Abstract: This article focuses on the implementation of a medical practice in Egypt, namely clitoral reconstruction surgery for women who have undergone female genital mutilation (FGM). Initially developed in the 1990s in France, the surgery has been over the past twenty years gradually ‘imported’ from European countries to some African countries. Egypt is an indicative case, since more than 80% of the female population is estimated to have undergone FGM. I explore from a sociological point of view the resistance and difficulties that accompany the ‘importation’ of this technique in Egypt and the relative discourses on national and sub-national cultural identity, especially when regarding gender issues.
Résumé : Cet article porte sur la mise en œuvre d’une pratique médicale en Egypte, à savoir la chirurgie de reconstruction du clitoris pour les femmes ayant subi des mutilations génitales féminines (MGF). Initialement développée dans les années 1990 en France, cette chirurgie a été progressivement “importée” des pays européens vers certains pays africains au cours des vingt dernières années. L’Égypte est un cas emblématique, puisqu’on estime que plus de 80 % de la population féminine a subi des MGF. J’explore d’un point de vue sociologique les résistances et les difficultés qui accompagnent l'”importation” de cette technique en Égypte et les discours relatifs à l’identité culturelle nationale et infranationale, en particulier en ce qui concerne les questions de genre.
Key words: female genital mutilation, feminine genital reconstructive surgery, Egypt, importation of medical techniques, national identity building.
Mots clés : mutilations génitales féminines, chirurgie reconstructive des organes génitaux féminins, Égypte, importation de techniques médicales, construction de l’identité nationale.
1. Introduction
This research article addresses the topic of the implementation of a medical practice in Egypt, namely clitoral reconstruction surgery for women who have undergone female genital mutilation (FGM). This technique was developed in the 1990s in France by a urologist, Pierre Foldès. Over the past twenty years, the surgery has been gradually “imported” from Europe to some African countries. Egypt is an indicative case, where more than 80% of the female population is estimated to have undergone FGM -and where the practice of FGM is increasingly medicalised (Population/Egypt, Associates/Egypt et International 2015).
This paper examines the resistance that results from the importation of this technique to Egypt from a sociological perspective. The discussion focuses on the following issue: how do imported medical practices such as clitoral reconstructive surgery confront discourses regarding national identity building and sub-national cultural identity, especially when regarding gender issues? This questioning is linked to the mistrust stemming from what would be akin to “sexual interference” from abroad.
The case of FGM reconstruction is a particularly heuristic solution to this problem. This analytical framework can also be used in other research topics related to gender issues and the way medical practices circulate. However, this framework constitutes one of my hypotheses used to explain the specificities of the development of this medical technique in Egypt. The effect of globalization on the circulation of medical practices, the history of Egyptian medicine, the socio-economic conjunctures, as well as the relations of gendered domination play also a crucial role in the way this question is addressed. Nevertheless, in this article I focus only on the question of the importance of this technique in relation to the subject of sexual nationalism – to use George Mosse’s (1985) concept. In addition, drawing from the growing body of scholarship on everyday nationalism (Ayuandini and Duyvendak 2017, Billig 1995, Fox and Miller-Idriss 2008, Skey 2011), I focus on how the Egyptian national identity enters the context of practising a medical procedure such as clitoral reconstructive.
2. Methodology
This research is based on data collected during five-months of fieldwork (in 2021) conducted in Cairo and Alexandria. During this period, I interviewed several types of subjects, asking them to respond to my research question. First, I interviewed women (n=12) who had undergone FGM, some had already done the surgery, some were thinking about it and others were strongly against the procedure. The aim was to understand the motivations behind this surgery, as well as to document the reluctant attitudes that coexist within the local social context. I also interviewed health professionals involved in this practice, and institutional representatives such as UN organizations, Egyptian public health authorities, as well as associative actors (NGOs, local association) whose work can be linked to this surgery (n=17).
I used two types of techniques to gain access to my female respondents, which was not easy for a foreigner in the Egyptian context. In the first one I used my interpersonal network and in the second “the snowball sampling method”. The second way of gaining access to the women was through an association in Alexandria that supports women in financial difficulties by providing social assistance and gynaecological care. Semi-directive interviews were conducted with them in Arabic with the help of an Egyptian colleague from CEDEJ.
