Pricking in the African Diaspora: Current Evidence and Recurrent Debates

While there are different perspectives of FGC within migrant communities, several studies report a high opposition towards all forms of FGC or a support of pricking (or ‘sunna circumcision’) [3, 19, 20••, 22, 31‐38]. For example, a Dutch qualitative study with men and women from Somalia, Eritrea, Sierra Leone, and Egypt found that many discouraged infibulation, but supported pricking as this was seen as a lighter form of FGC while still sufficient ‘to remain faithful to one’s own culture’ [39]. Yet, despite a proclaimed support of pricking, these participants expressed that they did not perform any kind of FGC on their daughters due to the perception that also pricking was strictly prohibited and thus feared losing custody of their children [39].

Yet, while attitudes and behaviour are related, individuals’ attitudes are not always reflected in their behaviour [40]. Prevalence estimates are therefore of value. However, there are several challenges in estimating the prevalence of pricking in diaspora. Some relate to the current FGC legislations in place, but also to that pricking may not cause visible changes. Yet, there are some cases of reported pricking in the diaspora, most performed before migration. In a study at a UK safeguarding clinic, 27 girls (all but one originating from an African country) were confirmed to have undergone FGC. Among those, a majority—11 girls (41%)—were diagnosed with FGC type IV. Six of these had evidence of a small genital scar, and five had normal genital appearance (pricking or nicking confirmed based on testimony) [41•]. Similar findings were reported from a study at a paediatric FGC clinic in the UK, in which 11 out of 18 girls (61%), the majority from Somalia, were diagnosed with FGC type IV. Ten had evidence of a small genital scar, while one had a normal genital examination but where the family confirmed that the girl had been cut [42]. Cases of type IV cutting, which may involve pricking, were also reported in a cross-sectional study among paediatricians/child health specialists in Australia where 6 out of 23 girls (23%) were classified as having FGC type IV [43]. The majority of identified cases of pricking (or FGC type IV) in these studies were performed before migration from a country where FGC type I-III are most prevalent [41•, 42, 43]. This could indicate a possible shift from FGC type I-III towards FGC type IV/pricking already in the country of origin. Yet, based on these few hospital-based studies, it cannot be concluded whether such a shift is actually taking place.

While FGC is legislated against in all EU member states [44], the wording in national and international legislation against FGC usually mentions practices that ‘mutilate’ the female genitals or involve the removal of genital tissue. For example, in the Swedish Act prohibiting FGC, it is stated that (translated from Swedish, emphasis not original): ‘Operations on the external female genitals with the aim to mutilate them or produce other permanent changes in them (genital mutilation) must not take place’ [45]. Yet, in the Swedish context, pricking was mentioned in the preparatory work of the Act on FGC, thus the practice is interpreted as illegal, which may also be the case in other countries. The Council of Europe Convention on Preventing and Combating Violence against Women and Domestic Violence (the Istanbul Convention) states that the following practices should be criminalised: ‘excising, infibulating or performing any other mutilation to the whole or any part of a woman’s labia majora, labia minora or clitoris’ [46]. As pricking does not include any removal of tissue and does not signify ‘mutilation’, it may be difficult to interpret the (il)legality of pricking. This has been demonstrated in two court cases concerning pricking (or ‘khatna’) among the Dawoodi Bohra community in Australia and the USA. In Australia, the three individuals who were convicted for being involved in arranging pricking on two girls were later acquitted on all grounds as no physical alteration of the genitals could be seen [47, 48]. And in another case in the USA, charges against several individuals for being involved in performing what appears to be some form of pricking were dismissed as the law was ruled to be unconstitutional [49, 50]. Also, to determine whether a practice that may not leave any visible trace has taken place will in most cases require that the girl was old enough to remember it, or that her caregivers admit she has been subjected to pricking. In contexts where pricking is illegal, obtaining such statements from the caregivers is unlikely as they would risk being convicted for a crime. Altogether, these factors complicate legal processes against pricking.

Further, differing laws on male circumcision versus FGC, in which girls are legally protected from all forms of non-therapeutic genital cutting while boys are not, is argued by Darby to represent a gender bias where girls are favoured over boys [51]. It has therefore been argued that circumcision of boys, just like all forms of FGC, should be prohibited [29••]. On the contrary, this ‘gender bias’ has also been used as an argument that some forms of FGC must be tolerated when circumcision of boys is [27••]. This has also been recognised by migrants in the African diaspora. For example, Hernlund writes, reflecting on a conversation with two Somali women following a Seattle seminar for health care providers and refugee women: ‘It had not occurred to these extremely bright, articulate, and politically astute women professionals that a simple pinprick of the clitoris could be illegal under U.S. law, while their own sons legally underwent much more invasive procedures.’ [52]. This ‘gender bias’ has been used by defence attorneys in legal cases arguing that pricking of girls’ genitals ought to be legal as long as removal of genital tissue from boys is [53]. As these controversies illustrate, the question of legalising pricking or not rests in different perspectives and cannot be resolved easily.

