If Egypt is to have any hope of shedding its status as the world's third-highest proponent of female genital mutilation (FGM), the role of advocates like the ebullient Doctor Magdy Helmy Kedees will be crucial.
The Cairo-based doctor has been one of the most outspoken voices against the practice since 1994, when he helped to form the country’s first FGM taskforce with the social development pioneer Marie Assaad.
Now working at humanitarian organisation Caritas Egypt, and with 25 years’ campaigning against FGM under his belt, his staunch belief is that the country is at a pivotal moment in its fight against the practice.
Despite it having been illegal in Egypt for almost a decade – thanks in part to the tireless work of Dr Kedees and the National Program for Family Empowerment and Abandoning FGM that he also co-founded – the country is still lumbered with the FGM millstone. If you ask Dr Kedees why this is, his answer is simple: it is the ‘medicalisation of FGM’ that is stifling any progress that has been made towards stopping it.
“The problem in Egypt lies in doctors and physicians,” he explains. “In a survey the Egyptian Ministry of Health published in 2014, more than 82 per cent of FGM cases were implemented by doctors – even after the law banning it was announced.
“People now believed that it was wrong to go to a midwife, so they were saying ‘let’s take our girl to a doctor’ instead. The law was passed mainly to oblige doctors to stop, but what happened was the opposite.”
Predictably, the price of performing FGM also increased, sometimes by as much as ten times the amount paid to a midwife. Dr Kedees explains why: “When a doctor performs FGM he tells her father that it's a crime, so he can't commit a crime for only 100 Egyptian pounds.”
Now the price to perform FGM can reach 2,000 Egyptian pounds if practiced by a nominated doctor or in Cairo.
Before the law was passed there were some nurses practicing FGM, which was a cheaper option than going to the doctor. But when the law was passed they became afraid and stopped. “The problem is always in the doctors who practice FGM,” says Kedees. “They don’t want to stop.”
As a result, in 2016 the Egyptian parliament passed a new law approving more stringent penalties for people carrying out FGM. Now, culprits face prison terms of five to seven years if found to be practising it, or up to 15 years if the case results in permanent disability or death.
“The punishment in the old law was very simple: you could pay a fine and escape,” says Dr Kedees. “FGM was only considered a ‘misdemeanour’, but now it represents a crime. Now, a doctor practicing FGM will be imprisoned and banned from practicing medicine.”
In the old law doctors could reach a compromise with the girl’s family, escaping punishment even if the girl had died after having the procedure. Families weren’t held accountable, and only the doctor or the one who practiced FGM would be punished. Now, by contrast, families are also punished under the new law if they force their daughter to undergo genital cutting.
But despite these changes, two big obstacles stand in the way of an Egypt without FGM: “FGM is demanded by the family, so they can protect the doctor and help them escape punishment by arranging for it to be performed confidentially and in private – either at the family’s home or at the doctor’s clinic,” says Dr Kedees. “Even where girls have lost their lives, it’s not the parents or the families who report it.”
This secrecy makes it almost impossible to monitor FGM-related deaths, and it’s not uncommon for the cause of death to be omitted from Egyptian death certificates. Dr Kedees recalls how one girl’s death had been reported as a ‘blood pressure disorder’ by her parents until an examination confirmed the suspicions of the health inspector, who found that she had undergone genital cutting.
Genital cutting in Egypt is carried out for four main reasons according to Dr Kedees, the first being that it’s a tradition with a deeply rooted social and cultural background. Girls usually undergo FGM between nine and 12 years old. As many as 75 per cent undergo the procedure before puberty, some even before reaching the age of seven.
However, according to Dr Kedees, in many cases, the mother doesn’t know the advantages and disadvantages of FGM: “They only know that it belongs to tradition. Mothers have no means of reading information leaflets because most of them are illiterate. It is merely passed down from one generation to the next that this is what they must do.”
“Related to this, young men always require their future wives to be circumcised. Not because they know about FGM, but due to their mothers' requirements.”
Child’s rights organisation Plan International is countering this dearth of information by working with local communities, such as in the Giza village of Tamouh, to raise awareness about FGM and other gender-related issues with both women and men.
