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| Ritual female genital surgery among Ethiopian Jews |
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by Nimrod Grisaru , Simcha Lezer , R.H. Belmaker
KEY WORDS: female circumcision; female genital mutilation; Ethiopian Jews. INTRODUCTION Ritual female genital surgery (RFGS) is a widespread practice in Africa and the Middle East (Female circumcision, 1983). More severe and less severe forms exist in different areas, ranging from total clitoridectomy and removal of the labia to removal of the clitoral foreskin only. Moslems in many countries practice RFGS, although the custom is not based on the Koran and is not part of Islamic ritual. Christians in Ethiopia practice RFGS (Dagnew and Damena, 1990) although the exact anatomic nature of their RFGS has not been described (Messing, 1957). Jews from Arab countries where RFGS is practiced, do not practice RFGS. However, the recent major immigration of Jews from Ethiopia to Israel has permitted study of this practice in an unusual Jewish population. We confirm the report that Ethiopian Jews did practice RFGS in Ethiopia (Harel, 1967). Moreover, we report the dramatic and total cessation of this custom among this community after immigration to Israel. This study of RFGS is one of the few to combine anthropological interviewing techniques with physical gynecological examination. METHODS Anthropology Interviews were conducted in two different absorption centers for recent Ethiopian immigrants. One of us (N.G.) interviewed six elderly women from the Tigray area in Ethiopia and six elderly women from the Gondar area in Ethiopia. They were considered to be good informants by social welfare staff. Two young educated translators, one from the Tigray and one from the Gondar, were also interviewed. One member of each group had been a professional female circumcizer (Gherazit) in Ethiopia. Interviews were conducted by a Jewish male Israeli psychiatrist with experience in Ethiopian Jewish culture and ties to the Ethiopian community. Nevertheless, the topic was felt to be highly embarrassing and subjects were reluctant to discuss it. Coffee was served at each interview group and confidentiality was guaranteed. In addition, six men of Ethiopian origin presently working in the paramedical field in Israel were interviewed. Examination An experienced gynecologist (S.L.) examined 113 Ethiopian Jewish women in the course of routine gynecological examinations at Kupat Holim Beersheva gynecological clinic. A high-intensity lamp was used to examine the introitus and clitoris of the women. The women's age ranged from 16 to 47. Only women who declared themselves Jewish from birth and who were aware of Jewish religious customs were included. Women originated from both Tigray and Gondar. RESULTS Anthropology All interviewed women agreed that RFGS was normative among Jews in Ethiopia. None felt that the custom was a result of assimilation into Christianity. Attitudes were different in the group from Tigray and the group from Gondar. In Tigray the ceremony is done on Day 14 of life, in the hut where women remain after childbirth. The ceremony is performed by a special circumcizer. The mother is present, as are respected female guests. Males are not allowed. While the ceremony is not considered religious, only a Jewish woman is allowed to perform it on a Jewish infant girl. The infant is dressed in white new cloths. The infant is held with legs spread apart, the clitoris and labial folds are held between thumb and middle finger and cut with a new disposable razor blade. The Gherazit warned that the base of the clitoris is never to be injured. The amputated clitoris is removed from the room and buried. Blessings are said in the ancient Geez language holy to Ethiopian Jews, including the Biblical Ten Commandments. A feast is then had. The purpose of the RFGS, in the view of the interviewees, is not to reduce female sexual pleasure but to create adhesions that prevent premarital intercourse. In Gondar the RGFS is performed on Day 7 rather than Day 14. The interviewees reported that in Gondar the clitoris is not cut but the labia minora and clitoral prepuce are removed. The removed parts are buried as in Tigray. In Tigray the reason given for the ceremony is esthetic, since uncircumcized girls would be seen to have a "long and ugly clitoris." Creation of adhesions is not seen as a goal of the RFGS. The interviewees rationalized the absence of need for the ceremony after immigration to Israel by saying that in Israel the clitoris does not grow long for some reason. Two educated young Jewish women of Ethiopian origin, in Israel for more than 10 years, were interviewed at length and in an individual setting without translation. Both were aware of RFGS as normative in Ethiopia, and both confirmed the above reports. Men of Ethiopian origin reported being aware of RFGS among Jews in Ethiopia but knew no details. Physical Forty-two (37%) of the women examined had evidence of old scars. In 11 (10%) there was total amputation of the clitoris and prepuce. In 19 (17%) the clitoris was partially amputated. In 8 (7%) other women there was a 1 [cm.sup.2] removal of the