Delineating the subject
The ‘terminology’ discussion (FGM, FGC, circumcision, FGM/C, FGMo, and local language labels), summarised in the Introduction, points to the fundamental dilemma: the practices are multiple, the meanings are hugely varied, the labels may be colonial or skewed with purposeful condemnation, or they may be uplifting or treasured in a faith or identity tradition. Yet despite the wide spectrum of severity, context, and meaning, the global discourse conflates them all to ‘female genital mutilation’ (FGM) and its connotation of harmful intentions. But a nick to an assenting seven-year-old girl’s prepuce, performed by a doctor, in a diaspora community of the South Asian Dawoodi Bohra sect of Ismaili Shi’a Islam,
1 The Dawoodi Bohra sect believes girls’ circumcisions, called khatna, are a religious obligation equivalent to the circumcision of boys. In South Asia, where most Dawoodi Bohra live, the procedure is thought to affect the clitoral tip or the prepuce. Among Dawoodi Bohra living in Australia, North America, or Europe, the procedure is described as a prick or scrape to the prepuce only, usually by medical personnel. For a discussion of lawsuits in 2017 and 2018, in the US and Australia respectively, and more broadly on the controversy over customary ‘gender equal circumcision’, see Shweder (2022). is a far cry from the most serious forms. It is quite unlike the Sudanese- and Somali-heritage ‘pharaonic circumcision’ practices that involve removing the clitoris tip, inner labia, and the edge of outer labia, and infibulating (by stitching or sealing) the opening, performed on a girl too young to fully understand the implications, sometimes in hygienic conditions, but other times not. Though both types of cutting may involve harm, risks, violations of laws or human rights and ethical principles, they are not equivalent. The wide range of effects, ages, and meanings across global contexts renders generalisations about ‘FGM’ futile. Most traditional meanings offer positive intentions, since they are part of preparation for marriage, a rite of passage, a mark of adulthood and inclusion in a desired identity group, a religious rite, or a procedure to improve beauty or health. Practices preserved or adopted to protect daughters from shame, isolation, or spinsterhood and to protect families from dishonour, or to maintain social status and avoid ethnic discrimination, are also understandable. But in the global discourse, the variety of practices are simply ‘FGM’, the language implies harmful intentions, and one-size laws and policies are recommended.
2 The Policy Advisory Network on Genital Mutilations which discusses the harms that result from the discourse itself (Ahmadu 2025).Granted, many practising communities and individuals, where there is awareness of health risks, human rights expectations, laws, and professionals’ restrictions, or autochthonous rethinking, and the ability to mitigate the social risks of discontinuing, have chosen abandonment or transitional lesser forms. But other communities and individuals react with resentment to outside pressures, defending or reframing their traditions in positive ways. Scholars tasked with critiquing these situations have also recognised similarities with male circumcision rationales, subjecting infant male circumcision and intersex infant ‘normalisation’ surgeries to ethical review. Additional arguments swirl around the inconsistencies emerging when tolerance for Western-originating cosmetic surgeries co-exists with criticism of comparable African cutting. We ask what really constitutes ‘harm’, what are children’s rights, and do cultural and religious rights merit special recognition?
Slogans using judgmental terms like ‘zero tolerance’ or ‘eradication’, as well as the insistence on using ‘mutilation’ and ‘barbaric’, are not going to promote the discussions that might foster mutual respect or serve as precursors to social change. Instead, reform efforts should start with listening to people and fostering discussions, as the 1990s Inter-African Committee activists were shown to do in their film Female Circumcision: Beliefs and Misbeliefs (Gruenbaum 1994) and as decades of subsequent African actors have done. To promote discussion and avoid stigmatising, scholars should avoid the word ‘mutilation’ and use plurals (‘cutting practices’, ‘modifications’) whenever possible.
Should rights be the focus and all forms banned? Proponents of some practices resist the idea that FGC violates human rights, asserting competing rights based on cultural identities and religious rights. Others consider medical permissibility (for comfort or appearance) and choice as sufficient reasons not to ban female genital cosmetic surgery (FGCS), if consent is assured. The communities who believe God demands their male or female genital modifications (e.g. prepuce removal for most Jewish and Muslim boys and genital khatna for Dawoodi Bohra girls) are also resistant to bans. An adult woman’s right to choose whether to restitch an infibulation after childbirth or seek deinfibulation is another example. And the rights movement for Bondo initiations in Sierra Leone (‘All Women are Free to Choose’) seeks to alleviate stigma and assert the right to follow identity traditions. For these, contentious scholarly research and journalism seek understanding across perspectives and shift ethics debates away from ethnocentric or ‘colonial’ judgments that tend to be applied to African- or South Asian-heritage peoples but not to others who practise FGCS or male cutting.
