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RHO archives : Topics : Harmful Traditional Health Practices

Annotated Bibliography

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General

Airhihenbuwa, C.O. Health and Culture: Beyond the Western Paradigm. London: Sage Publications (1995).
In a balanced, academic manner, the author looks beyond traditional Western notions of health toward an integrated approach that encompasses traditional beliefs and practices. His vision includes novel approaches to culturally-appropriate health promotion and communication, and a framework for analysis of non-Western health practices.

The Alan Guttmacher Institute. Risks and realities of early childbearing worldwide. Issues in Brief Report (February 1997). Available online at www.agi-usa.org/pubs/ib10.html.
While early childbearing is on the decline in Asia, North Africa, and the Middle East, it is still quite common in Latin America and especially in sub-Saharan Africa. Early childbirth often ends a girl's schooling; the less schooling a female has, the more likely she is to face economic and health hardships. Conversely, the more education a female receives, the more likely she is to postpone marriage and childbearing. Physically, the younger a mother's age, the less likely she is to receive adequate prenatal care, and the more likely she is to suffer complications from pregnancy. Infants born to young mothers are more likely to become ill or die.

Bunch, C. The intolerable status quo: violence against women and girls. Women Commentary. Harmful Traditions section, from UNICEF's publication, Progress of Nations. New York. (1997). Available online at www.unicef.org/pon97/women1b.htm.
The author argues that many harmful traditions actually are forms of violence against women, which in turn is a "a construct of power and a means of maintaining the status quo." Therefore, harmful practices can potentially be dismantled within societies. For example, Bunch describes FGM as an expression of the "concept of male honourand fear of female empowerment," comparable to the abandoned Chinese practice of female foot binding, Indian "dowry deaths," Asian son preference, and rape in war. The chapter includes an outline of how to create positive change.

Graham, M. et al. Son preference in Anhui Province, China. International Family Planning Perspectives 24(2) (1998). Available online at www.agi-usa.org/pubs/journals/2407298.html.
Preference for sons may impact the reproductive practices of Chinese couples and their treatment of their children. In the rural province studied, there is an unexplained high male-to-female birth ratio. Boys also are breast fed longer than girls, and intervals between pregnancies are shorter when the previous child was a girl. However, such indications of son preference are diminishing in large cities in China.

Hassan, A. Sudanese women's struggle to eliminate harmful traditional practices. Planned Parenthood Challenges (1995/2).
Based on her work in Sudan, the author identifies the four most pressing harmful practices in context: FGM, nutritional taboos, early marriage, and non-spaced pregnancy. First-person testimonies illustrate how children and men suffer from these practices as well as women. A major obstacle to ending FGM is the opposition of medical providers who depend on income from FGM. Progress is slowly being made on this issue.

Hersh, L. Giving up harmful practices, not culture. Passages. Advocates for Youth: Issues at a Glance (1998). Available online at www.advocatesforyouth.org/PUBLICATIONS/iag/HARMPRAC.HTM.
This issue reviews three harmful practices that have received global attention: FGM, son preference, and early marriage resulting in early childbearing. Lack of access to education, information, and health care services allow these and other harmful practices to persist. Most harmful traditions have common origins in unequal power distribution between women and men, socially and economically. The United Nations and governments worldwide are calling for an end to gender discrimination and human rights violations.

Schoofs, M. AIDS. The agony of Africa. Part five: death and the second sex. Village Voice. New York. (December 1-7 1999). Available online at www.thebody.com/schoofs/africa5.html.
Vaginal drying practices, HIV/AIDS, wife inheritance, and bride prices are linked and result in the inequality of men and women in Africa. This article discusses how women ultimately are socially—and often physically—forced into sexual subservience and poverty as a result of inequity. Traditional practices like dry sex and husbands' infidelity leave many women with the choice of HIV infection from their husband or complete community rejection and the inevitable poverty that results. Such poverty usually means raising children in slums, with little food and no hope of an education, which in turn places them in a high-risk group for future HIV infection and prostitution.

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Communication for improved health

AIDSCAP Behavioral Research Unit. Behavior Change - A Summary of Four Major Theories. AIDSCAP Project (August 1996).
The AIDS Control and Prevention (AIDSCAP) Project (funded by the U.S. Agency for International Development and managed by Family Health International) produced this eight-page report. It contains information that is applicable to any behavior change effort and includes an extensive list of suggested readings.

Graeff, J. et al. Communication for Health and Behavior Change: A Developing Country Perspective. San Francisco: Jossey-Bass Publishers (1993).
The HealthCom project was funded by the U.S. Agency for International Development and managed by the Academy for Educational Development. This book presents a detailed overview of the project's experience, including models of health behavior; practical information on assessing, planning, training, monitoring, and maintaining behavior change; and lessons and implications. Practical tools include checklists, guidelines, and worksheets.

