Female genital mutilation and the responsibility of reproductive health professionals

International Journal of Gynecology & Obstetrics 46 (1994) 127-I 35

Female genital mutilation * and the responsibility of reproductive health professionals N.

Toubia

’

Global Action Againsi FGM Project, P. 0. Box 1554. Cooper Station, New York, NY 10276, USA

Received 4 February 1994; accepted 7 April 1994

Keywords: Female circumcision; Female genital mutilation

Introduction According to a report by Dr. A.H. Taba, regional director of the World Health Organization, Eastern Mediterranean region, female circumcision (FC) was recorded as early as the fifth century B.C. by Herodotus and practiced among the Phoenicians, Hittites and Ethiopians [ 11. Other reports suggest that female circumcisions have been practiced in many civilizations in every continent over the years [2]. A variety of these operations are still practiced today, mostly in Africa and in sporadic areas of Asia [3]. Historically, genital surgeries were used in Europe and America to treat psycho-social disorders [4,5], and today there are reports of a variety of cosmetic labial operations performed at the request of women for nonmedical indications, usually because they or their *The tenonfemale genital mutilation and female circumcision are used synonymouslythroughoutthe text. ‘NahidToubia is a physicianand surgeonfrom Sudan,and currentlyAssociateProfessor at Columbia University, School of Public Health, New York.

partners think their labia are ugly [6]. Despite the widespread practice of non-medically indicated genital surgeries, consistent performance of female circumcision on large numbers of children is known to occur mainly in Africa. This paper will concentrate on female circumcision in Africa, its types, epidemiology and health consequences. It will reflect on the psycho-sexual consequences of female circumcision, and discuss medico-legal and health service measures to combat these dangerous and unnecessary practices. clinical topogrPphy In the past, there has been confusion on how to describe and classify the different types of female circumcision. A frequently quoted classification was first described by Shandaal[7], and later made popular by Verzin [8]. This classification starts with Type I, or ‘circumcision proper,’ described as the removal of the prepuce or the skin around the clitoris. Such a procedure would be comparable to male circumcision, and is erroneously termed

0020-7292/94/$07.00 0 1994 International Federation of Gynecology and Obstetrics SSDI 0020-7292(94)02109-C

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‘Sunna circumcision’. There is no conclusive evidence that such a type of female circumcision exists. In fact, Sunna circumcision as practiced in some Muslim communities involves partial or total removal of the clitoris. Another classification is described by the author [9] which groups the main types of female circumcision into two broad categories: (a) clitoridectonnes: Type I and II; (b) Infibulations: Type III and IV. Type I, or clitoridectomy, involves partial or total amputation of the clitoris. It is called Sunna circumcision in Arabic speaking communities, and goes by other names in others. When clitoridectomy is accompanied by partial or total excision of the labia minora the operation is termed excision, or Type II. Bleeding from the raw surfaces and from the clitoral artery is secured with a few stitches of catgut or thorn, or by application of hemostatic poultices made of herbs, ash, mud, coffee ground, egg-white or dung. Modified infibulation (also known as intermediate circumcision), or Type III, is a milder form of infibulation with the same amount of amputation, as type IV but the incision of the labia majora is limited to the upper two-thirds, thereby leaving a larger posterior opening. Total infibulation, or Type IV operation, involves the removal of the clitoris and the labia minora, plus incision of the labia majora, to create raw surfaces which are stitched together to cover the urethra and the entrance to the vagina leaving a small opening for passage of urine and menstrual blood. Introcision is another rare genital operation described in parts of Southern Africa and among some indigenous peoples of South America and Australia. Introcision involves the incision and inward folding of the vaginal entroitus. This anatomically precise and simplified classification is suggested to help clinicians and researchers standardize their description of a multitude of operations. The diagrams shown here depicting different types of circumcision may falsely give the impression of surgically accurate and neat operations, In reality, however, the extent of cutting, packing or stitching varies considerably, since the operator is usually a layperson with limited knowledge of anatomy and surgical technique. With