In addition to this, I made ethnographic observations in waiting rooms of clinics and had regular informal meetings with health professionals and medical students in Cairo. Medical confidentiality denied my access to gynaecological or surgical consultations. However, by regularly meeting the same health professionals, their colleagues, medical students, and by following some of their training — notably one organized in the premises of the Ministry of Health for gynaecologists wishing to specialize in genital cosmetic surgery — I was able to attend a large number of informal discussions and thus, to collect a large amount of ethnographic data.
3. Historical background on female genital interventions in Egypt and the process of nation building
3.1. Nation building and female genital mutilation
In this paper, I argue that the process of nation building (Wimmer and Schiller 2002) is not independent from gender norms and representation in societies. It is thus a question of combining in the same theoretical framework gender studies and research works on national identities, mainly developed within the discipline of history studies. Indeed, throughout history, gender roles, sexuality and gendered body images have played a significant part in the process of national identity building: in other words, by establishing clear boundaries between “us” and “them” (Barth 1998, Poutignat, Streiff-Fenart and Barth 2008).
In the early 1980s, historian George Mosse introduced the concept of sexual nationalism, which refers to an overlap between discourses on sexuality and the process of establishing national boundaries. He argues that the definition of the nation influences the construction of sexual norms and the so-called “respectable” sexuality, and in turn these norms shape national identity. He describes, for example, how Jews and African peoples were presented in the 19th century as counterexamples of “bourgeois respectability”. Jews and African peoples were indeed at the time seen as having a “deviant” sexuality (Mosse 1985: page?). Currently, several contemporary works have taken up this concept to question the issue of excision and gender norms in immigrant societies (Ayuandini and Duyvendak 2017, Bader 2016, Fassin 2006, Jaunait, Renard and Marteu 2013). However, there are few works that examine the sexual nationalisms of the countries of the “South” and in which this type of discourse is developed, and this only as reactions to the symbolic attacks that have been made in Europe. Moreover, they seem to use these discourses within the framework of claims linked to the history of independence or in order to express a defensive counter argument. They are linked to a rhetoric of resistance against the norms and knowledge “imported” from abroad – and particularly from the countries of the North.
Recent work on gender and women’s issues in Arab countries highlights a wide social division between “feminist, so-called ‘Westernized’ elites and Islamist currents, which resonate with large sectors of the female population (Roussillon and Zryouil 2017). This cleavage exposes a common accusation regarding gender related topics in the public sphere: on the one hand, there is the “Western” point of view represented by foreign authorities and privileged isolated elites, against the more “local” point of view, sometimes called “traditional”, “national”, or even linked to a religious characterization: “Islamic”. While this rhetoric is often played out at the level of representations or ideology, it ultimately expresses internal social economical fractures. The important thing remains that the discourses play a central role in the construction of cleavages and strategies of rejection and resistance to “normative imports” likely to detract from national unity and cultural legitimacy.
The purpose of this line of argument is not to assert that this medical technique, the practice of female circumcision or the performance of gender roles would intrinsically have to do with the constitution of some kind of Egyptian identity. However, at the semantic level, in the discourse of the actors, these practices and the question of gender are very often instrumentalized to orient public policies and establish nationalist discourses. Baron (2006) studied for instance, the use of visual images of femininity and the question of female honour, in relation to Egyptian nationalism. She “juxtaposes the idealization of the family and the feminine in nationalist rhetoric with transformations in elite households and the work of women activists striving for national independence” (Baron 2005: page). Thus, in this article I situate my questioning in the context of these works. This framework of historical interpretation around gender norms and post-colonial issues, as well as North-South discursive rivalry, sheds light on what I develop in this article.