International Institute for Environment and Development (IIED). Rapid rural appraisal/participatory learning appraisal notes. Special Issue on Applications for Health Number 16 (July 1992).
This report offers participatory techniques designed to help health professionals create a dialogue within a community about health beliefs. This dialogue can provide perspective into the logic behind harmful and healthful practices, and begin a process of change. The report contains fifteen chapters on applying these techniques to health, fostering community discussions, and specific case studies. For example, one project in Zimbabwe resulted in "body maps" created by community members, which shed light on beliefs about pregnancy.

Nutbeam, D. and Harris, E. Theory in a Nutshell: A Guide to Health Promotion Theory. New York: McGraw-Hill (1999).
In a concise and readable style, this book discusses the background, basic tenets, advantages, and disadvantages of more than ten health promotion theories, all potentially applicable to reproductive health efforts. The authors contend that experience has demonstrated that health projects and programs based on theory are more effective because an applied theory helps to identify and understand the problem at hand, and to design and manage an approach—that is, create a program that "fits" the problem. Theories reviewed include those that serve programs geared toward individual level behavior, community/communal action, communication methods, organizational change, intersectoral action, and public policy.

Rogers, E.M. Diffusion of Innovations. 4th ed. New York: Free Press (1995).
This book analyzes the spread of behavior change within a society according to the well-developed model of Diffusion Theory. Case studies of successful and unsuccessful change efforts around the world are presented, including many developing country health behavior examples. Change is examined from the perspectives of history, starting the process, decision making, rate of adoption, change agents, diffusion networks, and consequences.

Werner, D. and Bower, B. Helping Health Workers Learn. Palo Alto: Hesperian Foundation (1984).
A classic in the international health field, this book contains a chapter called "Helping People Look at their Customs and Beliefs." The authors cite three common mistakes made in dealing with local health traditions: looking down on them all as unscientific or worthless; looking up to them all; or failing to ever look at them. This book outlines training methods to help people build on what they know to change harmful customs and presents a short framework for assessing the worth of a local practice.

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Human rights, law, and harmful practices

Center for Reproductive Law and Policy (CRLP). Female Genital Mutilation: A Matter of Human Rights. An Advocate's Guide to Action. CRLP (June 2000). Ordering information available online at http://www.crlp.org .
In a clear, basic style, this handbook presents background information about FGM, the extent of the practice, health consequences, and historical efforts to stop the practice. The authors present the issue as a violation of the following international human rights: to be free from gender discrimination, to life and physical integrity, to health, children's rights, and others. Governmental obligations and recommendations are outlined, as well as legal and political strategies for NGOs at multiple levels. The handbook demonstrates that no single approach can stop the practice: a multifaceted strategy is called for. Finally, the publication provides prevalence rates by country as well as legal information and treaty ratification information.

Crawley, H. Women as Asylum Seekers - A Legal Handbook. London: Immigration Law Practitioners' Association and Refugee Action (1997).
This handbook discusses issues related to women seeking asylum in the United Kingdom. One issue is women's fear that they or their daughters will be compelled to undergo FGM.

Heyzer N. Gender justice in post-conflict countries. Presented at: Security Council Open Debate on Women, Peace and Security, October 28, 2004; New York. Available at: www.unifem.org/speeches.php?f_page_pid=77&f_pritem_pid=179.
Addressing a United Nations Security Council Open Debate on "Women, Peace and Security," Noeleen Heyzer, Executive Director of the UN Development Fund for Women (UNIFEM), emphasized that any real solutions to eliminating violence against women must derive from a concerted attack on its origins -- deeply rooted, historical patterns of discrimination against women and systemic gender inequalities that are pervasive both in peacetime as well as during conflict.

Hopkins, S. A discussion of the legal aspects of female genital mutilation. Journal of Advanced Nursing 30(4):926-933 (October 1999).
The author examines the role of the nurse/midwife with a woman or girl client who has undergone FGM. She presents an overview and the nursing implications, specifically within the context of the United Kingdom. As gynecological nurses and midwives struggle to answer questions regarding responses to this issue, this article offers increased knowledge of the topic, designed to inform relevant nursing decisions.

Rahman, A. and Toubia, N. Female Genital Mutilation: A Guide to Laws and Policies Worldwide. New York: Zed Books (2000).
Written by a human/reproductive rights expert teamed with an African physician and leader in the fight against FGM, this comprehensive work provides a sophisticated look at the potential of international human rights law as a foundation upon which to build government responses to the violations inherent in FGM. The case is made for the obligation of governments to protect their citizens; at the same time the authors emphasize the destructive potential in poorly planned criminalization and persecution of FGM. They argue that FGM should never be criminalized "in the absence of broader governmental strategy to change individual behavior and social norms." The book details programmatic approaches, policy ideas, and law reforms. The final section consists of 41 country profiles containing statistical and legal information, sources of law and their potential use within each government's systems.