local or no anesthesia, the child’s wriggling often causes inaccurate cutting and damage of neighboring organs. The shape of the healed scar will therefore depend on the skills of the operator and the complications that follow. Although clitoridectomies (Types I and II) have many short- and long-term complications, they do not create mechanical obstruction to intercourse or labor. A tight infibulation on the other hand, can pose serious risks to both the mother and the fetus if not handled by a skilled operator. Women with infibulation will most likely need a ‘de-infibulation,’ to allow for passage of the fetal head without tearing of the perineum. De-infibulation may also be necessary for first intercourse. The procedure may be done by a physician or midwife; however, when a trained practitioner is not available, the husband or a female relative cuts the infibulation open using any available sharp object. Traditionally, re-infibulation is performed after delivery of the fetus and placenta, and the posterior opening is reconstructed to a size similar to that of the virginal state. Re-infibulation is physically harmful and health professionals should refrain from performing it. Circular stitches around the edges of each labium are necessary to stop bleeding and to keep the edges from fusing. This partial restoration of normal anatomy allows the free flow of urine and menstrual fluids, reduces pain during intercourse, and removes the threat of obstructed labor. In some countries where female circumcision was made illegal, re-inlibulation is correspondingly interpreted as illegal. For example, in the United Kingdom the Royal College of Obstetricians and Gynaecologists [lo] declares that: The agreed definition of the word intibulation is that it is ‘a stitching together of the labia.’ By definition, therefore, when an obstetrician is faced with the repair of the vulva of a woman who has delivered a baby vaginally following a previous intibulation it is illegal then to repair the labia intentionally in such a way that intercourse is diffkult or impossible.

Many women demand to have re-inlibulation with the erroneous belief that it is more pleasurable for the man. Although professional health personnel should not advocate or perform re-intibulation, neither should they ignore the woman’s feelings and beliefs. Counselling services to dissuade women and their partners from going to lay practitioners for re-

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construction should be linked to delivery and postpartum units. Geographical distribution (Table 1) Female circumcision, also considered female genital mutilation (FGM), is reported in at least 26 African countries that form a continuous belt across the northern sub-Saharan region, from Sudan to Senegal, and along the Nile valley from Egypt down to East Africa (see Fig. 1). The variation in prevalence between countries ranges from 5% in Uganda and Zaire, to almost 98% in Somalia and Djibouti. Intibulation is predominant in Sudan, Somalia, Djibouti and Mali, and is sporadic in other countries. Estimates of prevelance range between 85 million [ 1l] and 114 million [12] girls and women, with an annual rate of increase of about 2 million per year, due to the increase in population. This translates to around 6000 girls circumcised every day, or live every minute. The relative distribution of clitoridectomies and intibulations is not well documented. A crude estimate of 80-85% clitoridectomies and l&20% infibulation, or a ratio of 4: 1, is made based on reviews of both statistical and non-statistical data [ 131,(which is likely to have a wide margin of error). Mass immigration of African women to Europe, Canada, Australia and the United States in the past decade has brought the problems and controversies of female circumcision/female genital mutilation to these countries, and intensified world attention to this major health risk and human rights violation. The above data is gathered from a range of studies with varying degrees of validity. Many samples are based on clinical data or limited surveys, resulting in reporting bias that does not accurately reflect the national picture. The types of questions asked and the way the data has been analyzed vary considerably. Some country prevalence figures are informed only by estimates from anecdotal evidence. Better base-line information is needed to establish current prevalence by type of operation, age at circumcision, practitioner, socio-economic status of the family, and ensuing mortality and morbidity. Such information is necessary to design programs against the practice, set up services to treat its complications, and monitor the effectiveness of interventions over time.

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Recently, the Demographic and Health Survey (DHS) group developed a survey questionnaire module covering some of this information [ 141. It will be included in DHSIII surveys to be conducted in the next 3-5 years. If the DHS group secures the cooperation of researchers and governments in the concerned countries, more accurate data will be available to the world in the near future. Physical complications The delicate genitals of young girls are particularly vulnerable to damage by the surgical interference of lay practitioners using crude instruments. The vulva contains the specialized sexual organ of the woman, the clitoris, in a bed of rich neuro-vascular erectile tissue. The functional anatomy of the female genitals is identical to that of male genitals, but condensed in a much smaller area. The removal of even a few millimeters of the clitoris or a very small amount of vulva1 tissue causes grave damage, and has serious and irreversible effects. The following are some of the complications common to all types of female circumcision, but which occur most frequently with intibulations. Hemorrhage and severe pain are common, and may lead to shock, and occasionally, death. Prolonged bleeding may lead to severe anemia, and can interfere with the normal growth of an already poorly nourished child. Local and systemic infections are very common consequences, with both immediate and long-term effects, including abcess and ulcer formation, septicemia, tetanus, gangrene, and severe scarring. Chronic pelvic infection may cause chronic pelvic pain, severe dysmenorrhea, and infertility; [ 151 bladder infections can lead to urinary stones and kidney damage. The most common complication is the formation of dermoid cysts in the line of the scar, as a result of embedded epithilial cells and sebaceous glands in the stitched area. Dermoid cysts as small as a pea or as large as a football [16] have been reported. Keloid formation is another disfiguring complication, which, together with dermoid cysts, causes much anxiety, shame, and fear in women who think that their genitalia are re-growing in monstrous shapes or fear they may have cancer. A painful stitch neuroma may develop as a result of a nerve ending being trapped in the scar; this can cause severe

