I recently had a conversation that challenged what I thought I knew about the controversial ritual known as “female genital cutting,” or, more commonly, "female genital mutilation."

FGC, as it is abbreviated, involves an elder or other community member slicing off all or part of a woman’s clitoris and labia as part of a ceremony that is often conducted around the time that the woman reaches puberty. Many international groups are concerned about FGC, which is practiced extensively in parts of Africa and the Middle East and is linked to infections, infertility, and childbirth complications.

Organizations such as the United Nations have campaigned against the practice, calling for its abolition as a matter of global health and human rights. But despite a decades-old movement against it, FGC rates in some countries haven't budged. While younger women are increasingly going uncut in countries such as Nigeria and the Central African Republic, according to a survey by the Population Reference Bureau, in Egypt more than 80 percent of teenagers still undergo the procedure.

So what can foreign activists—as well as locals who oppose female genital cutting—do to curb the practice? For starters, Bettina Shell-Duncan, an anthropology professor at the University of Washington who has been studying the practice in many countries for years, suggests using the term “cutting” rather than “mutilation,” which sounds derogatory and can complicate conversations with those who practice FGC.

She also challenges some common misconceptions around FGC, like the belief that it is forced on women by men. In fact, elderly women often do the most to perpetuate the custom. I thought African girls were held down and butchered against their will, but some of them voluntarily and joyfully partake in the ritual. I thought communities would surely abandon the practice once they learned of its negative health consequences. And yet, in Shell-Duncan's experience, most people who practice FGC recognize its costs—they just think the benefits outweigh them.

Shell-Duncan recently joined a five-year research project, led by the Population Council, whose goal is reducing female genital cutting by at least 30 percent across 10 countries over five years. I spoke with her about how activists, policymakers, and everyday people can better understand FGC so that they can avoid alienating the communities they aim to help.

An edited and condensed transcript of our conversation follows.

Olga Khazan: How did you get into this topic?

Bettina Shell-Duncan: In 1996 I went to Kenya—northern Kenya among an ethnic group called the Rendille. I was doing research on anemia, iron deficiency. I started asking questions about what people in the community perceived were the major health problems. I talked to men and women throughout the community, and they listed a whole host of things: malaria, men talked a lot about diseases in their animals.

People started saying, “We don’t have enough antibiotics for our weddings.”

I was so confused, like, what does that mean? I couldn’t understand what they were talking about. And they pulled me aside and said, “You know, we’re talking about circumcision.”

I said, “I know what circumcision is. I’ve had my son circumcised.”

And they said, “No, we mean for our girls.”

I was completely confused. And they realized that not only had I gotten married without being circumcised, but that I had obviously delivered children without being circumcised, which in their culture was unthinkable.

These women were my very good friends, and they were covering up their faces to not show how repulsed they were by the idea of somebody being uncircumcised and delivering a baby. They were, you know, revolted.

Khazan: Well, wait, what did you say? Because I could imagine—and this is probably why I’m not an anthropologist—but I could imagine myself saying something untoward in that moment, like, “What do you mean? What I’m doing is fine! ... What are you doing?”

Shell-Duncan: On the other hand, these are women who live in a drought-prone region of Africa. Living in circumstances that are so dire. And they’re smart. They know how to cope in those circumstances. And honestly, I have a Ph.D. Would I know how to raise a kid under those kinds of conditions?

Khazan: So when they say that they don’t have enough antibiotics for the wedding, is it because they would do the cutting at the wedding?

Shell-Duncan: Different ethnic groups do it differently. Among the Rendille, they do it as part of the first part of the ceremony. The wedding ceremony spans years.

There’s the time where the bride is transferred to the groom. This is a nomadic tribe. They live in huts that are made from branches. And what they do is they take apart the hut of the mother and father and they divide the branches. They get green branches. They divide them in half—half the old branches, half the new. And they build two new huts.

It symbolizes two new homes, sort of a fusion of the two. And when they have the new hut built, they have a procession that goes from the groom’s family to the bride’s family and bring the groom to the bride. And then they have a ceremony where the bride is transferred to the new home. The morning part of that is the circumcision part.

Khazan: And what type of circumcision do they do?

Shell-Duncan: Excision, which is the World Health Organization Type 2. They cut off the clitoris and the inner labia. [The World Health Organization ranks FGC procedures in terms of escalating severity. They range from Type 1, in which only the clitoris is cut, to Type 3, infibulation, in which the labia are stitched together.]

Khazan: I read you were invited to watch one of these. How old was the girl?