Research, Action and Information Network for Bodily Integrity of Women (RAINBO). Intersections Between Health and Human Rights: The Case of Female Genital Mutilation (1995).
Based on a one-day workshop held at the National Council of International Health, this report summarizes presentations by experts who analyzed FGM from medical, historical, sociocultural, religious and legal perspectives. The underlying theme was deepening the understanding of how human rights apply to FGM as a health issue, and how those rights are best realized.

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Female genital mutilation

Afro-Arab Expert Consultation. Cairo Declaration on Legal Tools to Prevent FGM. Cairo, June 23 2003. Available at: www.stopfgm.org/stopfgm/doc/EN/216.rtf.
The seventeen-point “Cairo Declaration” was drafted by government and NGO representatives from 28 FGM countries, with assistance from international experts. The declaration calls for governments to outlaw FGM—ideally, as part of broader legislation that addresses gender issues, women’s and children’s health and rights, and protection from violence. Governments must also enforce the legislation, within the context of a multi-strategy effort to end the practice, and with reasonable outreach and sensitization before enforcement. Governments of countries where FGM is practiced by minorities are urged to take care to respect the human rights of FGM practitioners and families.

Almroth, A. et al. Male complications of female genital mutilation. Social Science & Medicine 53(11):1455-1460 (December 2001). Abstract available online at www.med.uio.no/ism/inthel/foko/abstracts2.html.
While the physical, psychological, and economic impact of FGM on Sudanese men pales in comparison to the pain and complications suffered by women, the authors feel that these issues "may open new possibilities to counteract the practice of FGM." FGM-related problems reported by 59 men included penetration difficulties; penis wounds, bleeding and inflammation; psychological problems; desire to hurt their wives or make them suffer; decreased sexual desire and enjoyment; costs of associated medical care; and problems after reinfibulation.

American College of Obstetricians and Gynecologists (ACOG). Female Cirumcision/Female Genital Mutilation: Clinical Management of Circumcised Women. (August 1999). Ordering information available online in the "Multimedia" section of ACOG's Resources Catalog (http://sales.acog.com/). Cost for ACOG members: US$95; Cost for non-members: US$125.
In the introduction to ACOG's clinical guidelines on FGM, U.S. Health and Human Services Secretary Donna Shalala notes that currently "Many health practitioners...will see a woman [who has undergone FGM], who is pregnant or in labor, and will confront medical decisions that must be made quickly and which they have never before considered." To help obstetrician-gynecologists and other health care providers deliver optimum care to affected women, ACOG's Task Force on Female Circumcision/Female Genital Mutilation has developed this slide/lecture presentation and companion manual. This educational module is intended for use as a formal 60-minute presentation in undergraduate medical education and ob-gyn residency programs. It includes 56 slides, accompanying speaker's notes, learning objectives, and a resource listing. Learning more about FC/FGM and its concomitant consequences can help physicians play a vital role in preventing this harmful and unnecessary practice.

Anonymous. MSF denies "pragmatic approach" to genital mutilation. Johannesburg Daily Mail and Guardian (August 27, 1999).
The international NGO Medecins Sans Frontieres (MSF) denied that it takes a "pragmatic approach" to FGM by providing clean medical equipment for the practice, as reported the previous week. The president, Philippe Bikerson, characterized that report as a misrepresentation. He stated the MSF was clearly opposed to FGM, despite any mistakes staff people might have made, and described FGM as a human rights violation and "a ritual act" rather than a medical or surgical act. (Also see Veash 1999).

British Medical Association. Female Genital Mutilation: Caring for Patients and Child Protection. Guidance from the British Medical Association (January 1996; revised April 2001).
Beginning with an overview of FGM and a clear condemnation of the medicalization of FGM, this concise set of guidelines includes UK-specific FGM statistics and legal information, addressing requests for FGM and reversals, and resources. Concise recommendations are made on many related issues, including cultural sensitivity, informing families of UK laws, confidentiality, documentation, referrals, urgent situations, and child-protection actions.