Less extensive forms of FGC, such as pricking, have been suggested as a strategy to minimise harm [27••, 54, 55]. One important aspect in the so-called harm reduction approach is to accept a milder form of FGC as a first step towards complete abolishment of the practice. Another is to allow for diverse religious and traditional practices important for minority populations living in a country where FGC is not traditionally practiced and/or outlawed [14, 27••, 56]. However, this approach has been contested by those supporting a zero tolerance approach towards FGC. They argue that making a distinction between ‘high risk’ and ‘low risk’ forms of FGC in regard to health complications might be interpreted as condoning the ‘low risk’ form(s) and thereby undermining efforts to end FGC completely [57, 58]. There is also a fear that girls who have been pricked will have to go through a second, more extensive, cutting in the future [59]. Further, there seems to be disagreement, largely based on lack of empirical studies, regarding the possibility of negative psychological, physical, and sexual consequences of pricking. In a review of immediate health consequences of FGC, the authors found that also ‘nicking’ presented a risk of such complications [60]. However, they pointed out uncertainties of the validity of the findings, mainly due to challenges in determining the extent of tissue removed or altered. As pricking involves no removal of tissue, some argue that a medically safe pricking would have limited or no impact on health and sexual function [27••, 48, 61, 62]. Yet, even though pricking involves no removal of tissue, one cannot exclude the possibility that pricking procedures may cause psychological consequences and have a negative impact on sexuality when performed on girls who are too young to consent or make informed choices. Studies are therefore needed to elucidate possible effects of pricking on women’s psychological well-being and sexuality. Also within the Somali diaspora in Sweden, there were divergent views of the possible negative health effects of pricking; some made the conclusion that it cannot completely be ruled out that pricking causes no harm, while others were of the opinion that a practice resulting in no visible change cannot cause any harm [63••].

The previously mentioned suggestions from the Netherlands, USA, and Italy [24] entail that pricking should be performed in a medical setting with sterile equipment and anaesthesia. This argument has also been made by Swedish Somalis [63••]. Opponents of such medicalisation of pricking argue that allowing pricking to be performed in a medical setting is a violation of health care ethics as there are no clinical reasons for having it performed. Furthermore, it is said that the risk of health complications such as infections and bleeding can never be completely avoided, even if performed in a medical setting [64‐66]. It is also argued that whether pricking is harmful cannot be used as grounds for determining if it should be allowed. Rather, pricking performed on girls who are too young to consent or make informed choices is viewed as a violation of girls’ human rights and bodily integrity [10, 29••]. Another argument is that allowing pricking to be practised in a medical setting poses a risk that other practices of FGC will become normalised and legitimised, thereby impeding the work to abolish all forms of FGC [10, 65]. However, evidence regarding the effect of medicalisation on the prevalence of FGC in general is conflicting [67]. For example, a study based on data from 25 countries in African and the Middle East could not demonstrate an association between medicalisation and rates of decline, or increase, in the prevalence of FGC [68]. It remains a question to whether similar findings would occur if considering only pricking.

Medical practitioners’ views on pricking are diverse. In a survey among gynaecologists in Belgium, 51% (155/306) rejected a symbolic incision/pricking as an alternative to FGC, while 47% expressed a support for such a strategy. Further, 77% (243/317) did not support medicalisation of FGC as a harm reduction strategy, while 21% were positive towards such a strategy. Many expressed that they wanted more clarity in the ethical-legal issues of practices such as symbolic incisions [69], something which has also been reported among midwives in Belgium [70].

The perception that FGC is related to religion is particularly the case for practices termed ‘sunna circumcision’, in which pricking usually is included. In Islam, the term ‘sunna’ means ‘the tradition of the Prophet Mohammed’ [71]. The Somali-Norwegian researcher Gele has expressed a concern that, although pricking seems to commonly be viewed as ‘sunna circumcision’ and accepted by religion, individuals arguing to support pricking or ‘sunna’ may in actuality practice a more extensive form of FGC [72], a concern also echoed by the WHO [1]. Similarly, Hernlund observes that ‘sunna circumcision’ for some Somali women entails a nicking, while for others, it entails a pinch of the clitoral prepuce with a verbal declaration of altered status [52]. While these authors refer to ‘sunna’ more than pricking, it is interesting to consider that terminologies used to describe different genital cutting practices sometimes are mixed together and may mean different things to different people. Similarly, among Swedish Somalis, 32% (198/612) did not define pricking as a form of FGC [20••]. Thus, there is a risk of a ‘mismatch’ between individuals’ and (inter)national organisations and governments’ views of what practices are defined as FGC. This emphasises the need to be specific to what practices one is referring to, both in research and anti-FGC campaigns. However, the majority 91% (560/616) of Swedish Somalis in the above-mentioned study knew that also pricking is illegal in Sweden [20••], indicating an awareness of the dominant definition of FGC.

The religious imperative in the continuation or abandonment of FGC is worth considering. Encounters with other Muslims in diaspora are suggested to lead to a ‘redefinition’ of what characterises a good Muslim, where prior FGC-supporters start to question the religious imperative of FGC. As a result, while infibulation is increasingly viewed as un-Islamic, some may still support ‘sunna circumcision’, which is often synonymised with pricking, based on a religious rationale [3, 19, 63••, 73]. Qualitative studies from the Somali diaspora in Sweden show that some perceive pricking as an acceptable or even beneficial religious practice [63••]. It is yet largely underexplored whether pricking could be replaced with other completely non-invasive, symbolically, practices while still keeping its perceived religious value.

After migration, pricking has been described as a way to balance between the ‘old’ and ‘new’ culture in that one replaces the traditional form of FGC with a less extensive form [63••]. This could be seen as a willingness for FGC-practicing migrants to adapt to their new social context/society, without totally giving up their cultural practices. In a study with Swedish Somalis, pricking was perceived by 10% (64/611) as a way to ensure respectability [20••], yet little is known about how this connection was made. Further, some supported pricking on the basis that it was perceived not to have a negative impact on health or sexuality [63••]. This is interesting since a commonly mentioned motive of FGC is to ensure chastity or limiting excessive female sexuality. For example, infibulation has been described as a way to create a culturally constructed virginity in Somali populations [74]. How infibulation can be replaced with pricking and still imply meaning for those practicing it, needs to be further explored.