Embedded in religious expectations, ethnic identities, gender identities, and loyalties to grandmothers, the practices change and evolve, sometimes swiftly, sometimes slowly, or meet with resistance. Understanding what triggers different responses is not easy, but history offers examples of aggressive opposition encountering resistance (e.g. the Rufa’a Revolution against the 1946 ban in Sudan, Gruenbaum 2001). There needs to be a process for rethinking.
Discussion allows new thinking and can result in cultural norms shifting or rigidifying. And social marketing generates discussion, sometimes inspiration and excitement about images of uncircumcised ‘Saleema’, but hopefully always discussion and questions that help people decide their futures. Clear ‘anti-FGM’ laws – pushed by global reformers and embraced by some African feminists as a tool to help convince people to change their traditions – can be helpful at times. But laws are sometimes used by non-cutting majorities to stigmatise and criminalise ethnic or religious minorities. Ironically, the laws and WHO policy generally defend the rights of dominant groups to acquiesce to marketed cosmetic genital enhancements, such as amputating healthy labia (without full understanding of their life-long value) and other cosmetic surgeries, pursue genital piercings for pleasure, or push circumcisions of male babies and men in non-circumcising groups with dubious claims of health benefits.
Problems with the reform agendas
A Sudanese friend once scoffed at spending energy arguing about terminologies, saying we should just get on with making change that benefits women and girls. There’s wisdom in this. To focus on change that benefits people, we must listen to women and girls, and also men and boys, about their desires and hopes. Anti-FGM reform agendas and programmes are too often driven by imposed goals or donor metrics, despite frequent invocations of the need for ‘community-led’ change. People’s agendas for needed changes in their lives tend to centre on clean water, health services, educational opportunity, and economic development. Changes in genital modification practices may eventually be welcome, but it is often in the context of meeting other needs – poverty alleviation, women’s empowerment, or peace and security. For outsiders who imagine ‘mutilation’ only in its most forced, drastic, and nonconsensual forms, the reform agenda centres on ending ‘FGM’ at all costs. But ending cutting is not seen as desirable from the viewpoint of people who believe they are enhancing, elevating, beautifying, or spiritually purifying their girls. They are preparing them for adult lives and providing them with peer support, status, a special occasion when they are important. They are following a religious rite or providing access to future marriage and family life. Any reform effort against such positive goals must offer something other than condemnation. One strategy is to broaden the agenda, working with communities on multiple self-defined goals, as the NGO Tostan in Senegal has emphasised. It might be water supply, literacy, women’s leadership, economic opportunity, or better services. Tostan found taking these other needs seriously eventually led to a desire to end FGC.
Reform agendas like Tostan’s (www.tostan.org), or those of Amref Health Africa (amref.org) in Kenya, have sometimes produced broader programmes. The Alternative Rites of Passage strategy used for decades in Kenya (Conradi et al. and Hughes, this volume) also tries to meet social needs for girls’ solidarity groups, cultural learning, and life transitions, while achieving organisers’ intentions to prevent cutting. But as the chapters here show, the results of good ideas are not necessarily what is anticipated, nor are they easily replicable across the landscape of cultural variation. The organisers of anti-FGM/C programmes need to remember that having a good life, and the things that make that possible, are central, and ending female genital cutting practices may not be top of the list when families face conditions of poverty, inadequate food and water, lack of healthcare or schools or economic opportunities, or war.
Two decades ago, a Sudanese colleague, Lena El-Sheikh, and I spent a week doing ethnographic research in a community in western Sudan to determine whether an NGO’s year-long anti-FGM/C programme, completed two years earlier, had been successful. The programme’s monthly lectures by visiting awareness-raising speakers resulted in about 120 boys and men signing a ‘pledge’ to stop cutting their daughters and to ‘allow their sons to marry uncircumcised women’. Our sponsors sent us to learn more about ‘health issues of women and girls’, hoping that the pledge had been honoured and would have spontaneously spread to neighbouring intermarrying communities.
