cut these things. How can a girl be like a man? If she would not be circumcised, she would be like her husband. This is not right. At the same time, it is cleanliness for her too.” Mother, Assiut
“There was a doctor and I heard him saying “I was assisting a woman in her delivery and her genitalia looked so ugly from beneath. If I am a doctor and not her husband and see it this way, what does her husband do with her?” And I heard the same doctor saying we need to set up a committee of obstetricians/gynaecologists and Al-Azhar to do a medical examination for the girl to decide whether she needs it or not.” Nurse, Al Gharbeya
“I saw a girl who has large things, skin protruding down and long and the whole thing looks very bad. I saw many cases like that. I work in rural areas. If you are working in the urban areas, you have not seen anything. I stayed 20 years in rural areas and saw a lot of cases that had to be done [circumcised].” Male physician, Assiut
The mystery client exercise reinforced these findings, as female and male providers alike repeatedly referred to ‘beauty’ and ‘ugliness’ in regard to girls’ genitalia. As demonstrated below, their words were usually set in the context of assistance and support to ensure the best outcome for the girls concerned within marriage and otherwise:
“Yeah, there are girls God created them looking normal and beautiful from underneath [genitalia], and there are girls who have large organs. As the prophet said, don’t overdo it and cut a little, from the clitoris; we cut a small part because if it [protruding genitalia] is long, it causes problems and looks very ugly.” Female physician, Al Gharbeya
“Bring her. I’ll take a look (examine her) and then I’ll decide. If it [genitalia] looks ugly and will affect marriage, we cut it and if it is okay, we leave it. By the way, there are married women who come for us to do corrections for them. I just have to see what is there. I haven’t seen anything...you are telling me something vague. I have to see with my own eyes and will do what is needed for her.” Male physician, Cairo
Nurses in Al Gharbeya were more likely to support the cosmetic and hygienic indications of FGM/C than providers in other settings. Providers’ focus on enhancing bodily beauty is arguably linked to issues that are perceived to ensure girls’ well-being, including their marriageability. In some rural areas, uncut girls were reportedly required by their fiancés to undergo FGM/C. Moreover, some mothers mentioned that husbands would force uncut wives to get cut to avoid shame or to ensure their wives’ fidelity. The views are illustrated in the quotes below;
“A man from Upper Egypt married a woman from Lower Egypt and he swore not to consummate the marriage unless she is circumcised.” Nurse, Assiut
“People would repeatedly tell him ‘your wife is uncircumcised’. The whole village knows each other and knows who is and who isn’t circumcised.” Mother, Assiut
The discursive (re)framing of FGM/C by the medical community casts the practice in a positive light
Findings demonstrate how the language around FGM/C is being reframed by health care providers. As shown in the following quotes, many physicians who performed FGM/C denied that they practiced FGM/C, preferring to refer to the procedure as ‘a cosmetic operation’ instead. It is plausible that providers rely on such terms to free themselves of the blame directed to the physicians when cutting girls. Providers claimed that in most cases, they only cut the labia minora and not the clitoris, except when the clitoris was enlarged and protruded out of the labia minora.
“A doctor in Assiut in a training workshop said we beautify women, although he has a high scientific degree and knows this practice is harmful.” Female physician, Assiut
“I don’t call it circumcision, I call it “refinement”. For me, as a doctor, I don’t do this case as female circumcision, I do it as a technical case. For example, after the age of 16 to 17, when everything is clear and there are problems from it, so I do this refinement or cosmetic operation.” Male physician, Al Gharbeya
“There is a woman doctor who told me that many people come to ask for this operation. They say they feel that the labia minora is large and she does it to them, but she does not come close to the clitoris. I told her that is circumcision, she said no. People ask for it as a cosmetic need, she considers it cosmetic and not circumcision because it is the labia minora only.” Female physician, Assiut
“This is not considered circumcision with the common meaning that we remove the clitoris, but you are beautifying the labia. It’s normal. I have patients who are married and do it after marriage and birth too.” Female physician, Al Gharbeya
In speaking about FGM/C, providers described female genitalia as either ‘normal’ or ‘abnormal,’ depending on the extent of labial protrusion. Provider narratives cast labial protrusion in a negative light. Most physicians and nurses mentioned that they had female patients with oversized genitalia, which they thought should be removed. They mentioned that they examined girls’ genitalia and classified them into “indicated” and “non-indicated” cases for cosmetic correction to the normal shape, which they considered ‘non-protrusion of the clitoris out of the labia minora’. They mentioned several complications of non-removal, such as repeated infection, bad odors, bleeding, sexual excitement and dyspareunia. Some of them considered these cases to be “congenital anomalies” thus providing further rationale for performing FGM/C.
“There are cases that are in need [of cutting]. If I have an extra finger, I will accept it but others might not especially those who live with me. We don’t remove it completely. We make it normal, the extras [skin] are not normal. If someone is going to do something [FGM/C], he has to know, understand and then decide that this has to be removed.” Male physician, Assiut
“If anatomically the girl is all right, there is no problem. But if she is not, she should be circumcised. Otherwise, if she does not observe hygiene, she can get a fungal infection. She can also bleed from the extreme friction, and it could cause her pain in sexual intercourse and result in divorce. It has happened in our village that people got divorced because of this issue.” Male physician, Al Gharbeya
“Look, the normal size is that when the labia majora are closed. Nothing is protruding from them. That one does not need it but if there are protrusions outside the labia majora, there would be a need [to cut the girl].” Female physician, Al Gharbeya
Responses of the physicians to clients’ requests to perform FGM
When physicians were visited in their clinics by the mystery client (an actor mother) and were requested to perform FGM/C to the daughter, they had different responses. Four physicians accepted to perform FGM immediately, and asked the “actor mother” to bring the girl for the operation. They were very supportive to FGM and even convinced the hesitated mothers about its importance regarding the cosmetic and hygienic indications.
Almost half of the physicians (14 out of 30 physicians) asked for examining the girl before taking a decision whether to accept or not to perform such practice. They mentioned that they would decide the need according to the size of the clitoris and labia minora. We can’t conclude what would happen after examination. They could have done so to prepare her for the procedure or to convince the mothers that their girls aren’t in need for such practice, as mentioned by some physicians in the FGDs.
“I will give you my decision after examining the girl, as circumcision could be indicated for some cases and not for others. Some girls have a large clitoris which needs to be cut. If not, it is not indicated for this case.” Male physician, Al Gharbeya
Six physicians refused to perform FGM but referred the cases to other colleagues who are known to perform such practice. They refused performing FGM either due to being against the practice or because their clinics were not equipped for performing such procedure. Only six physicians were very determined in refusing to perform FGM and also refused to recommend other colleague for performing it.
“I will be honest with you. I never perform female circumcision, but I will tell you about a trusted colleague who would perform it. This procedure needs to be performed in a private hospital, not a clinic, even if it is more expensive.” Female physician, Cairo
“I don’t circumcise girls. First, this is criminalized by law and the penalty has been also increased recently. Second, it has no indications and has nothing to do with sexual purity. You should better discuss her fiancée and convince him with what I told you.” Female physician, Assiut