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Table I Statistical estimates of FGM in Africa. Estimated prevalence rates have been developed from reviews of national surveys, small studies and country reports and from Fran Hosken, WIN NEWS, 18(4): Autumn 1992 Country Benin* Burkina Faso* Cameroon* Central African Republic* Chad CBte d’lvoire’ Djibouti

Prevalence

Number 1200000 3290000

50%

70% 50%

-

Information on prevalence not available. 750 000

60% 60% 98%

1530 000 3 750 000 196000

Wpt

50%

13625000

Ethiopia and Eritrea

90%

23 940 000

Gambia* Ghana

60% 30%

270 000 2 325 000

Guinea* Guinea Bissau* Kenya

50% 50% 50%

I 875 000 250 000 6300000

Liberia* Mali* Mauritania* Niger* Nigeria

60% 75% 25% 20% 50%

810000 3 112500 262 500 800 000 30 625 000

Senegal

20%

750 000

Sierra Leone

90%

I 935 000

Somalia Sudan (North)

98% 89%

3 773 000 9 220 400

Tanzania

10%

I 345 000

Togo* Uganda* Zaire*

50% 5% 5%

950 000 467 500 945 000

Total

Notes

I I4 296 900

*Anecdotal information only; no published studies.

Prevalence based upon 1990 and 1991 studies in three regions. Irdibulation almost universally practiced. The Union Nationale des Femmes de Djibouti (UNFD) runs a clinic where a milder form of infibulation is performed under local anesthesia. Practiced throughout the country by both Muslims and Christians. Infibulation reported in areas of south Egypt closer to Sudan. Common among Muslims and Christians and practiced by Ethiopian Jews (Falashas), most of whom now live in Israel. Clitoridectomy is more common, except in areas bordering Sudan and Somalia, where intibulation seems to have spread. A 1987 pilot survey in one community showed that 97% of interviewed women above age 47 were circumcised, while 48% of those under 20 were not.

Decreasing in urban areas, but remains strong in rural areas, primarily around the Rift Valley. 1992 studies in four regions found that the age for circumcision ranged from eight to I3 years, and traditional practitioners usually operated on a group of girls at one time without much cleaning of the knife between procedures.

Two national studies conducted, but not released. A study of Bendel state reported widespread clitoridectomy among all ethnic groups, including Christians, Muslims, and animists. Predominantly in the north and southeast. only a minority of Muslims, who constitute 95% of the population, practice FGM. All ethnic groups practice FGM except for Christian Krios in the western region and in the capital, Freetown. FGM is universal; approximately 80% of the operations are inlibulation. A very high prevalence, predominantly infibulation, throughout most of the northern, eastern and western regions. Along with a small overall decline in the l98Os, there is a clear shift from infibulation to clitoridectomy. Clitoridectomy reported only among the Chagga groups near Mount Kilimanjaro.

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complications during labor, are reported anecdotally, but have not been quantified in any published study. The psychological ad sexual effects

Fig. 1. Distribution of FGM in Africa.

dysparunia, which may prohibit intercourse. Recurrent stitch abcesses and splitting of poorly healed scars, particularly over the area of the clitoral artery, can plague the woman and her physician for many years [17]. Labor adds other risks for infibulated women, particularly those with Type IV procedure [18]. If de-circumcision is not performed, obstruction of the exit of the fetal head may be overcome by strong contractions that lead to perineal tears. If contractions are weak and delivery of the head is delayed, the fetus will die, and pressure of its head on the pubic bone will cause necrosis of the septum between the vagina and bladder, resulting in vesicovaginal fistula (VVF). This results in a distressing condition of urinary incontinence, for which women are often ostracized from their community [ 19,201. Another labor-related problem is emerging among immigrants in Europe and North America, where physicians are not trained to handle infibulated women. Resort to cesarean section for fear of handling the infibulation scar adds the risks of general anesthesia and major surgery. This unnecessary surgery can be avoided with a simple de-infibulation performed under local anesthesia. The deaths of girls from circumcision complications, and of mothers from circumcision-related