3.2. Emergence of a new “imported” technique of genital reconstruction
Why should we speak of importation, when it is a technique that has already been available in Egypt since 2003, according to the existing literature (Thabet 2003)? The technique was mainly developed in France by the surgeon-urologist Pierre Foldès in the 1990s and is progressively spreading to African countries, especially those with a particularly high rate of female circumcision. However, it is mainly in Europe that this technique has been developed with the creation of “multidisciplinary” centres (sexology, psychology, gynaecology, surgery) in France, Switzerland, Germany, Sweden and the United Kingdom. Moreover, this first paper of Thabet regarding the Egyptian context drew information only from a single clinic in Cairo where clitoral reconstructions was performed. At present, about twenty doctors in Cairo are familiar with this technique and less than a dozen uses it regularly with their excised patients. This reconstructive surgery involves the aesthetical and functional recovery of the clitoris. The reconstruction of the clitoris after FGM aims at restoring a “normal” anatomy of the clitoris and if possible, convert it to a functional organ. It is a process comprising scar revision and then freeing the body of the clitoris while preserving the innervation. A clitoral glans is reconstituted by wedge-shaped plasty, then re-implanted in its position (Foldès, Droupy and Cuzin 2013).
This medical practice was gradually introduced into the Egyptian context and was the initiative of Egyptian doctors who had been trained abroad or influenced by the work of Foldès. During my investigation, many people pointed out this clear affiliation, others defended themselves by explaining that they had “improved” or “revisited” the technique of Foldès. The fact remains that the circulation of this technique follows a north-south flow. One surgeon I met, Rana, even told me that she would like to be able to build in Egypt a treatment centre like those in Europe:
I mean, the fact that those structures are open abroad is fantastic…. But we actually have the main problem here in Egypt so that is why you really need a centre like that. Look, I wish I could just take one of these centres and bring it here. You know just like, we are ready and give it to us (Rana, surgeon, Cairo, 2021).
The demand for reconstructive surgery may also have a distant link to the idea of importation, as it is implicitly nested in the preventive worldwide policies against FGM and therefore, generates reluctance among patients, as well as local institutional actors and part of grassroots health workers. For instance, there have been numerous prevention media campaigns in Egypt since the 1990s, nearly all of which have been conducted with the support of international UN organizations in collaboration with national actors (Ghafir 2021). These campaigns were the aftermath of the international conference of 1994 in Cairo. Ghafir (2022: 41) questions the impetus of “international norms” in the fight against FGM through national programs and mentions the theories of the “global convergence of norms” at an international level (see also Hassenteufel and de Maillard 2013). These theories identify a global movement of transferring international and transnational norms to national contexts and subnational communities in the form of discourses and public policies. These norms, far from generating perfect homogenizations, are then recovered, adapted, or rejected at the local level. This is the case of gender standards, an area where a top- down transfer predominates. Local actors are then able to identify and dismiss those imports under the pretext of foreign affiliations.
4. Discourse on “western” and “foreign” imports of gender standards in relation to medical practices
4.1. Distrust among patients towards the doctors’ expert knowledge on sexuality
What is reflected in the discourse of the women interviewed is the accusation that doctors convey “foreign” discourse, which results in a mistrust of identity; a fact that also betrays underlying social tendencies. Medical students intending to perform this operation in Egypt explained to me the difficulty of its implementation and questioned the effectiveness of national awareness campaigns against FGM.
Some health professionals also confided in me that they are victims of very serious threats related to their practice. They are accused of participating in the “westernization of women’s bodies”, as one surgeon told me (Ali, surgeon, Cairo 2021), or of pushing women to have an “immoral sexuality”. I argue that this criticism is only linked to the idea of sexual nationalism because the image of the “virtuous” woman has become a national pride (Baron 2006). Associating the image of the Egyptian woman with that of a woman having sexuality and pleasure is therefore problematic. Most of the anti-FGM awareness campaigns do not mention the sexual consequences for women as part of the harmful effects of this practice. Some campaigns have even glorified the image of the “virtuous” Egyptian woman to encourage mothers to stop cutting their daughters (Ghafir 2022). In order to dispel suspicions about this medical practice and promote this surgery, health professionals try to circumvent the problem by avoiding talking openly about the surgery. One of them said that when he talks to public health authorities, he focuses on the idea of repairing the physical consequences for women.