Secondly and thirdly, families believe FGM controls sexual desire and that it brings medical benefits, especially regarding fertility. “It is about eliminating ‘useless’ organs, and it supposedly aids marital intercourse,” Dr Kedees says.
Three main types of FGM procedure, which Dr Kedees refers to as ‘degrees’, are carried out. “The first degree is about cutting off the clitoris only,” he says. “This is the most common procedure in Egypt, especially if performed by doctors, but they are often too afraid to perform second-degree FGM.”
The second degree is about cutting the clitoris and either the whole labia minora or a part of it.
“There are some cases where, after circumcising their girls at a doctor’s surgery, mothers have gone to midwives to circumcise their daughter again,” he explains. “The grandmother has usually ordered the mother to do that after examining the girl and deciding it wasn’t enough and that the girl should undergo FGM another time. The grandmothers are used to the circumcision being done by midwives, so they blame the mothers for taking their daughters to doctors.”
“The third degree, known as African circumcision as it is commonly practiced by traditional practitioners, entails cutting off the clitoris, the whole labia minora and a part of the labia majora before stitching the labia majora together.”
A small part is left unstitched to allow urine and blood (during menstruation) to pass. Before she is married the girl’s labia majora will be unstitched to let her have intercourse with her new husband.
And then there is the raft of often-complicated consequences, which Dr Kedees describes in harrowing detail, starting with the physical effects: “In the short term there is the bleeding, the shock, infection and injuries in other surrounding areas.”
As if that wasn’t enough, it doesn’t stop there: “The long-term effects include deformity of the girl’s organs, chronic infection in the urinary and genital tract, urinary and vaginal fistula or inner vaginal fistula…” It’s as if he is reeling off a particularly gruesome shopping list.
“Regarding the psychological effects, there are many. The girl loses confidence in her family. She feels humiliated. There is also a very important effect in the long run: girls become afraid of marital intercourse and the inability of circumcised women to reach orgasm.
“We try to explain to people that FGM doesn’t prevent the first phase of sexual relations from happening because FGM doesn’t control the sexual desire. But it does affect the third phase, which is reaching orgasm. The circumcised organs prevent orgasm and at the same time the husband has reached orgasm and started to withdraw from the intercourse, while the wife is still in the middle phase. Therefore, she suffers from strong pains at the bottom of the belly and at the back.”
“Time after time, by repeating the same intercourse by the same means, wives lose the desire to have a sexual relationship with their husbands due to the pains they suffer. This is the main problem of FGM – an absence of harmony between a couple during intercourse – and as a consequence, husbands become disappointed.”
The fourth reason is the conviction that FGM is related to religious beliefs, although in fact the practice is not endorsed by any religion.
Despite the challenges, Dr Kedees is confident that FGM can be eradicated in Egypt in 15 to 20 years.
“In the two latest Demographic and Health Survey reports, FGM prevalence in the 15-49 age group is still above 90 per cent. However, we can easily notice a clear and tangible change of attitudes in the first subgroup aged 15 years old, where the percentage of the circumcised girls was 74 per cent according to the DHS in 2008, and decreased to 61 per cent in 2014.”
He adds that the law change has brought about some positive change, and that the practice is decreasing in younger age groups. From 2008 to 2014 the percentage of FGM prevalence decreased from 95 to 92 per cent: small progress, but tangible nonetheless.
All these years after he first joined forces with Marie Assaad, he is certain that they have made some progress: “I think we moved the issue,” he says. “You can now say with an open heart that nobody hasn’t at least heard about FGM in Egypt from the media, the law, and so on. I’m sure of that.”
Only time will tell if the relentless and dedicated work of Dr Kedees, Assaad – now 95 years old – and other prominent figures will ease the pain for Egypt’s girls, but a decrease of 13 per cent in six years constitutes a good indicator, Dr Kedees says, hopefully.
Does he have a message for doctors who are still practicing FGM? Dr Kedees sits upright and straightens a slightly shaky finger. “One message: this is a crime. No doctor can pretend there are benefits to FGM. He wasn’t taught FGM while studying medicine and it’s not even mentioned in any surgery book.”
“FGM is a tradition, and we should insist on conveying to our society that it is a crime.”
Read more about Plan's work in Egypt and how you can help end FGM.