In contrast to the number of studies and case reports on the physical complications of genital mutilations, little scientific evidence is available on the sexual and psychological effects of the practices. This has left the field open to the unsubstantiated speculations of literary and ethnographic writers [21,22]. For children, the desire to gain social status, please the family, and comply with peer pressure coexists with the fear and trauma of the operation [23,24]. If complications follow, they serve to add psychological effects and may ultimately outweigh the social benefits, tipping the balance towards deep psychological trauma [25]. In the author’s own experience in Sudan, clinicians see many infibulated women report a syndrome of ‘genitally focused anxiety-depression.’ This syndrome is characterized by constant worry over the state of their genitals, intolerable dysmenorrhea, and fear of infertility. A major study conducted by two Egyptian psychologists on 651 circumcised women suggests that a woman’s sexual desire is usually not affected by circumcision, but her ability to achieve orgasm varies, depending on the severity of the operation and the extent to which social messages inhibiting sexual expression are internalized. [26] The assump tion that all circumcised women have sexual problems or are unable to achieve orgasm has no scientific evidence to substantiate it. The extent and nature of the anatomic and psychological damage to the sexuality of circumcised women cannot be verified without further specialized and well controlled studies. For some girls and women, the psychological impact can be extreme. Cases of psycho-pathology directly attributable to genital mutilation were reported by Baashar in Sudan [27]. The first case he cites is one of anxiety hallucinations in a 7-yearold child; the second is a case of reactive depression due to delayed wound healing in a 32-year-old post-partum woman; the third is psychosis in a 30year-old woman who did not disclose the presence of large dermoid cyst. These are cases of extreme

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psychological reaction. For the majority of girls and women, the psychological effects are more likely to be subtle, and buried beneath layers of denial, mixed with resignation and acceptance of social norms. Understanding the psycho-social balancing act which allows the child to overcome the trauma of circumcision, and the adult woman to live with its consequences, is important to helping women overcome their resistance to change. Revealing cases of extreme psycho-pathology is less important than understanding the psycho-social mechanisms that perpetuate the practice among women. Such an understanding of acceptance at the individual and community level will be central to the design of messages against the tradition. Female genital mutilation as a human rights violation and the case for national legislation For years the debate over genital mutilation concentrated almost exclusively on the health risks of the operations [28]. The passage of the Convention on the Elimination of All forms of Discrimination Against Women (CEDAW) in 1981 alerted the world community to gender specific violations of women’s human rights, and the passage of the Convention on the Rights of the Child in 1990 directed world attention to the plight of the female child [29]. Although several articles of these two conventions could be applied to genital mutilation, it was not until 1993 that traditional practices were specifically mentioned as violations of women’s and children’s rights, in the Vienna declaration of the World Conference on Human Rights [30,31]. Infibulation was first made illegal in Sudan in 1946; however, clitoridectomy was still allowed under that law. Sweden (1982) and the United Kingdom (1985) have passed specific legislations to make all forms of female circumcision illegal, while other countries like Australia, Belgium, Canada, Cote d’Ivoire, Guinea, France, Holland, Italy, and the United States consider female circumcision illegal under existing child abuse laws. Specific antifemale circumcision laws are under discussion in Egypt, Burkina Faso, Kenya, the United States, and Australia. Whether specific legislations are in place or the practice is covered by child abuse laws, a case

against female circumcision for children under the age of consent is not difficult to make. Children are unable to give consent regardless of whether the child is consulted before the procedure or not. Parental consent for a procedure that damages rather than preserves a child’s health is ethically and legally unacceptable. Making the operation illegal for consenting adult women is more problematic, particularly when, as is the case in Europe and the USA, sex change operations and cosmetic surgery on the genitals and other parts of the body are allowed. More discussion must be generated about the similarities and differences between circumcision and other nonessential surgeries in adults. It is also necessary to standardize legislation, consent, counseling, and approval procedures for all body alteration operations. Thorough medico-legal deliberation on the issue will possibly result in the conclusion that female circumcision and re-inlibulation for adult women are not illegal, but are subject to the same rigorous approval requirements as sex change operations. These prerequisites would include adequate psychological counselling, proof of sound and independent decision-making ability, and a prolonged waiting period. Another area of legislative difficulty surfaces when the procedure is performed on young women between 14 and 20 years of age, as in some parts of West Africa. In these countries there are two problems with establishing consent and personal choice. First, in most African countries where genital mutilation is practiced, there is no established age of consent in the legal code. Second, consent and choice are meaningless unless the individual is given adequate information on the consequences of the procedure. They are equally meaningless unless the benefits of not having the procedure are fully explained, and the woman has the explicit power and right to refuse the operation. These prerequisites are not available for young women in most societies, and are certainly unavailable for the millions of girls and women who suffer this operation in Africa. It is therefore clear that unless the proportion of women’s social and economic power grows dramatically, no true choice can be claimed. The difference in how laws may be articulated in Europe and America versus their delineation in Africa must be left to a more specialized forum.