4.2. Resistance and scepticism regarding surgical genital reconstruction based on national and subnational identities
The practice of female genital cutting has various justifications depending on the context, the family, and local beliefs. Some of the reasons given are traditional, others hygienic, others aesthetic, others symbolic — the practice signifies a rite of passage in the development of sexual bodies and the passage to adulthood — yet others are based on religious arguments, although FGC is practised in very different religious communities, not in Christian, but either in animist or Islamic, and that in cases recommended by Islamic canonical texts. The fact remains that these justifications are often linked to discourses of identity, either national or local. One respondent, Nouran, who is reluctant to undergo surgery and has already undergone several medical consultations in connection with her excision, angrily tells me the extent to which the practice of excision is linked to her roots and her environment: “All the sheikhs say it’s sunnah and you have to cut your daughters and the priests in Upper Egypt say you have to do that because it’s the Egyptian way (Nouran, 42, Cairo 2021)”.
She told me that the thought of having reconstructive surgery was something that made her “aware that she was going against her culture”. Another woman, Inaya, who was interviewed, was very pro-excision and had been excised, and explained that “that’s how girls are at home [cut]”. Later, when she learns of the existence of reconstructive surgery, she explains that such surgery can only be for wealthy, foreign women. She is very surprised to know that this could exist in Egypt:
Inaya: oh no, they are spoiled people, it’s in France, in Europe and not here. G: There are some here in Egypt, and even in Alexandria.
I: What economic level are we talking about?! Do we need cosmetic surgeries for the genitals?!
G: Yes.
I: You have to work on what is visible before looking for what is hidden (laughs), That’s too much! (Inaya, 46 years old, Alexandria 2021)
The social stratification and the environment (urban or rural) are factors affecting the current discourse. The logic of identity linked to a local or national custom seems stronger in lower social classes. A surgeon in Alexandria says, for example, that the demands for genital operations are very different as they depend on the social background and the geographical area.
He emphasizes that in Upper Egypt, it is excision that is requested from the doctor while in the large urban areas, cosmetic operations. For him, reconstructive surgery can only be performed in large urban areas, which are more open and cosmopolitan: Alexandria and Cairo only, as there would be fewer reactions against such practices. Thus, these varied distributions of medical care in terms of social differences, differences of culture and in accordance with local-foreign logic also correspond to the medical discourse. Doctors believe, even if they are not against reconstructive surgery, that in places where customs play an important role, it is unacceptable to employ this medical technique. Even if this discourse is based on a certain number of practical facts, it also arises from the doctors’ unwillingness to exercise such practice as they fear that “they will not have a client”, that “people will not understand”.
4.3. Difficulties of implementing this medical technique because of the prevailing sexual nationalism
The implementation of this medical technique in Egypt is thus subject to resistance at both a micro and national level. As a result of these identity-related tensions linked to national discourses on sexuality and the image of women in Egypt, many taboos and difficulties stand in the way of a smooth implementation of this technique. These difficulties are of an institutional nature, linked to the reality of the Egyptian medical environment. This medical practice still has a clandestine dimension due to its lack of legitimacy.
The introduction of this surgery is quite recent and has not yet been met with great institutional support. All of the doctors who were interviewed spoke about their various, fruitless attempts to mobilize public authorities. Some have organized conferences in Egypt that had no effect, others have asked for funding. One of my interviewees even explained that he had taken part in a commission on medical care before 2011, but that all the work had been abandoned with the political upheavals and regime changes (the Arab spring in 2011).
This can be explained by the fact that for a long time, prevention actually took precedence over medical care, as explained by an employee of UNFPA Egypt:
We do theatre [in the villages] to raise awareness, so that women don’t do it to their daughters. But we once found ourselves in front of women who asked: ‘What do I do now? You know… there is no option… well, there is nothing we can do… (FGM Program Manager, UNFPA Egypt).
The problem of public health and medical care for women with FGM is not articulated in political terms. Therefore, the medical procedure is largely impacted: less standardized, not well known, not available everywhere.
