Excision: The cutting or removal of some or all of the external female genitalia, her clitoris, her inner labia. “Cutting is a form of violence committed against little girls. It is one of the most serious types of sexual violence,” says Dr Ghada Hatem, an obstetrician-gynaecologist, in front of a crowded room at Hospital Delafontaine in the French suburb Seine-Saint-Denis. The practice, which some describe as “traditional”, “religious” or even “mandatory”, is difficult to eradicate, including in France, where it is nevertheless punishable by law.

Diaryatou Bah was circumcised when she was 8 years old in Guinea Conakry where she lived before coming to France: “It happened one morning. A woman came and took me outside. I found myself surrounded by aunts, neighbours and my grandmother. Two held my feet while two others help my hands. They covered my face with leaves. No one explained what was going to happen to me.” 

The founder of the “Espoirs et combats de femmes” (“Hopes and dreams of women”) association and author of the book “They stole my childhood from me”,  Bah remembers certain details vividly.

“I’ll never forget the knife and the feeling when the woman cut me. My own scream. I am 37 and I still remember the details. I knew I was going to endure the procedure one day because it was what every little girl went through; that was the ritual. All the women in my family have undergone the practice.” 

What followed was “indescribable pain and three weeks without being able to walk”. She took a long time to understand her experience, she says.

“Until the age of 20, I thought all the women in the world went through the same procedure.”

Risk of FGM increased by Covid pandemic, war in Ukraine

Bah’s story is similar to the one shared by millions of little girls in Africa, the Middle East and Asia. Out of the 200 million women who have been victims of FGM worldwide, 125,000 who have undergone the procedure live in France, according to statistics published by the Weekly Epidemiological Bulletin (BEH) in July 2019. The overall number of victims could even be revised upwards, according to projections by the United Nations.

The Covid pandemic and the war in Ukraine account for the increasing number of women suffering FGM. “In Africa, some circumcisers have begun to re-adopt the ritual. Families do not have enough to eat, schools are being closed and the solution is to marry off their daughters,” says Isabelle Gillette-Faye, sociologist and director of GAMS (Group for the Abolition of Sexual Mutilation, Forced Marriage and other traditional practices harmful to the health of women and children).  Globally, she adds, we have gone from a risk of 2 million victims of FGM per year to 3 or 4 million by 2030.

Despite the gloomy predictions, and even if she says it is necessary to remain “attentive”, Gillette-Faye prefers to concentrate on the achievements of 40 years of prevention and education. In France, the first cases of FGM appeared at the end of the 1970s. Men from Sub-Saharan Africa who had come to France to work also brought their wives. Paediatricians from the Maternal and Infant Protection (PMI) service discovered the first mutilated girls during medical examinations. In 1982, a three-month-old girl died in hospital in Paris following an excision. A wave of shock rippled across France. The little girl’s doctors filed a civil action lawsuit.

At the time, even though excision was not mentioned, FGM was considered a crime punishable by 10 years in prison and a €150,000 fine, according to article 222-9 of the penal code. The law applies whether or not FGM took place in France or during a vacation in the country of origin, as long as the victims live on French soil.

“Families find it difficult to understand that the law applies in France even if they have their children circumcised outside the national territory and regardless of their nationality,” says Gillette-Faye.

Since the 1980s, nearly 30 circumcisers or parents of mutilated girls have been put on trial in France. In April 2022, a 39-year-old mother received a five-year suspended prison sentence for the excision of her three oldest daughters, including one who is mentally handicapped, between 2007 and 2013. The procedures took place during the girls’ visits to their grandmother in Djibouti, a country where FGM has been banned since 1995.

“Up until then, we had only been talking about West Africa. We discovered that families from East Africa could be judged, condemned and owe damages to their children for having practiced FGM even if the procedure took place outside the national territory,” says Gillette-Faye, who attended the trial.

Silence prevails

What accounts for the persistence of this tradition despite the laws against it?

For uprooted families, perpetuating this tradition allows them to cling to their cultural identity.

“Many use the religious argument that it is written in the Koran,” says Dr Ghada Hatem, also founder of La Maison des femmes (The House for Women) in the Parisian suburb of Seine-Saint-Denis. She adds that the practice does not exist in any of the books of the three Abrahamic religions: Judaism, Christianity and Islam. There is also the fantasy that a “pure” woman is an excised woman, that it increases fertility and that the child has a better chance of being born alive.