Chege, J.N, Askew, I., and Liku, J. An Assessment of the Alternative Rites Approach for Encouraging Abandonment of Female Genital Mutilation in Kenya. New York, New York: FRONTIERS Project, The Population Council (September 2001). Available at: www.popcouncil.org/pdfs/frontiers/FR_FinalReports/Kenya_FGC.pdf.)
This study of PATH and MYWOs Alternative Rite of Passage Projects in three districts thoroughly explores the dynamics of their processes. The report draws attention to those families who are abandoning the practice and participating in the practice of FGM in the project sites, and concludes that "the combination of intensive community sensitisation about FGM and offering an Alternative Rite have clearly played a role in the attitudinal and behavioural changes that are occurring in the project sites." The report notes the difficulty in evaluating and developing a strict model for replication given the variability of socio-cultural reasons for practicing FGM, the role of public ceremonies, and the most appropriate format for the rituals. The report stresses the importance of "a preceding or accompanying process of sensitisation in which an attitudinal change has to have occurred."

Cook, R.J. et al. Female genital cutting (mutilation/circumcision): ethical and legal dimensions. International Journal of Gynecology and Obstetrics 79(3):281-287 (December 2002).
With respect to the antiquity and complexity of the practice of FGM, this article concludes that the practice is not acceptable. Except for the mildest forms, FGM constitutes child abuse and violates international standards of human rights, including women’s human rights as “innately sexual beings.” Therefore physicians should not support medicalization of it in any form, including reinfibulation of a patient after giving birth.

Dorkenoo, E. Combating female genital mutilation: an agenda for the next decade. Women's Studies Quarterly 1-2 (1999).
The author provides an overview of the practice of FGM, health complications, and relevant human rights agreements, and discusses gaps in knowledge about how to end the practice. These gaps include the lack of comprehensive global surveys on the prevalence of FGM, few national surveys, and fragmented data on types of FGM. Reliable and accurate data are needed as baseline data for evaluations, and to influence and formulate national policy. At the local level, rapid-intervention surveys may be most useful. Any data collected should include information on sociodemographics, types of FGM, and the prevalence and nature of short- and long-term complications. Magnitude should be measured in terms of prevalence, incidence, and recurrence rates. Qualitative research is necessary for a better understanding of sociocultural factors. The author also provides information on lessons learned, which include the clear need for a multidisciplinary approach. The author calls for governmental and international support for grassroots work. This should include national policies, interagency coalitions, more research, strong community outreach and family life education, and training for health workers. Ultimately, "the roots of the practice lie in the patriarchal family and society"—therefore, gender equity and women's empowerment (often promoted through women's education) must be seen as key.

Essen, B. et al. Is there an association between female circumcision and perinatal death? Bulletin of the World Health Organization 80:629-632 (2002).
A panel of physicians reviewed 63 cases of perinatal infant deaths in Sweden that involved women from the Horn of Africa who had undergone FGM. The panel concluded that none of the deaths were related to complications of FGM. The deaths were associated with other conditions including maternal avoidance of operative delivery, verbal miscommunication, and insufficient obstetric care. The authors suggest these findings be used to support design of interventions that address the greatest obstetric risks faced by circumcised women in both high- and low-resource settings.

Female genital mutilation: is it crime or culture? The Economist (February 13, 1999).
An internal and international debate has been generated by Senegal's new law banning FGM. Some feel it was put into effect to please the State Department of the United States—rather than as a productive way of actually ending FGM. In response to the controversy generated, the government of Senegal has decided not to enforce the law for a year. Other African governments are facing the same kind of pressures not to ban FGM, often from the very groups trying to end the practice.

Fernandez-Aguilar, S. and Noel, J.C. Neuroma of the clitoris after female genital cutting. Obstetrics and Gynecology 101(5):1053-1054 (May 2003)
This article describes the “first well-documented case of clitoral amputation neuroma occurring after female genital cutting.” Surgeons removed a painful tumor from a 27-year-old woman. As more “Western” medical professionals treat women who have undergone FGM, this type of documentation is becoming more common.

Gruenbaum, E. The cultural debate over female circumcision: the Sudanese are arguing this one out for themselves. Medical Anthropology Quarterly 10(4):455-475 (1996).
The author questions the depth of analysis outsiders have used in order to understand FGM. Labels like "tradition" actually may serve as barriers to reaching the goal of ending FGM. She proposes incorporating political and economic analyses into the debate since people use arguments for and against FGM to serve other national and international ends.

