Sitting with her head bowed, Abayenesh Mekonnen snapped her razor blade. It was a symbolic gesture meaning she would no longer practise female genital mutilation (FGM) - an arcane custom shrouded in secrecy, still performed in 28 African countries.
Abayenesh, from Wollo in Ethiopia's northern highlands, was an 'excisor'; the name for women - often with no medical training whatsoever - who perform the brutal genital cutting of children, leaving some scarred for life. "I feel ashamed about what I have done, because I now realise the dangers from circumcisions," she said. "At the time we didn't know - we did this because it was our custom."
This mother of nine, who received just four years of schooling, has now given up her blade and been trained to help women during childbirth.
Dating back more than 4,000 years, FGM has always been little understood, but its legacy has been one of death and severe physical discomfort or injury for millions of women and girls.
Despite an international campaign to outlaw FGM, launched in the 1950s by the United Nations, an estimated two million girls are still at risk each year. An estimated 100 to 130 million women have suffered it, and activists say FGM, circumcision or genital cutting is deeply entrenched in society.
Perhaps more alarming, according to the Inter-African Committee (IAC), FGM is becoming one of the most serious health issues affecting women, and is helping to spread HIV/AIDS.
FGM is also blamed for the high female mortality rates that occur in Africa. Dr Dehab Belay, a project officer with the National Committee on Traditional Harmful Practices (NCTHP), based in Addis Ababa, said FGM should be criminalised because it is a breach of human rights.
"Ethiopia has one of the highest levels of female mortality and that, in a large part, is due to FGM - the number of women dying in Ethiopia is higher than for men," said Dehab. "We think the government in Ethiopia could do more. It is not yet a priority for the government, but it should be."
Nevertheless, she acknowledges from studies NCTHP have carried out that the prevalence is falling.
There are four main types of FGM: Sunna, a word meaning 'tradition', involves the removal of the clitoral hood with or without all or part of the clitoris. The most severe form of FGM is infibulation, a practice performed in the Horn of Africa and in parts of southern Egypt, northern Nigeria and Mali, which involves removing the entire genitalia. Anaesthetics are never used or, at best, extremely rarely.
FGM is most widespread in Djibouti and Somalia, with up to 98 percent of women undergoing it. In Ethiopia an estimated 90 percent of women are circumcised, according to the NCTHP.
In countries like Ethiopia, FGM can be carried out on babies just 80 days old, particularly in the predominately Christian highlands, while in the lowland Muslim regions, girls up to the age of 14 are subjected to the custom.
Some excisors use the same knife or razor blade on all their victims, regardless of the danger of spreading infections. "Often the young girls will be given a few glasses of local alcohol to help the pain, but they are expected to scream and feel the pain," said Dehab. "It is seen as part of womanhood."
Myths and superstitions often form the basis of the practice. Many cite traditional beliefs that FGM ensures moral behaviour by women, preserves virginity, calms young girls, or give religious, aesthetic and hygienic reasons, or say it increases matrimonial opportunities, commented Dehab, adding: "None of these reasons has a basis in fact or science."
The 'operation' cutting away a young girl's genitals can take at least half an hour, and usually begins with the young girl's legs being tied to two women, sitting on either side. A third, at her head, will hold down her chest and arms. Then the cutting begins.
Thorns from acacia trees are used to sew the wound. A small prayer is said, the girl is then told not to struggle and, most importantly, never to show anyone what has happened to her until she marries.
Immediately afterwards she is taken home, where her legs are strapped together for a month while the wound heals. Some girls, however, never make it into marriage. They either bleed to death or develop infections like septicaemia that kill them in a matter of weeks.
Others end up infertile, or suffering from bladder and kidney problems for the rest of their lives. According to a recent scientific study, published in the International Journal of Gynaecology and Obstetrics, almost one in 10 women will suffer a stillbirth.
Although predominately performed in Africa, FGM is also carried out on rural Kurdish women in northern Iraq and among certain tribes in other Arab countries like Yemen, the United Arab Emirates, Bahrain and Qatar.
The act was also sometimes performed in Europe during the 19th century, with physicians believing it was a cure for a number of mental and physical disorders.
Although it is practised in mostly Islamic countries, it is not an exclusively Islamic practice. "FGM is cross-cultural and cross-religious ritual," said Winnie Byanyima, director of gender in the African Union, a 53-nation political, social and economic bloc.
The African Union has been campaigning to put an end to the practice. In July last year, African leaders adopted new laws to help protect the continent's women. Called the Protocol to the African Charter on Human and People's Rights on the Rights of Women in Africa, it spells out key policies to protect women, including anti-FGM legislation.
Some countries have incorporated those laws into their domestic policies. The Ethiopian government introduced specific FGM laws in 2004, and anyone practising it faces a prison term of up to three years if it causes injury.
Byanyima says the real struggle is changing the tide of tradition - the greatest hurdle in bringing an end to FGM. "Communities that perform FGM sometimes resist change because they have felt all their customs - whether good or bad - are threatened."
Abayenesh concurs. "I think education, rather than prison, will bring about change. If you jail people it could make circumcision more secretive."
First recorded in the fifth century BC by the ancient Greek historian, Herodotus, campaigners say they still have a long way to go to eliminating FGM, and are unlikely to meet the 2010 target of eradicating the practice. "If I am optimistic I think it will take another 15 or 20 years," said Dehab. "But it could take a few generations before real change is felt."
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions
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