labia minora beneath the clitoris; in some this was bilateral and in some unilateral. In 4 (3%) women, there were scars of incision only on the clitoral prepuce, about 4 mm long. In the remaining 71 women (63%) there was no evidence of any genital past incision or ablation. DISCUSSION We recently reported a study of RFGS among the Bedouin of Israel (Asali et al., 1995). Among several tribes, the practice is considered normative. However, physical examination revealed that all girls from these tribes had small, minor scars of incisions on the labia with no functional implication. These Bedouin, both women and men, consider RFGS part of their culture that they insist on continuing for future generations. In practice, they have apparently modernized the custom and all that remains is a minor ritual. In contrast, Ethiopian Jews practiced a major form of RFGS. The examinations revealed that not all women had RFGS, but those that did often had major mutilation, although akin to the moderate "Sunni" rather than the most extreme "Pharaonic type" among Muslims (Lightfoot-Klein, 1989). Unfortunately, no physical examination data are available on RFGS among Christian Ethiopians. By contrast with the Bedouin, Ethiopian Jews give up RFGS immediately on arrival in Israel. They see themselves a part of a Jewish society without RFGS. No signs of distress or nostalgia for the custom were expressed. These data suggest that cultural change is often a function of identity. Rapid cultural change without evident distress may be possible if individuals or a group consciously accepts a new identity. An incidental finding in this study, as in the Bedouin study, was a gap between physical findings and anthropological report. Although RFGS was normative for all Jewish female infants in Ethiopia, only about a third had evidence of old genital scars and only 27% had clitoridectomy. This illustrates a well-known phenomenon in anthropology whereby interviews elicit descriptions of accepted norms that may reflect behavior of only a minority of individuals in practice. For instance, interviews of Israeli or American adults about marriage would yield various normative customs, although in practice divorce, out of wedlock motherhood, and adultery are commonplace. It would be interesting to discover what factors affect whether a Gherazit made a major or minor incision in practice, despite the normative custom of clitoridectomy. Harel (1967) reported medical complications of RFGS among Ethiopian Jews in Ethiopia, including urethral constriction and vaginal adhesions. Adhesions appear unlikely with those RFGS lesions found on physical examination in our study. It is possible that some Gherazit rarely perform a much more extreme operation involving removal of the labia minora and we did not observe this phenomenon; it is also possible that RFGS has become less severe among Ethiopian Jews since Harel's study. This study and its predecessor (Asali et al., 1995) are among the few studies of RFGS to combine anthropological interviews with physical examination (Dirie and Lindmark, 1991; El Dareer, 1983). Most knowledge of the physical nature of RFGS comes from the occasional cases that reach hospital because of medical complications; these could be only the most extreme forms in the population. Our study also emphasizes the dangers of drawing conclusions from interview data only, since many women are unaware of the anatomical nature of their own RFGS. Lightfoot-Klein (1989) reported orgasm among women in a culture where severe RFGS is normative, but one could question whether all or even a majority of women undergo the normative operation. Medical case reports, unsystematic oral accounts, and reviews based on the foregoing represent almost the entire literature in this field. To plan strategy to reduce morbidity from RFGS, systematic anthropologic field work and physical examination of significant samples of women in multiple cultures is needed. REFERENCES Asali, A., Kharnaysi, N., Aburabia, Y., Letzer, S., Halihal, B., Sidovsky, M., Maoz, B., and Belmaker, R. H. (1995). Ritual female genital surgery among Bedouin in Israel. Arch. Sex. Behav. 24: 573-577. Dagnew, M. B., and Damena, M. (1990). Traditional child health practices in communities in northwest Ethiopia. Tropical Doctor 20: 40-41. Dirie, A., and Lindmark, G. (1991). Female circumcision in Somalia and women's motives. Acta Obstet. Gynecol. Scand. 70: 581-585. El Dareer, A. (1983). Attitudes of Sudanese people to the practice of female circumcision. Int. J. Epidemiol. 12: 138-144. Female circumcision (editorial). (1983). Lancet 1: 569. Harel, D. (1967). Medical work among the Falashas of Ethiopia. Israel J. Med. Sci. 3: 483-490. Lightfoot-Klein, H. (1989). The sexual experience and marital adjustment of genitally circumcised and infibulated females in the Sudan. J. Sex Res. 26: 375-392. Messing, S. (1957). The highland plateau amhara of Ethiopia. Phi) thesis, University of Pennsylvania. Nimrod Grisaru, M.D.,(1) Simcha Lezer, M.D.,(1) and R. H. Belmaker, M.D.(1) (1) Ministry of Health Mental Health Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva, Israel. |
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