As for the taboo about openly discussing FGM, it is almost omnipresent within the family and the community of origin. “In the community silence prevails, as always in the case of violence, guaranteeing that the practice will be maintained,” says Hatem. “Girls are excised without an explanation. Over there [in the country of origin], what is not normal is an uncircumcised girl. She is seen as impure and above all, she will not be able to marry. In order for her to remain a virgin until marriage, she must be circumcised,” confirms Bah.

Sometimes these women are unaware of their excision. “I see women on a daily or at least weekly basis who have undergone FGM. Some of them do not even know they have had it,” says Agathe André, a midwife at a public hospital in Nanterre, near Paris. “There is no easy way to say it but it is important that we inform them, especially when they give birth to a little girl. They will potentially return to their country of origin and they must be made aware that in France, the practice is forbidden.”

“Many women don’t know if they are excised because they were in the cradle when they went through the procedure,” says Gillette-Faye. Very often, they only discover what happened to them during a visit with their gynaecologist or sometimes during childbirth. “I have patients who were very angry. Some had given birth four times in France and no one ever told them anything,” says Hatem.

Do some doctors and women stick their head in the sand when it comes to FGM? Certainly. Fear also plays a role. As with other cases of violence against women, doctors must measure their words in order not to accentuate or awaken sometimes buried trauma. “If you approach the subject in an inappropriate, humiliating or critical way, you will do a lot of harm to the young woman you’re dealing with,” says Hatem, who trains health workers in best practices.

“As soon as you start talking about ‘normal’ vulvas, you do damage,” adds Gillette-Faye, speaking from her own experience and also referring to reconstructed genitals seen in pornographic films. “It’s a form of aggression against mutilated women who already have a tendency to beat themselves up because they tell themselves that they are not normal.” 

For Hatem, a victim expects above all that “you explain to her what FGM is, what has been done to her, the consequences, if she can live normally and what you can offer her”.

Repairing lives

Victims sometimes suffer silently for many years. FGM can lead to sexual problems such as a lack of desire and/or pleasure, and shame. The trauma runs deep. Excision, forced marriage, rape, abuse – “The average fate of a little girl in Sub-Saharan Africa is often a continuum of violence,” says Hatem.

To help them rebuild their lives, repairing the anatomy of FGM victims is possible. In 1984, Dr Pierre Foldès, an urological surgeon and co-founder of Doctors without Borders, developed the only surgical method to repair the clitoris. “Everything is absolutely repairable…,” says Foldès. “The technique is reliable and there is an extremely low failure rate.”

The traditional circumcisers do not cut everything. “There is scarring that hides what remains of the clitoral glans. The technique consists of finding all these dead parts and gently removing them,” Foldès explains. “In this process, the clitoral stump is pulled upwards by the scarring and the pubic bone. When these abnormal adhesions are removed, the clitoris will descend and reposition itself normally.”

In 35 years, Foldès has performed reconstructive surgery on 6,000 women and his waiting room is always full. The victims sometimes come from very far away. And they’re ready to wait as long as it takes for an appointment.

All eyes on men

Having surgery is far from the end of the ordeal. “The goal is not to restore the clitoris but to restore normal sexuality,” says Foldès, who also helped found Women Safe & Children, the first care centre to provide full recovery for women victims of violence, in the Paris suburb of Saint-Germain-en-Laye. “We must consider all aspects of the trauma, treat each and accompany the victims throughout. If we operate, we have to accompany the patient for two years. We will treat the patient, teach her how to live with a normal organ and try to rebuild her sexual life. When you take time, the healing process works better.”

Repairing a woman’s mutilated genitals without repairing her mental health inevitably leads to failure. “Some women are disappointed because they do not see any improvement. Often, it is because their healing process is not optimal,” says Foldès. “Some women’s condition deteriorated after their operation…,” says Gillette-Faye. “Sometimes they skip steps and go to a plastic surgeon. There is a real market for cosmetic surgery. At GAMS, we have chosen to promote global care.”

To help eradicate FGM, all eyes are now on men. In Belgium, GAMS has launched awareness campaigns called “Men speak out”.

In France, the national federation also works with the association Femmes Entraide et Autonomie (FEA) (Mutual aid and autonomy for Women).

“We have to leave behind the notion that this is a women’s problem and that men don’t have to be involved,” says Gillette-Faye.

“We need to involve men so that they say ‘I will not marry a woman who has been circumcised’,” says Hatem. “Women circumcise little girls for men. If men say no, they will stop getting circumcised.”