Our mission must have been obvious, because people dutifully denied they did any FGC and the local midwife we sought to interview made herself scarce. But our conversations paid off, and in the course of the week we learned FGC was still practised. The midwife initially denied ever having done circumcisions of any type but eventually welcomed us into her home along with a group of friends and neighbours, once she realised we were there to learn, not report her. She described her version of sunnah – that sounded more like Type 3 than Type 1 – as involving a few stitches. She gestured at the open window and the open countryside beyond, ‘I can’t just leave the girls open, like the road to [the city of] Omdurman!’ It turned out most of the women knew nothing about the pledge the men had signed, though they fully understood the NGO’s opposition to ‘FGM’. Later, one of the men laughingly confided that if Lena and I had been men, they would have beaten us up, because they felt so angry at the NGO. They had expected that by cooperating with the anti-FGM/C campaign, the NGO would build them a new classroom at the school or add another room to the clinic. But, when the funding for the campaign ran out, the NGO just didn’t come back. In an arid environment with no regular electricity, dependent on an ancient pump for their well, an inadequate school and clinic, but with hopes and dreams of a good life, they had a long agenda of needs, and they had expected the NGO would reward their pledge. It was a transaction that failed, from both points of view.
By 2025, an estimated fifteen million Sudanese civilians are displaced by a senseless civil war that has killed perhaps 150,000 in just two years. The war erupted in 2023 between the Sudan Armed Forces and the Rapid Support Forces militia group, between the two generals who had led the 2021 military coup against the civilian and military Transitional Council working to stabilise Sudan after an inspiring and costly pro-democracy revolution in 2019. That struggle against Beshir, the long-time president/dictator responsible for the Darfur genocide two decades ago and a long reign of oppression, had succeeded, gender equality policies were being pursued, and even a comprehensive law against ‘FGM’ was introduced. But the generals fought over military control of the gold industry and other economic interests, and sacrificed peace. The circumstances of civilian suffering of the Sudanese have been appalling, with massive destruction of homes, livelihoods, hospitals and schools, millions fleeing from bombings, home-takeovers, rape, pillage, hunger, and senseless destruction. The Sudanese agenda surely puts peace, restorative justice, safe shelter, and a return to something approaching normal life (schools, markets, neighbourhoods, and so on) at the top.
The medicalisation conundrum
Another problem with the reform agenda stems from the WHO’s decision to oppose all involvement of trained healthcare providers in FGM/C. This flies in the face of what many families seek. Although it is likely that practising communities have always been aware that risks are involved, the anti-FGM/C campaigns have highlighted health risks in a way that contributes to greater concern, stimulating a strong desire for good medical care when daughters face their time for FGC. Also, if they seek the lesser Type 1 cutting, families pressure health practitioners to do the work, a situation where ‘medicalisation’ can be a ‘driver’ that many believe could lead to normalisation of FGM/C instead of abandonment (e.g. Bedri et al. 2019). This is the contention of the WHO, and it is a widely-held belief. Yet, normalisation is not yet clearly demonstrated in data, nor can it be, because ethical and professional limits would prohibit such a study. All we have are ethnographic clues.
Nevertheless, families continue to seek safer venues and providers to do the cutting they feel compelled to do. This demand drives medicalisation, as the choice of a healthcare practitioner – whether trained midwife, nurse, or physician – offers ‘harm reduction’ advantages over the cutting done by TBAs. Many posters and pamphlets of the past graphically and emotionally depicted the horrors of health consequences, blood, and fear, with the image of the ‘evil midwife’, her razor blade, needle and thread at the ready, looming over a frightened girl. Those images, and what Johnsdotter calls ‘the Standard Tale’ of forced, drastic cutting with crude instruments, have been used by reformers to convince families to stop cutting immediately. I have sympathy for this message, but not its form, as there are many who recall their own experience with traumatic, dangerous, unconsented procedures and seek to prevent such painful experiences for girls in the future. But the fear evoked seems to have failed to inspire abandonment, and instead drives families to seek medicalisation.
