This article was initially published in Arabic on Masrawy
“I’ll never forget when they stripped me of my clothes and tied me.”
Reem didn’t know she was going to undergo female genital mutilation. Her mother took her to visit her grandmother, where she was ambushed, and her legs and hands were tied. The nurse, whose face still gives Reem a panic attack, pulled out a tool that looks like a scalpel and cut a part of Reem’s body that she deemed unnecessary.
Medicalized female genital mutilation (FGM) is a procedure performed by healthcare providers, such as a doctor or a nurse. Eighty-three percent of FGM procedures done to girls between ages 0-19 are performed by a doctor or a nurse, according to a 2021 health survey.
Egypt ranks first in medical FGM among 31 countries where FGM is still practiced. Furthermore, according to UNICEF, the practice has given parents a false sense of confidence in this procedure, particularly because of the fact that doctors, nurses, and other professional healthcare providers perform it.
Dr. Maria Armia, an OBGYN specialist, said that the culture and practice of FGM is still common in Egypt. In fact, the young girls’ families resort to doctors and nurses to perform the procedure in order to protect their girls from infection or bleeding, and also to try and ease their consciences by having a healthcare provider do such a procedure.
Meanwhile, these healthcare professionals practicing FGM violate the girls’ and women’s rights in leading physically and mentally healthy lives. According to the United Nations, they also violate basic medical ethics represented in not inflicting harm.
In many places in Egypt, people who practice it do not call it FGM, but proudly and loudly call it “purity”, an expression that casts an angelic shadow and wide societal acceptability on this crime.
Reem: “I remember everything as if it happened just yesterday.”
At the time of her FGM procedure, Reem was only ten years old. She didn’t understand what was happening to her body and no one cared to explain to her. Her mother only told her that “purity” is necessary for all girls, and those who are not circumcised “will become immoral when they grow up.”
In Reem’s village in the Monufia countryside in Lower Egypt, girls are still tied and forced to undergo FGM by a doctor or a nurse, but now, it happens in secret unlike before, Reem and her mother confirm.
Reem’s mother, just like all mothers in the village, decided to resort to doctors and nurses to perform the FGM, unlike asking the midwives in the past, thinking that specialized doctors can perform such procedures correctly without harming their girls.
Despite all what is said about FGM and its harms, and despite its criminalization, Reem’s mother is still convinced that what she did to her four daughters was a necessity, and she is trying to convince one of them to subject her daughters to this procedure or at least let a doctor check them, denouncing her daughter’s refusal.
Meanwhile, Reem experiences a panic attack whenever she ventures by the nurse’s house or runs into her by coincidence, even though it has been fifteen years since her FGM procedure. “I remember everything as if it happened yesterday, I will never forget when they stripped and tied me. I’m still scared of her”.
Reem says that all girls undergo FGM, and those who don’t are criticised even by other girls and are accused of immorality.
Reem, who got married a couple of years ago, feels that FGM ruined her sexual relationship with her husband and doesn’t care to carry on with it, although she loves him and has no marital problems with him.
Dr. Maria Armia says that girls never forget when their intimate parts are revealed for everyone to see, nor do they forget being tied and having parts of their bodies cut. They suffer from negative psychological effects which are later on reflected on their relationship with their husbands as well as their self-esteem: They feel that they lack something and their bodies are flawed, and things get worse in case they get criticized by their husbands.
Who put the FGM scalpel in the hands of doctors and nurses?
In September 1994, while Egypt was hosting the Population Conference which had female genital mutilation as part of its agenda, CNN broadcasted a disturbing report about a child called Najlaa. The child’s father stripped her naked, tied her hands, and opened her legs for a ‘health barber’, the term for a street doctor performing FGM, to circumcise her.
The girl was shaking and her screams deafening, whereas everyone around her, most of whom were men, were smiling, enjoying themselves on the melodies of her mother’s cheers.
Weeks after broadcasting the TV report and following the criticisms it sparked, the Minister of Health issued a decision aiming at wringing the scalpel from the hands of the ‘health barber’, placing it into the hands of doctors and nurses. Until now, no one has succeeded in removing the scalpel from their hands, despite successive decisions and severe penalties.
UNICEF points out that the ministerial decisions issued in the nineties, which restrict performing FGM to specific medical facilities and in cases of medical necessities, leaving the decision to medical practitioners, is among the factors that contributed in medicalizing FGM.
Moreover, the campaigns against FGM, which exclusively focused on the health risks of the procedure, encourage perceiving the issue as a medical issue.
Iman: “I’ll never forgive her … I have felt naked ever since.”
Cairo native Iman and her educated mother, who is employed at the Ministry of Health, have watched many awareness campaigns on FGM and its harms. Although the mother was a victim who suffers from the effects of being subjected to FGM, she didn’t spare her daughters the pain of the scalpel or being subjected to examination.
On that day, Iman’s mother asked Iman to shower so they can go shopping for hair bands and nail polish, yet the outing the little girl was enthusiastic about ended inside one of the hospitals, which at that time was under the supervision of one of the Islamist groups, specifically inside the obstetrics and gynecology clinic.