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Although legislation against female genital mutilation is not yet very advanced in Africa, some lessons learned from past attempts to ban the practice through legislation are important to note. In Sudan the colonial administration made inlibulation (but not clitoridectomy) illegal in 1946. Today, almost 50 years later, the Sudan DHS shows that 89% of women and girls in Northern Sudan are infibulated. This shows that legal action that is not accompanied by information and education programs is ineffective. Evidence clearly indicates that a rush to legislate without first generating enough social awareness against the practice increases resistance to change and may merely push it underground. In addition, the potentially powerful tool of criminalization is useless when the legal system as a whole is non-functional, as is the case in many African countries. It is not necessarily a priority action in most African countries and will require careful assessment by local legal experts. Female genital mutilation and the ethics of the health profession Apart from criminal legislation against female genital mutilation, another set of regulations may be pursued. These are civil laws governing the health profession, Ministry of Health (MOH) regulations, and ethical guidelines of health professionals’ associations [32]. Such measures would effectively prohibit the practice by trained health professionals. In Egypt, for example, such regulations were put in place in the 1960s and have successfully kept the practice out of the modem health system. Egyptian regulations are said to be contributing to the decline of the practice among the educated and urban populations. Beyond passing such regulations, publicizing them through doctors’ and nurses’ associations, as well as through the media to the general public, is an important tool in eradicating the practice. Prescribed penalties for breaking the regulations should be made explicit, and offenders must be shamed in public and have their licenses revoked. Such action would send a strong message of condemnation of the procedures from the highly respected professional health establishment to the general public. In the past there have been suggestions that health

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professionals should take over performance of the practice and perform its milder types under hygenic and controlled conditions. Such suggestions are unacceptable. The unnecessary removal of a functioning body organ in the name of tradition, custom, or any other non-disease related cause should never be acceptable to the health profession. All childhood circumcisions are violations of human rights, and a breach of the fundamental code of medical ethics. The World Health Organization (WHO) adopted a policy of opposition to the practice in the 1960s which it has since maintained. In 1993, the World Health Assembly issued a strong statement denouncing the practice and calling for concerted measures to abolish it. Similar statements have been published by the International Federation of Gynecology and Obstetrics [33] and the Royal Colleges of Obstetrics and Gynaecology in the United Kingdom [34] and Canada [35] in the last 2 years. Another aspect of female genital mutilation legislation is the issue of the legality and ethicality of re-intibulation. Many women demand re-infibulation after vaginal delivery because they are strongly socialized to find ‘exposed vulvas’ unacceptable, and to believe that it makes intercourse more pleasurable for the man, and would secure his fidelity. From a legal point of view, the argument could be made that these women are usually above the age of consent and can choose to be re-infibulated. Ethically, based on the increased health risks of inIibulated women, health professionals should opt not to re-infibulate. However, the woman’s feelings should not be ignored either. Counselling to help the woman work out why she wants to re-inlibulate should be pursued, and as much as possible women should be supported to make their own decisions without pressure from their partners, if they are suspected to be in favor of intibulation. The partner also should be counselled, and in many cases could prove to be an ally in dissuading the woman from the practice. It is important that existing and future actions against female genital mutilation by the health profession be consolidated through the following steps: The articulation of a clear code of ethics regarding the involvement of health professionals in the practice of female genital mutilation on children and on consenting adults.