Two midwives I met during my ethnographic work in Sudan were particularly helpful to my understanding (Gruenbaum 1991, 2020). The first, Sister Battool, was a highly experienced professional nurse midwife I interviewed in the city of Wad Medani in the 1980s and 1990s. She considered FGC unnecessary but was frequently asked to do it by clients worried about marriageability. She tried to talk them out of it, telling parents to let the daughter and her future husband decide later, when they were adults. If they persisted, she agreed to do the lesser non-infibulating cut only. The other midwife was Besaina, a farmer in the Gezira who, as a widow with young children, had had a year of formal training so that she could serve as midwife for her community. Midwifery school did not teach circumcision, which she learned from others. But when she carried out the severe pharaonic circumcisions, she applied hygienic practices she had mastered, and offered skilled cutting, suturing, and follow-up visits for the circumcisions and births she attended. I followed her career at intervals for four decades (from 1977 to 2016) as she moved through a series of changes. Initially she was proud of her extreme cutting and tight infibulations that left a smooth vulva with a tiny matchstick-size opening. Later, her experiences, her son’s comments after marriage, and her own religious learning and pilgrimage to Mecca led her to change from ‘pharaonic’ to sunnah. It took many years to fully implement that intention, since her community demanded pharaonic, but the national discourse and local teachers’ advocacy for the lesser form resulted in a community-wide shift to sunnah, around 1994, then to complete abandonment of even sunnah by about 2010, when Besaina took the oath the Sudanese Ministry of Health expected. This oath, which involved pledging to not do FGM/C, was first introduced in the early 2000s for midwives graduating from training facilities; later, it was asked of others already in practice. Some midwives continue to understand it to mean only giving up pharaonic cutting (Type 3) in favour of a lesser form (Bedri et al. 2019). My research participant Besaina understood it clearly as stopping all forms. And when she took the oath, her community was mostly ready, they had a supportive medical assistant to chase out two midwives from a neighbouring community who tried to do secret procedures, and the decision stuck.
Midwives have not always been included as allies in change, since they are often thought to be motivated to continue cutting in order to collect fees. But if ministries of health were to compensate midwives and offer them greater supervision, instead of leaving them to earn fees for their services, perhaps midwives could more effectively work in abandonment efforts. This could be a fruitful area of research: asking midwives and other healthcare practitioners about their patients’ attitude change over time, and about their roles in persuading clients against infibulation and educating for abandonment. Researchers could also examine whether midwives et al. are, on the other hand, normalising and reinforcing intermediate forms of the practice. It is important to find out how practitioners are influenced and how they may or may not be persuaded to change over time. The effectiveness and limitations of oath-taking, and whether midwives think it applies only to particular types, deserve deeper analysis in future research.
In peacetime contexts, local NGOs with women’s or development agendas found that international revenue streams flowed their way more readily once they added violence against women (VAW), gender-based violence (GBV), or ‘FGM’ eradication to their programmes. ‘The new “traffic in women”’, a Sudanese academic friend quipped, when he described this competition for funding. But it would be wrong to assume that organisations pursue this goal only when pushed by international actors to do so. Many NGOs with this agenda are far from cynical, exercising agency as ardent proponents of ending FGM/C. In Sudan, reformers know the potential for serious health consequences from the pharaonic circumcisions (WHO Type 3) that continue to be the most common form, and which were practised by untrained and ill-equipped dayat al-habil (TBAs called ‘midwives of the rope’).
Many Sudanese women know from their own experience that pharaonic cutting and infibulation are harmful to their health and comfort, even though they may have accepted it as necessary to meet other goals, like marriageability, avoiding shame, or meeting a religious expectation. A persuasive interview came from a woman I had known for many years, since her childhood, in a Gezira Province community. It wasn’t until middle age that she told me she experienced repeated hospitalisation and surgeries as a child, because her severe infibulation did not heal well. Growing up, she knew she would not want to cut her future daughters, but she dreaded the likely confrontation with her mother. She smiled: ‘Thank God all my children were boys!’ Such women are sincere in their desire for change – whether reduction in severity or abandonment. Survey data (Alassad, Chapter 7, this volume) demonstrate that such attitudes are widespread. But to implement change in their lives, they need a supportive social environment.
Fortunately, national scholars and academic institutions, ministries, and other local actors involved in the design of anti-FGM programmes are exerting a positive influence on agenda-setting in some countries. In Sudan, for example, the Gender and Reproductive Health and Rights Resource and Advocacy Center (GRACe) has initiatives in research, conferences, education, and outreach to end FGC. Led by Sudanese gender experts like Professor Nafisa Bedri at the dynamic Ahfad University for Women,
3 Ahfad is an independent Sudanese university with about 26,000 graduates from Sudan and other regional countries, offering studies in many professional and service areas, including a medical school and School of Public Health, with a commitment to experiential education and community service. The founding family, descendants of early girls’ education advocate Shaykh Babikr Bedri, had quietly stopped doing FGC by the 1950s or earlier, and by 1979 the university-affiliated Babikr Bedri Scientific Association for Women’s Studies was founded for educational outreach to end FGC. As of early 2025, with civil war continuing, the university is struggling from exile to provide online education until there is peace. and benefiting from international funding and in partnership with the Ministry of Social Welfare and Ministry of Health, a Sudanese-led agenda to address FGM/C is moving forward.
