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Alumni Dispatches: Paul Converse

Alumni Dispatches: Paul Converse

Paul Converse

PhD '84, MHS '80, MSc

Female Genital Cutting and Male Circumcision

First, a word about terminology. I am pleased that the editors decided to recognize the term female genital cutting (FGC). As inconceivable as it may be to our Western sensibilities, many women who have experienced one of the various forms of the procedure are extremely proud to have done so and do not consider themselves mutilated at all. Other women who regret having had to undergo FGC and wish to protect their daughters from it certainly should not also bear the stigma of being regarded as mutilated. Finally, given our understanding of the nature of the female sexual response, it is difficult to imagine that women with an excised clitoris experience pleasure during intercourse. However, there is ample anecdotal evidence that these women do enjoy sex and many achieve orgasm (Nahid Toubia, New Eng J. Med., 331:712-716, 1994), suggesting that as typically occurs in biology there may exist a compensatory, likely less efficient, pathway to female sexual fulfillment.

I spent three years in the Peace Corps serving as a teacher in secondary schools where nearly all the students were Kikuyu, mostly coming from the surrounding community in central Kenya. As detailed by Jomo Kenyatta in his anthropological treatise on his tribe, adolescent boys and girls became men and women through a puberty ritual culminating in circumcision for the boys and clitoridectomy for the girls. British missionaries were, not surprisingly, horrified by the latter practice. To confront it, before World War II, they declared the practice to be incompatible with Christianity, a religion many of the Kikuyu had adopted, and against biblical teaching. Although this led to or coincided with some chiefs proscribing the practice in their subdistricts, others joined new, independent churches whose leaders also happened to note that there is in fact nothing stated one way or the other in the Bible about the practice. Given this background, I asked my students in an essay assignment to marshal their arguments for or against the practice. There was indeed a spectrum of responses, but all acknowledged the importance of the practice in Kikuyu culture and, as Mr. Kenyatta, the highly respected first president of Kenya, had written, the greatest insult for a man was to be a kihii, "a large uncircumcised boy," and that there was a similar, but possibly waning, lack of respect for "uncircumcised" women.

While I was in Kenya, a prominent politician from the Luo tribe in western Kenya was assassinated in Nairobi. A great deal of tension between these two groups, the two largest tribes in the country, arose. Among the Kikuyu, there were "oathing" or "tea-taking" ceremonies swearing fidelity to the tribe, including never accepting an uncircumcised man as president of Kenya. Luos have no tradition of genital cutting. For the Kikuyu, they are all kihii and, therefore, unworthy of respect and the presidency. In late 2007 and early 2008, we have seen this issue return tragically to Kenya in a disputed election in which male circumcision as a cultural issue has trumped, at least temporarily, the more recent electoral tradition as an overriding value for many Kenyans.

When I first read reports from Kenya that there appeared to be a higher prevalence of HIV in uncircumcised men, my first impulse was to suspect biases in the selection or presentation of the data. Over time, it has become clear that although circumcision does not guarantee protection from infection and there have been thousands, if not millions, of fatal AIDS cases in circumcised men, there is a reduction in risk. I remain curious that I can find no study examining female genital status and HIV and no pathology studies regarding the presence of HIV target cells in external female genitalia. We would probably rather not know. Nevertheless, large clinical trials involving the Luo have shown the benefit of genital surgery on men and now many have opted for circumcision. It is intriguing to speculate, now that even among the Kikuyu the practice is more medical and less ritualistic, if the election of a Luo president will in the future be less problematic on a cultural basis for the Kikuyu.

Africa is a remarkably diverse continent geographically and culturally. I later worked in Ethiopia for four years. Genital cutting was and is commonplace but also less commonly discussed among the Highlander tribes such as Amhara, Tigray, Guraghe and Oromo. Nearly all men are circumcised within the first few months after birth. There are no "large uncircumcised boys" here. Girls may undergo a cutting procedure in infancy or in childhood before adolescence or, in some areas, not at all. The absence of practice does result in some whispers about sexual self-restraint, but I am aware of no major interjection of missionary edicts on the practice. In addition, Ethiopians have been practicing Christianity since about 325 AD, longer than have most Europeans. FGC and Christianity have coexisted for a long time in Ethiopia, but gradually the practice is being abandoned, particularly in urbanized families.

Paul Converse currently works as a research associate at the Johns Hopkins University School of Medicine. He has served as an assistant professor in the Department of Immunology and Infectious Diseases and the Department of Molecular Microbiology and Immunology and is now an associate at the Johns Hopkins Bloomberg School of Public Health. In addition, he has worked as a scientist in Stockholm and Addis Ababa, served in the U.S. Peace Corps (Kenya), and traveled by motorcycle from Nairobi to Capetown.

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