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A discussion followed by a clear statement on how to manage the surgical and emotional aspects of infibulated women after vaginal delivery including the question of re-infibulation. The promotion of adopting similar policy statements and ethical guidelines by all other health professional associations, and medical and nursing schools. This effort should be directed at countries where the practice is prevalent, and where health personnel are faced with societal demands to provide female circumcision and may be tempted by financial gains. Integrating female genital mutilation abolition programs within health services Although abolition of female genital mutilation cannot be the exclusive responsibility or domain of health providers, it is their responsibility to deal with this major health hazard. Physicians and nurses have two important advantages in dealing with this deeply entrenched social practice. First, they command social respect and authority which can be effectively utilized in the fight against female genital mutilation. Second, they have direct contact with women who may not be accessible to other professionals like lawyers, teachers or social workers. Complications of circumcision can be detected and treated in gynecological and anti-natal clinics. Intibulated women may be advised and counselled to have a de-intibulation long before delivery in order to avoid obstructed labor, or the added risk and discomfort of a perineal cut during labor. Counselling against re-inlibulation and against the circumcision of daughters could also take place within obstetric and gynecological services. Counselling can be conducted with the woman, the husband or sexual partner, with other family members, or in support groups. Family planning services also have a role to play. Providers can be trained to detect and treat circumcision complications. Women with tight inlibulation may be advised to de-infibulate to improve treatment of infection, and to increase contraceptive choice by facilitating the introduction of an IUD. Marital and sexual counselling within family planning clinics is necessary for better contraception, but can also be an entry point for discussing female gen-

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ital mutilation and its consequences for women and their partners. Advice against circumcision of daughters can become part of a comprehensive reproductive health information and counselling package delivered through oral, written or audiovisual media. Similar treatments and messages can be integrated into child health services, where pediatric nurses and physicians could become important agents of change. Conclusion In many societies, health professionals have successfully opposed tribal ritual and other customary bodily mutilations. Female genital mutilation should not be exempt from such opposition. The practice is damaging to the physical and psychological health of girls, and is performed without true consent. It is the moral duty of educated professionals to protect the health and rights of those with little or no social power to protect themselves. In fact, in many countries, such as Sudan, health professionals have been in the forefront of exposing and opposing this practice. But more needs to be done. Physicians, nurses, and midwives should be made familiar with the practice, its types and distribution, and their complications. An active debate should exist within the health profession and with other groups, including legal specialists and grass-roots women’s organizations, to determine the appropriate ethical stance and legal actions needed to combat the practice. Health services should design and integrate programs to combat the practice and should do so in close consultation and collaboration with individuals and groups familiar with the community. The women’s decade has helped make the world realize the importance of gender equality for just and civilized societies. Today, women’s rights are accepted as human rights to be protected and defended. Female genital mutilation is a clear violation of women’s rights, and the de-sexualization of women an affront to their dignity. From now on, the question should never be whether the practice should be abolished or not, but how it can be abolished sensitively and effectively, without hurting those who already suffer from it.

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cum&ion in Somalia. In: Female Circumcision: Strategies to Bring About Change, pp. 94-99. Italian Association for Women in development, Rome, 1989. [211 Light-Foot Kline H, Shaw E: Special needs of ritually circumcised women patients. J Obstet Gynecol Neonat Nurs 20: 102, 1991. 1221 Walker A: possessing the secret of joy. Harcourt, Brace and Jovanovich, New York, 1992. Walker A, Pannar P. Warrior marks. Harcourt, Brace and Jovanovich, New York, 1993. 1231 Baasher T: op. cit. 1241 Warsame A: op. cit. 1251 Singhateh SK: The incidence of female circumcision in the Gambia and its effects on women and children. In: Female Circumcision: Strategies to Bring About Change, pp. 77-85. Italian Association for Women in Development, Rome, 1989. 1261 Karim M, Ammar R: Female Circumcision and Sexual Desire. Ain Shams University Press, Cairo, 1965. r271 Baasher T: op. cit. 1281 46th World Health Assembly press release: female genital mutilation - World Health Assembly calls for the elimination of harmful traditional practices. World Health Organization, Geneva, I2 May 1993. (291 The World’s Women 1970-1990. United Nations Publication Sales No. E. 90.XVII.3, USA, 1991. 1301 Sullivan D, Toubia NF: Female genital mutilation and human rights. Report for the World Conference on Human Rights: Vienna, June 1993 (available from authors). 1311 The Vienna declaration and program of action: June 1993. World Conference on Human Rights. United Nations Publication DPI/1394/39399, August 1993. 1321 A’Haleem, AM: Claiming our bodies and our rights: exploring female circumcision as an act of violence. In: Freedom from violence, pp. 154-157. UNIFEM, New York, 1992. 1331 Joint WHO/FIG0 Task Force. Female Circumcision (Female Genital Mutilation) Int J Gynecol Obstet 37. 149, 1992. 1341 Press release: female circumcision (female genital mutilation). Royal College of Obstetricians and Gynaecologists. London, June 1993. (351 New policy: female circumcision, excision, and infibulation. College Notices 25: The College of Physicians and Surgeons of Ontario, March 1992.