Sudanese academics and programme providers have long recognised the limitations of the international MICS and DHS prevalence data, which do not differentiate between the various types of severity and can only show very slow changes in prevalence of some form of FGM/C in successive cohorts of fifteen- to forty-nine-year-olds. GRACe scholars (Bedri et al. 2019) carried out research to identify indicators (‘drivers’) of readiness for change and the steps of change, short of abandonment, that could be utilised for better theories and programmes. Bedri et al. (ibid.) found that shifts in popular thinking and practice were widespread, and there were moves toward a preference for Type 1. Furthermore, limited laws in individual states (during the period prior to enactment of the national law) appear to have negatively affected healthcare professionals’ ability to be candid with researchers, as they claimed not to participate in cutting despite community members saying they performed Type 1. The data discrepancy is understandable, as professionals do not want trouble. Nevertheless, the findings suggest that Type 1 is becoming more widely practised in Sudan, and that it is being done by healthcare providers. Where there is a medicalisation option, it can be hypothesised, people are shifting to Type 1. Indeed, these authors argue that the medicalisation option has encouraged communities ready for change to see a shift in type, rather than abandonment, as an acceptable option. (Data are not provided on the question of whether that regularises Type 1 long term.)
Laws have limitations as strategies of change. Historically, Sudan’s national law only banned pharaonic (from 1946–2020) and was not enforced for decades. Feminists worked for a ban of all forms in the Child Rights Act of 2011, but it was blocked politically by the then president Beshir. A few states enacted weak laws that had little effect. In 2022, after the overthrow of Beshir, a new law banning all forms was adopted as Article 141 of the Criminal Act. But by 2023, that was derailed by war. Instead, research suggests that the most significant drivers of change are the awareness-raising about health risks from individual healthcare providers and in hospitals as well as educational sessions in mosques (where the religious association of sunnah Type 1 FGM/C is a likely factor in the preservation of some forms of cutting) and the oath required of trained midwives. But the brakes holding back change – or perhaps driving in another direction – were still the ‘strong cultural commitment to the practice of FGM/C, social networks and reference groups … forcing continuation of Type 3, and the practice of community social ostracism’ that threatens midwives ‘who refuse to do FGM/C’ (Bedri et al. 2019:172).
This research shows no conflict of mission between outsiders and insiders, but rather a genuine goal among Sudanese activists, healthcare providers, scholars, and community members alike to figure out how to make things better for women and girls. If we are convinced that medicalisation lengthens the road to abandonment, then it is banned or discouraged. Families who see it as saving a girl from infections or the other horrors the awareness-raising campaigns have publicised do not see why they cannot make this choice, a dramatic change away from ‘pharaonic’ toward ‘sunnah’, and why they cannot have good healthcare in order to do it. The healthcare providers, faced with families that insist on cutting and who may endanger girls with TBAs, and pressured by social opinion, appear to make the choice to medicalise quietly. It is not surprising that medicalisation continues in many countries, nor that Type 1 is gaining ground in Sudan.
Persistent medicalisation is an inevitable reality that coexists with striving for abandonment. The medicalisation ban also affected the government-employed maternal and child health aides I interviewed in Sierra Leone in 2008, who revealed that they indirectly, and secretly, assisted Bondo rituals by giving tetanus shots or providing sterile tools to the circumcisers to reduce the risks. Nevertheless, Sudanese reform activists continue to oppose medicalisation and seek a law to ban all forms of FGM/C – even though laws alone do not result in change and can create obstacles for obtaining accurate research data. Since the earlier law banned only ‘pharaonic’ and permitted sunnah, many midwives continued infibulation but relabelled their Type 3 cutting as sunnah, as for example the midwife in western Sudan who did ‘sunnah with a few stitches’ so the girls would not be too open. Eschewing the lack of clarity for their persuasion efforts, activists argue that they need the law to clearly ban all forms, no matter how minor or how hygienically performed.