Gryboski, K. and Samson, R. Community-based Research on Female Genital Mutilation in Three Eritrean Towns. Washington, DC : PATH (1999).
FGM prevalence in Eritrea is estimated to be 95 percent, and most female circumcision takes place before the age of one. The National Union of Eritrean Youth and Students (NUEYS), with technical assistance from PATH (Program for Appropriate Technology in Health), conducted qualitative research in 1998 to document community perceptions and beliefs about FGM and explore how best to end it. This report presents information obtained through 21 focus group discussions and 20 in-depth interviews. It reviews the role and attitudes toward traditional birth attendants and excisers, both of whom perform female circumcision; participants' attitudes toward outlawing FGM; and the potential influence of religious leaders (both Christian and Moslem) and school teachers. Research participants provided suggestions for ending FGM, including community education and sensitization. While community-level participatory approaches and collaboration with local leaders and families should be the cornerstones of the behavior change effort, the report concludes that a central coordinating body to guide and manage the national program, such as a coalition of all the government ministries, also would be needed.

Hosken, F. The Hosken Report. Lexington: Women's International Network (WIN) News.
Continually updated, this book outlines basic information on FGM, strategies for change, case studies, and a bibliography. More information about the Women's International Network is available on the Feminist.com website at www.feminist.com/win.htm.

Hosken, F. The Universal Childbirth Picture Book. Lexington: Women's International Network (WIN) News (1995).
Available in many languages, including Arabic and Somali. A flip chart and a color slide program are available as well. This manual for health professionals includes an extra section with drawings on the complications of FGM during childbirth.

Inter-African Committee on Traditional Practices Affecting the Health of Women and Children (IAC). IAC Newsletter. Available at: www.iac-ciaf.ch/.
A regular publication that provides useful information about FGM.

Jones, H. et al. Female genital cutting practices in Burkina Faso and Mali and their negative health outcomes. Studies in Family Planning 30(3):219-230 (1999). Abstract available at: www.popcouncil.org/mediacenter/newsreleases/sfp999(2).html.
Trained clinic staff collected data on FGM and possible associated gynecological and obstetric complications, in rural Burkina Faso and rural and urban Mali. Over 90 percent of the women in both countries had undergone FGM. Type I was most common in Burkina Faso, and type II more common in Mali. The study found FGM of either type to be associated with complications, most commonly scarring. A positive relationship was found between FGM and long-term complications. A connection is indicated between delivery problems and FGM within the Mali sample. In Burkina Faso a relationship appeared between FGM and signs of genital infection.

Jones, W. et al. Female genital mutilation/female circumcision: who is at risk in the US? Public Health Reports 112 (September-October 1997).
The U.S. Centers for Disease Control estimates that there are 168,000 girls and women living in the United States who are at risk of FGM. Although Congress passed a law in 1996 making it a crime to perform FGM in the United States on girls under 18 years of age, few data have been collected about the extent of FGM. The Department of Health and Human Services and others are working to address the issue. This article provides an overview of what is known about FGM in the United States.

Koso-Thomas, O. The Circumcision of Women: A Strategy for Eradication. London: Zed Books (1992).
The author draws on her extensive clinical and research experience in this easy-to-read overview of FGM. The book covers the history, prevalence, and reasons for the practice, as well as the physical and psychological effects, with an emphasis on research findings from Sierra Leone. She presents a thoughtful strategy for ending the practice with a twofold focus on health education and health care. Her strategy is presented in a practical format, complete with straightforward suggestions on national program organization, administration, and budgeting.

Laboratoire de Sante Communautaire, Bazega; Ministry of Health; The Population Council, et al. valuation de la Prvalence, de la Typologie et des Complications lies L'Excision chez les Patientes Frquentant les Formations Sanitaires du Bazega. Sries Documentaire No. 21 Ouagadougou, Burkina Faso (November 1998). Contact [email protected] for more information.
This study was undertaken to evaluate the typology of FGM and visible effects among clients attending health clinics in two rural provinces. The majority of these clients were fairly young (mean age of 27), married, from the Mossi ethnic group, and had no formal education. Catholicism and Islam were the major religions found in the sample. Among the 1,920 women interviewed, 93 percent had undergone FGM. Three of the four types of FGM were found; the mean age for the procedure was eight years old. Numerous instruments were reported as being used during FGM, including razor blades, knives, fiber from millet, and stones. A variety of modern and traditional products were used to care for resulting wounds. Among cut women, 14 percent had visible complications, especially keloids (62%), stenosis (20%), and vaginal obstructions (6%). The study also found that the majority of clients were in favor of stopping the practice and did not want to have their daughters cut; the clients who were not cut wanted to remain that way. The report emphasizes the need to use these findings at both community and national levels.