The male doctor asked Iman to take off her pants to examine her, and when she refused and tried to escape from the room screaming and crying, her mother slapped her, dragged her to the bed, and stripped her of her clothes.
“I realized he will circumcise me; I was scared and ashamed”, said Iman.
When the doctor said that Iman doesn’t need FGM at that time, her mother started urging him saying, “Are you sure she doesn’t need it? Please make sure!”, which made the doctor re-examine her and say, “She doesn’t need it now, but bring her back in a couple years and we’ll see”.
Iman survived, at least from the scalpel, but her relationship with her mother was no longer the same. “I’ll never forgive her … I have felt naked ever since.”
While Iman escaped FGM, 14 percent of girls under the age of 19 have been mutilated, and 13 percent of mothers plan to have their daughters undergo FGM.
Tadween: “50 percent of medical students believe that some girls need to undergo FGM.”
A 2020 survey by Tadween Center of Gender Studies on medical school students’ knowledge of, attitudes towards, and practice of FGM, revealed that 10 percent of them intend to perform FGM in the future, whereas 8 percent didn’t specify their stance yet.
Half of the participants in the survey think that some cases call for female FGM, and 82 percent of them support FGM in the case of an “inappropriate” shape of the genitals.
Dr. Amal Fahmy, Director of Tadween Center and a researcher in the study, said that the purpose of the study was to specify the attitudes of medical students towards FGM, how much they support it, and their stances on performing such a procedure in the future.
Dr. Fahmy believes that the increase in medicalized FGM is connected with the awareness messages that initially focused on the medical risks of the procedure, such as bleeding, wound infection, sterility, and others. In return, people resorted to doctors to perform it.
She thinks that doctors agree on performing FGM because they are soaked in this social culture that connects FGM with disciplining women’s behavior, and some see it as a religious necessity. Some doctors perform it for financial gains, while others do it to receive social acceptance and avoid stigma.
“Some doctors told us that they tried raising the awareness of the risks of FGM, only to be stigmatised [as bad people]. People stop going to them, and some doctors resort to performing FGM, cutting a small part [of female genitalia] or even pretending to perform it so they won’t lose their social status,” added Amal.
Amal calls for ending medicalized FGM as doctors know its risks and harms, and they essentially violate their oath by performing it. Doctors have this social status that confers legality and social acceptance to FGM, making it difficult to fight such practice.
A doctor performing FGM: “We perform excisions and not FGM.”
Dr. M, who refused to reveal his name in fear of lawsuits, defends performing FGM in one of Lower Egypt’s cities, by calling the procedure an excision. “Of course FGM harms girls, and we do not perform FGM but refinement which is useful to girls and protects them, and that’s what our prophet recommended,” he confidently said.
The doctor believes that FGM will be performed, whether doctors accept or refuse to do it, because it is what the girls’ families want. Therefore, it is better to be done by a doctor to minimize risks of infection and bleeding, and so doctors can remove a small part only. He added that doctors were allowed to perform FGM a while back.
Commenting on the criminalizing law the and Dar Al-Ifta’s prohibition of female genital mutilation, the doctor said: “They are prohibiting [FGM] depending on the state’s stance and pressures from the West.” This opinion was also adopted by a nurse in the Ministry of Health, who refused to reveal her name. She usually arranges with doctors to perform FGM procedures on the girls from her city in one of Upper Egypt’s governorates.
Maria Armia, a specialist in obstetrics and gynecology, is often asked to perform FGM or examine girls to determine if they need FGM, which she refuses. In return, she faces condemnation and anger from the girls’ families, and they often never return.
Maria believes that some doctors accept performing FGM to gain acceptance and trust from their community, leading to more cases needing follow-up for pregnancy, childbirth, and other issues, not just FGM. Additionally, some are convinced it is a religious practice, which they call “Sunnah circumcision.”
Maria emphasizes that some doctors perform a superficial incision to convince the girl’s family that she has been circumcised, but she believes this is not an acceptable solution. While it may prevent the girl from undergoing FGM, it contributes to the continuation of the practice. Additionally, some families are not satisfied with the superficial incision and repeat the procedure.
Heba: It is a shame for an Upper Egyptian girl to not be “pure”.
Heba was about six years old, when the split-in-half-razor cut her and her sister. She didn’t know that she was going to be circumcised that day, as she didn’t recognize the place or realize the reason behind it.
“I was so young and understood nothing, but I knew that ‘purity’ was normal and all girls have to go through it,” said Heba.
To this day, group female genital mutilation procedures are performed on little girls in Heba’s village in Upper Egypt, most of them done by doctors or nurses in houses away from clinics and hospitals.
Heba talks about a recent group FGM procedure, when more than ten girls, including sisters, relatives, and neighbors when a doctor visited them in one of their houses and performed FGM on all the girls.