In Egypt, it is interesting to note that, unlike in France, this repair is little promoted by doctors, which may be understandable in the historical and social context of the country. Given that the majority of women in the country are excised, repairing means going against the majority norm. This is why one of the doctors interviewed explained that he performs this operation almost clandestinely: “It is a subject that is taboo, despite the laws. We get threats…” (Amr, surgeon, Cairo 2021). For him, it is also a question of protecting women from social reproaches, within the family and the community of relatives. One of the strategies for evading this is often to use other health problems as a reason to hospitalize a patient, such as an abscess or other genital problem with false medical certificates.
Publicising the possibility of such repair cannot be conveyed through conventional means: internet sites, advertisements in front of surgeries, explicit announcements in congresses, etc. Everything is done by word of mouth, especially through associations that act as intermediaries to the doctor who, in his own advertisements, never mentions the intimate repair surgeries that he performs:
And so doctors send me patients and priests too (…) I have been operating for 15 years there {in Egypt}, I have another specialty so I do different types of surgery, in a private clinic, I have a practice. (…) So as I see, I see knees, hips, in the waiting room, no one can guess why this woman, she is there (George, surgeon, Cairo 2021).
This surgeon has the advantage of having a double speciality, which allows him to mix his patients and thus, guarantee a minimum of discretion to the women who come to him for a repair. Some doctors make false medial certificates so that women do not have to explain their hospitalization to their family or husband. Thus, the secrecy surrounding this medical practice is directly related to the national context.
In contrast to physicians performing reconstruction or simply refusing to perform FGM, a significant number of women are circumcised by medical professionals (DHS, 2014). A 2009 study of 193 Egyptian physicians revealed that 51% of the physicians surveyed performed FGC primarily out of conviction and 30% for profit. The first determinant was cultural influence (81%), followed by “lack of knowledge” on the subject (35%) (Refaat 2009). The issue of lack of knowledge, both anatomical and statistical, about FGM, was confirmed in the interviews I conducted with medical students and a recently published survey, which revealed that most have very little knowledge about the effects and types of FGM (Tadwein for Gender Studies 2021). Moreover, a significant percentage of them still favours performing the practice. According to statistics (UNICEF 2013), more than 75% of the women who had undergone FGM, had it done by a doctor who in Egypt are highly skilled professionals, a fact that makes the Egyptian context unique. In the end, it is in this particularly divided medical context, where the reconstructive surgery of the clitoris emerged and has to continuously adapt, as it is being practiced in a medical world where FGM is both conducted and healed.
Finally, an interviewed surgeon mentioned the lucrative attraction of performing FGC by physicians and how it banalizes medical interventions on female genitalia:
E: Oh yes, no, but I think the doctors make a living out of it. It’s easy money, very easy… It’s a bit like circumcision…
S: And do you know any of your colleagues who do it or is it taboo to say so? Is it taboo for a doctor to say that he proposes excisions or not? Do you have any colleagues who have ever said to you: I do that.
E: No, but in general, they say that they do aesthetics (George surgeon, Cairo, 2021)
Today, since the recent criminalization of the practice prevents doctors from openly reporting that they perform FGC, they report that they perform “cosmetic surgery,” as also shown in a 2019 national survey (El-Gibaly, Aziz and Abou Hussein 2019).
4. Conclusion
To conclude, this new reconstructive technique has been introduced in Egypt for about twenty years. It is the result, in many respects, of an import by health professionals but also, at the normative level, an import at the level of international health standards and “Western” medical knowledge. It forms then the object of recovery and adaptation in the Egyptian context but comes up against gendered representations of female bodies. These representations seem to be partly conveyed by discourses of “sexual nationalism”: in public discourse, in the words of patients, but also among health professionals. The idea that this technique comes from outside (from abroad) leads to it being viewed with suspicion by patients, doctors and health authorities (not always explicitly, but often in connection with the implicit taboo surrounding female sexuality). This dimension is only one aspect of understanding the North-South circulation of this medical practice. It is interesting to underline the extent to which female bodies, and in particular their genitalia, are at the centre of political power issues.
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