Laboratoire de Sante Communautaire, Bazega; Ministry of Health; The Population Council, et al.Etude Participative pour L'Identification des Strategies Communautaires de Lutte Contre La Pratique de L'Excision dans le Bazega. Rapport Final. Serie documentaire No. 22. Ouagadougou, Burkina Faso (December 1998). Contact [email protected] for more information.
An estimated 78 percent of women in Burkina Faso have undergone FGM. Although the government of Burkino Faso declared it illegal in 1996, FGM is still practiced in many communities. This study obtained information from community members in the Bazega province about their perceptions of the practice and strategies to stop it. Study participants provided a variety of justifications for FGM, including educational, hygienic, and sexual reasons. Many participants felt that FGM is not harmful, and they had fatalist attitudes regarding FGM complications. Community members often associate supernatural powers with the procedure, thus affording circumcisers respect and prestige. Three intervention approaches emerged from the study's preliminary results: (1) information, education, and communication; (2) training and education; and (3) community-organizing activities. This study demonstrated that environmental and social precursors for enacting positive change exist. The critical task of acting upon these by continuing open discussions and implementing intervention strategies is the next step.

Larsen, U. and Okonofua, F.E. Female circumcision and obstetric complications. International Journal of Gynaecology and Obstetrics 77(3):255-265 (June 2002). Available at: www.womenshealth-elsevier.com/doc/journals/pdf/IJGO%2077%203%20Larsen%20and%20Okonofua.pdf.)
This study investigates the effects of FGM by researching the birth outcomes of 1,851 Nigerian women, 45 percent of whom had undergone type I or II FGM. Logistical regression analysis (including multiple socioeconomic and cultural indicators) found that women with FGM had significantly higher risks of tearing and stillbirths, with no significant difference between types I and II. The authors discuss possible reasons for the difference between these findings and other similar studies that found no relationship between FGM and obstetric complications.

Lightfoot-Klein, H. Prisoners of Ritual. Tucson: Lightfoot Associates (1989).
The author provides an extensive anthropological account of her research on culture and FGM, as well as details of the practice, with a focus on Sudan. Her outsider perspective serves as an interesting basis for her thoughtful investigation of the issue.

Magardie, K. Female genital mutilation shadow falls on SA. Johannesburg Daily Mail and Guardian. South Africa (September 10 1999).
In South Africa the health care system is responding to an increased number of clients who have undergone FGM with training for practitioners. Dr. Trudy Smith now routinely worries about her clients' potential complications, including death, that can arise from labor and delivery obstructed by the altered anatomy. She recalls an FGM victim who suffered from a critical case of necrosis between the vagina and the rectum who faced serious surgery as a result of FGM. The physician also commonly experiences a negative attitude of FGM victims toward caesarean births; these clients tend to opt for a hazardous and extremely painful labor in order to fulfill their concept of femininity.

Morison, L. et al. The long-term reproductive health consequences of female genital mutilation in rural Gambia: a community-based survey. Tropical Medicine and International Health 6(8):643-653 (August 2001).
Of the 1,157 women studied, 58 percent had signs of FGM, primarily type II. FGM status was closely associated with two of the three main ethnic groups represented. As a result, it is difficult to distinguish between effects of ethnic group and FGM. Women who had undergone FGM were significantly more likely to have bacterial vaginosis and herpes simplex virus 2. However they were not more likely to have damage to the perineum or anus, tumors, excessive keloid formation, prolapse, painful sex, infertility, or other reproductive tract infections. The authors stress the need to base opposition to the practice on a human rights approach rather than focusing on negative health consequences, given the questions about what the actual health effects are.

Msuya, S.E. et al. Female genital mutilation in Kilimanjaro, Tanzania: changing attitudes? Tropical Medicine and International Health 7(2):159-165 (February 2002). Abstract available at: www.blackwell-synergy.com/servlet/useragent?func=synergy&synergyAction= showAbstract&doi=10.1046/j.1365-3156.2002.00838.x&abbrev=Trop%20Med%20Int%20Health&vol=7&page=159&goto=abstract.
Examinations and interviews with 379 women found that three-quarters of the 17 percent who had undergone FGM did not plan to subject their daughters to the practice. No association was found between reproductive tract infections, HIV, or hepatitis B and FGM. The authors suggest that visitors to reproductive health care facilities should be educated about FGM.

Nour, N. M. Female genital cutting: a need for reform. Obstetrics & Gynecology101(5):1051-1052 (May 2003).
FGM is harmful to women’s health and a violation of human rights. Growing experience with medical treatment and documentation of the complications of FGM is already benefiting women. While medical professionals work on the physical and psychological aspects, national governments must commit to orchestrating multi-strategy, integrated efforts to end the practice.

Obermeyer, C.M. Female genital surgeries: the known, the unknown, and the unknowable. Medical Anthropology Quarterly 13:79-106 (1999).
After reviewing over 400 relevant documents, the author concludes that FGM does have short-term effects, including pain, hemorrhage, and shock, and long-term effects including urinary infection, scarring, infertility, and childbirth complications. Womens sexuality and relationships are also affected negatively. The author found little evidence of death or severe complications resulting from FGM.