Dr. Armia, who works in Sohag, Upper Egypt, confirms the occurrence of group FGM procedures by medical personnel, whether in her governorate or in Upper Egypt in general. Group FGM makes it harder for girls to escape such a procedure submitting to social culture and the fear of stigma.
Twenty years after Heba was subjected to FGM, the young mother with a university degree, thinks of the fate of a daughter she didn’t have yet: She hasn’t decided whether to subject her to FGM or not.
Heba fully realizes what a woman in her town would be subjected to if she refused to circumcise her daughter: “ [The woman’s] husband and his family would object. The news would spread and people would shame [the] daughter. This is why mothers do this against their will.”
Heba, like other women in her village, watch the campaigns raising awareness against FGM and criminalizing it, but she believes that they are not effective. “They think that girls not being circumcised is a shameful thing and that doctors perform it, so there’s no danger… One girl got married without being circumcised, and her husband criticized her and told his family.”
According to the United Nations Population Fund, FGM can never be safe, even if performed in a sterile location by a medical specialist, and medicalizing FGM gives a false sense of safety despite being associated with serious risks.
By accepting to perform FGM, workers in medical sectors falsely legalise this practice showing it as safe and healthy for girls and women, especially as they’re respected by society and hold high societal statuses.
No one reports FGM procedures
Maria receives little girls who were subjected to FGM and left to bleed for a long time, in the hope that the bleeding would stop without seeking medical care that may subject them to legal liability. This is why many of the girls arrive in bad conditions and most are subjected to FGM on the first or second degree.
Maria says that, in that case, the hospital offers medical aid to the patient, which usually includes suturing the wound and giving them a blood transfusion, then informs the hospital administration to contact the children’s helpline or report the child’s family to the police, but that does not happen often, especially in the villages.
Maria points out that police officers are usually from the same village and they try to settle the issue without filing a report. Doctors also fear that the family would assault them if they insisted on reporting the issue.
Everyone is pleased and girls are the only ones who pay the price. Maria believes that medical personnel who perform FGM are reassured that no one will report them as they do it at the request of the girls’ families, so they are more careful about disclosing the procedure for fear of legal accountability for both parties, and not because it no longer happens.
Severe penalties… suspended
In April 2021, the Official Gazette published Law No. 10 (2021), which addressed the medicalization of FGM, penalizing those performing it and requesting it, applying severe penalties on doctors and nurses performing FGM.
The United Nations praised the law, considering it a historical moment, as Egypt continues strengthening the legislations criminalizing FGM, especially that the new amendments shall have serious implications for those practicing or promoting FGM.
Maria believes that it is important to severely penalize medicalized FGM, however it is not enough to control the problem, and it may even contribute in pushing people to practice it in secret. Changing the culture surrounding it is more important, for after all, the medical staff are part of their environment and culture.
We conducted a search of news articles published about FGM in the news archive from April 2021 to the end of August 2023.
We found that one judgment was issued in September 2021 based on the strict law. It sentenced a father and a nurse in absentia to prison, with the father receiving 3 years of hard labor and the nurse receiving 10 years of imprisonment. They were convicted of circumcising the first defendant’s daughter and causing her permanent disability.
Asmaa: Waiting for the scalpel for years in fear
Asmaa, who used to live with her a family in a European country, knew quite well that she was to undergo FGM just like her eldest sister, and that it would happen during one of their summer vacations back home in one of Cairo’s neighbourhoods.
For years, Asmaa used to feel sick when the time came for their annual visit to Egypt, eavesdropping on her parents’ conversations so she would know their plans for her. She waited in horror for the scalpel for more than seven years.
And once upon a cursed visit, a doctor came to her family’s house in Cairo. She started with two of her relatives, while Asmaa listened to their screams and the sounds of scissors and scalpels being sterilized specially for her.
When it was her turn, the mother ordered Asmaa, the shy and scared girl, to take off her pants for the doctor to examine her. She was then laid down on a plastic table cover, the same one she saw her grandmother spread on the floor while slaughtering the sacrificial animal on Eid Al-Adha, but on that day, she was the one to bleed, with no feast to celebrate.
Two of her relatives helped her mother in forcing Asmaa to take off her clothes and restrict her movement, while the scary lady started to, what Asmaa describes as today, “rip her flesh [apart].”
“I think that the whole neighborhood heard my screams that day, but strangely after all the pain and shame I went through, I felt relieved for the first time in years. The tragedy of waiting was over, even if it ended in cutting my flesh… I lived in fear for years,” said Asmaa.
We tried to get a comment from Doctor Amr Hasan, advisor to the Minister of Health and Population for Population Affairs and Family Development, on the ministry’s measures to combat medicalized FGM, but we received no response until the publishing of this report.
The World Health Organization believes that Egypt should exert intensive efforts to prevent all forms of “medicalized FGM”, based on the basic ethical principles of health care.
Female genital mutilation cannot be allowed in any form or place, for it is harmful for girls and women in all its forms and degrees. Medical staff performing the procedure does not prevent harm, but rather facilitates the survival and continuity of such a practice.
