The cutter is usually an older woman, but in communities where the male barber has assumed the role of health worker, he will also perform FGM. When traditional cutters are involved, non-sterile devices are likely to be used, including knives, razors, scissors, glass, sharpened rocks, and fingernails. According to a nurse in Uganda, quoted in 2007 in The Lancet, a cutter would use one knife on up to 30 girls at a time. In several countries, health professionals are involved; in Egypt, 77 percent of FGM procedures, and in Indonesia over 50 percent, were performed by medical professionals as of 2008 and 2016. Classification
Variation
The WHO, UNICEF, and UNFPA issued a joint statement in 1997 defining FGM as "all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons". The procedures vary according to ethnicity and individual practitioners; during a 1998 survey in Niger, women responded with over 50 terms when asked what was done to them. Translation problems are compounded by the womens confusion over which type of FGM they experienced, or even whether they experienced it. Studies have suggested that survey responses are unreliable. A 2003 study in Ghana found that in 1995 four percent said they had not undergone FGM, but in 2000 said they had, while 11 percent switched in the other direction. In Tanzania in 2005, 66 percent reported FGM, but a medical exam found that 73 percent had undergone it.
According to the study, FGM was associated with an increased risk to the mother of damage to the perineum and excessive blood loss, as well as a need to resuscitate the baby, and stillbirth, perhaps because of a long second stage of labour. Psychological effects, sexual function
According to a 2015 systematic review there is little high-quality information available on the psychological effects of FGM. Several small studies have concluded that women with FGM develop anxiety, depression, and post-traumatic stress disorder. Feelings of shame and betrayal can develop when women leave the culture that practices FGM and learn that their condition is not the norm, but within the practicing culture, they may view their FGM with pride because for them it signifies beauty, respect for tradition, chastity and hygiene. Studies on sexual function have also been small. A 2013 meta-analysis of 15 studies involving 12,671 women from seven countries concluded that women with FGM were twice as likely to report no sexual desire and 52 percent more likely to report dyspareunia (painful sexual intercourse). One-third reported reduced sexual feelings. Distribution
Household surveys
Aid agencies define the prevalence of FGM as the percentage of the 15–49 age group that has experienced it. These figures are based on nationally representative household surveys known as Demographic and Health Surveys (DHS), developed by Macro International and funded mainly by the United States Agency for International Development (USAID); and Multiple Indicator Cluster Surveys (MICS) conducted with financial and technical help from UNICEF.