PACT. Training Module: Female Genital Mutilation. New York: The Institute for Development (1999).
This packet provides training on the types of FGM and their immediate and long-term physical and mental health consequences. Childbirth, sexuality, and health education information is included. The module is part of a training course consisting of 11 modules. The training course can be ordered in its entirety or by individual modules from the PACT website at www.pactpublications.org/item.asp?prod_cd=IDT012. The training course can also be ordered on CD-ROM at www.pactpublications.org/item.asp?prod_cd=IDT015.

PATH. The Facts About FGM. Available online at www.path.org/resources/fgm_the_facts.htm.
This online monograph contains bulleted lists of important facts and statistics related to FGM worldwide.

PATH. Kenya: Focus Group Discussion From Three Districts. Washington, DC: PATH (1996).
PATH conducted several focus group discussions on female circumcision (FC) with community members from Embu, Nyeri, and Machakos Districts in Kenya. The objective of the research was to determine why FGM has been abandoned in some communities but not in others. The majority of respondents felt that FC should be eliminated. According to the focus group discussions, most people know of the harmful effects of FC but continue the practice because of fear of curses and ignorance. Contrary to popular belief that fathers decide whether their daughters are circumcised, the study shows that mothers and grandmothers play a greater role in the decision. Mother-in-laws are also a major influence on the decision. Forceful circumcision is prevalent in all three districts. Despite positive comments regarding the benefits of FC (such as maturity and responsibility), the majority of the boys preferred marrying uncircumcised girls. This is based on knowledge of the adverse health complications of FC. Most participants recommend that the government should publicly denounce FC.

Penna, C. et al. Type III female genital mutilation: clinical implications and treatment by carbon dioxide laser surgery. American Journal of Obstetrics and Gynecology 187(6):1550-1554 (December 2002).
A study of 25 infibulated patients revealed the following conclusions. Deinfibulation must be offered to infibulated patients, and was successfully performed with a colposcopy guided laser beam. Carbon dioxide laser surgery is an effective method when inclusion cysts are present. This surgery is especially important to ensure safer pregnancy and childbirth.

Population Reference Bureau (PRB). Abandoning Female Genital Cutting: Prevalence, Attitudes and Efforts to End the Practice. Washington, DC : Measure Communication Project, Population Reference Bureau (August 2001). Available for purchase at www.prb.org/Template.cfm?Section=By_Topic&template= /Ecommerce/ProductDisplay.cfm&ProductID=210.
A clear, concise summary of state-of-the-art anti-FGM programs, this document includes a basic overview of the practice of FGM, including prevalence and attitudes. The document describes effective approaches to abandoning FGM and summarizes WHO and PATHs specific recommendations for global planning, policy makers, and program managers (see WHO 1999).

Rich, S. and Joyce, S. Eradicating Female Genital Mutilation: Lessons for Donors. Wallace Global Fund (1996).
The author describes the rich and complex nature of the rituals that surround FGM and their meaning in terms of sexuality, power, and identity. Sensitivity is key in developing prevention programs. Africans who fight the practice risk ostracism and even violence. The book describes the elements of a successful program and advises donors how they can be most effective.

Shell-Duncan, B. The medicalization of female "circumcision:" harm reduction or promotion of a dangerous practice? Social Science and Medicine 52(7):1013-1028 (April 2001).
The author reviews the controversy surrounding medicalization of FGM through the lens of the new paradigm in the field of public health known as "harm reduction." This approach focuses on minimizing the dangers associated with unhealthy behaviors, such as intravenous drug use and high-risk sexual behaviors. Thus, although much of the damage inflicted by FGM is permanent, the author proposes using medicalization as a means to address the unsafe conditions under which FGM is typically performed.

Slanger, T., Snow, R., and Okonofua, F. The impact of female genital mutilation on first delivery in southwest Nigeria. Studies in Family Planning 33(2):173-184 (June 2002).
In this cross-sectional study, 1,107 women in Edo State, Nigeria—56 percent of whom had undergone FGM—reported on birth experiences. Once researchers controlled for sociodemographic characteristics of the women and the delivery setting, cut women were no more likely to report first-delivery complications or procedures than noncut women. The authors outline four implications of their findings. First, in a population where FGM types I and II predominate, FGM itself does not interfere with first delivery, once social characteristics and the delivery settings are accounted for. Second, cut women are more likely to give birth in places where delivery complications are more likely. Third, delivery setting and assistant are the best indicators for tearing, cesarean section, and episiotomy. Fourth, cut women who deliver in a private hospital are least likely to undergo episiotomy.

Toubia, N. Caring for Women with Circumcision: A Technical Manual for Health Care Providers. RAINBO (2000). Available for purchase at the RAINBO website's publication page: www.rainbo.org/.
This comprehensive resource earned a four-star rating from the British Medical Journal for its practical, clinical overview of the topic. It includes descriptions and illustrations of the variations of female circumcision, diagrammatic instructions for defibulation  (a process generally called for during childbirth), and a range of related medical, gynecological, and obstetric issues. In addition, a section on communication provides guidance on asking about circumcision, providing information, and working with interpreters. The author explores terminology as well: while she feels that the term "female genital mutilation" has its place, "female circumcision" is more useful in the clinic setting.

Toubia, N. Female Genital Mutilation: A Call for Global Action. New York: Women, Ink. (1993). Available for purchase at the RAINBO website's publication page: www.rainbo.org/.
Written by an international leader in the effort to end FGM, this booklet provides a thorough overview of FGM's complications, effects, prevalence, religious implications, cultural significance, children's rights, and a call to action. Dr. Toubia believes that more specific data on FGM must be collected and widely disseminated in an empathic—not alienating—manner. International and national legislation based on human rights is necessary. Health, economic, and human rights organizations as well as professional, legal, and medical associations should develop policy positions and press for change. National and community programs of all types can get involved, including media, artists, schools, government agencies and women's rights groups.

Veash, N. Aid staff caught up in mutilation rites. Johannesburg Daily Mail and Guardian (August 23, 1999).
Medecins Sans Frontieres (MSF) admitted that its staff had provided surgical equipment for the purpose of FGM. The organization stated that while it was opposed to the practice in principle, it didn't feel a statement condemning the practice was appropriate. MSF staff admitted feeling torn between its sometimes contradictory identities as both a medical and a humanitarian organization. They felt compelled to provide the equipment as a "first-aid response." (Also see Anonymous 1999.)

World Health Organization (WHO). Management of Pregnancy, Childbirth and the Postpartum Period in the Presence of Female Genital Mutilation. Report of a WHO Technical Consultation. Geneva: WHO Department of Gender, Women and Health/Department of Reproductive Health and Research/Family and Community Health (2001). Available at: www.who.int/reproductive-health/pages_resources/listing_fgm.en.html.
Outcomes of the technical meeting responsible for this report include five principles in addressing FGM: recommendations should be realistic; recommendations should be based on scientific data; emphasis should be placed on essential services; managing FGM obstetric complications should be integrated into RH services; and interventions should be effective, empowering, and community-based. The report cites conclusions of a WHO analysis of 67 studies of the health effects of FGM, and translates them into guidance for health care systems, training and educational efforts, legal and ethical approaches, and research.

WHO. Female Genital Mutilation Programmes to Date: What Works and What Doesnt. Geneva: WHO, Department of Womens Health Systems and Community Health (1999). Available at: www.who.int/docstore/frh-whd/PDFfiles/Programmes%20to%20Date.pdf.
This comprehensive document is based on a literature review, survey data from 88 anti-FGM organizations, and country assessments and case studies from Burkina Faso, Egypt, Ethiopia, Kenya, Mali, Senegal, and Uganda. It contains 19 detailed recommendations for effective approaches to FGM as well as extensive statistical and country-specific information.

WHO. Female Genital Mutilation: An Overview. Geneva: WHO (1998). More information available at: www.who.int/docstore/frh-whd/FGM/.
Beginning with an eloquent statement from the Director-General of WHO's Global Commission on Women's Health, this overview provides a comprehensive review of FGM globally, including a description of the practice, prevalence by country, involved organizations with contact information, United Nations statements, a bibliography, and more.

WHO. Islamic Ruling on Male and Female Circumcision. The Right Path to Health: Health Education through Religion No 8 [Non-serial publication of the WHO Regional Office for the Eastern Mediterranean]. Geneva: WHO (1996). More information available at: www.emro.who.int/Publications/HealthEdReligion/CircumcisionEn/.
Three noted Islamic scholars explain how female circumcision is not supported by their religion. One scholar even concludes FGM is "an odious crime." The practice of male circumcision is supported.

WHO/UNICEF/UNFPA. Female genital mutilation: a joint WHO/UNICEF/UNFPA statement. Geneva: WHO (1997). Ordering information available at: www.who.int/docstore/frh-whd/publications/p-fgm1.htm.
This concise, 20-page document outlines the position of these United Nations agencies on the issue of FGM. While keeping the cultural context in mind, the document systematically portrays FGM as an unacceptable practice that must be eliminated. The human rights basis for this approach is explained, and a wealth of information follows, including an overview of the types and global prevalence, the physical and psychological effects, relevant international agreements, and an 18-point plan of action.

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