Shell-Duncan: The girl was 16. Which was young by their standards. Mostly they’re 18, 19, 20, around that.

Women were going to a dispensary the day before and they were getting antibiotics and an anti-tetanus injection. They would get a clean disposable razor. Before they had a traditional knife that was used, but they stopped using that, and now every bride has her own clean razor.

Khazan: And you watched this unfold?

Shell-Duncan: Well, they invited me. They said, “There’s a wedding going on, do you want to go?” And I was like, “Alright.” They took me to this blended-branch hut. They brought in the bride, and they brought in the circumciser, a woman, and a couple of other women followed. And I just sat on the edge in this tiny hut, and watched what was going on. It all happened pretty quickly. They had one woman working, and other women held each leg. The circumciser came in and lifted this cloth that the woman had been wearing draped around her. The circumciser kneeled, and did basically this.

[Flicks her wrist twice.]

And it was done. They poured some water with herbs boiled in it over her body. They moved her up to this little loft.

After a little time everybody looked to see if the cut was okay, and after that, they started brewing some tea. One woman went outside and announced the circumcision was successful. People started roasting lamb, meat. A little while later, warriors came over to the hut and started singing and dancing praises to the bride and the groom. This went on for hours. There was this complete celebration. I was completely perplexed. I sat there just sort of, you know, “Did anyone just see what I just saw?”

Khazan: Was the girl like, “No, don’t do this to me!” or was she like, “This is happening.”?

Shell-Duncan: No, no, she was proud. She sat there stoic and looked up at a focal point. She didn’t flinch, and that’s apparently a really important part of showing your maturity: Can you withstand the pain? It shows that you have the maturity to face the hardship that is coming as a woman.

A little bit later, I excused myself and ran back to the hut where I was staying, and I travel with a little medical first-aid bag. I raced back to the hut and gave her these codeine tablets. The women were like, “What is this, what is this? Does it cure malaria?”

I said, “No, no, it’s not for malaria.”

They said, “Does it restore fertility?”

I said, “No, this is only for the pain for the bride.” I gave it to the bride, and I gave her instructions on how to use it.

The bride came out and joined the dancing. I almost died. I thought she must be on codeine, but she wasn’t. She was joyful. I didn't understand the joy about this.

But later I remembered that when I gave birth to my first son, I had a very difficult delivery. After my son was born, everyone in the delivery room popped a bottle of champagne. I felt like I had been hit by a Mack truck and they were toasting champagne. But it was a good pain, and that’s what this was. This girl had become a woman.

When I went back two years later, the girl came to me and gave the pills back. She said, “You don’t understand, this is not our way. And if I didn’t do that, I wouldn’t be a woman now.”

I understood why. And I respected her.

Khazan: Yeah. So, wow. I guess the biggest question for me is what do they see as the benefit? Are there any benefits?

Shell-Duncan: This is not true everywhere, but there, there it’s not about virginity. It’s not about modesty. And it is in some other cultures. The Rendille are sexually active before they’re married, both men and women. And it’s completely culturally acceptable.

The woman is going to go live with her husband’s family, and it’s part of inclusion among other women whose identity is as a circumcised woman. She’s reliant on her mother-in-law and her husband’s kin. So it’s part of becoming inducted into this female network that’s really important.

Also, for us, we believe that bodies are natural and perfect. Not everybody believes that. Some people in Africa believe that bodies are androgynous and that all male and female bodies contain male and female parts.

So a man’s foreskin is a female part. And for a female, the covering of the clitoris is a male part. The idea of becoming a wholly formed female includes being cut—having any part that is somewhat male-like removed from the body.

Khazan: That actually makes logical sense to me. We have shaving your legs, or wearing makeup. We have weird things that we do that are less painful. But the pain in their case is kind of the “proving yourself” aspect.

Shell-Duncan: Right.

Khazan: So this was in 1996. Is this group still doing this?

Shell-Duncan: Oh yeah.

Khazan: It has not gone down at all?

Shell-Duncan: No.

Khazan: What other reasons do people have for doing this in other countries?

Shell-Duncan: For example, in certain Muslim groups, they talk about it being promoted as cleanliness, and it’s the cleanliness you need to pray to Allah.

Khazan: And where is the support for this practice coming from?

Shell-Duncan: The sort of feminist argument about this is that it’s about the control of women but also of their sexuality and sexual pleasure. But when you talk to people on the ground, you also hear people talking about the idea that it’s women’s business. As in, it’s for women to decide this. If we look at the data across Africa, the support for the practice is stronger among women than among men.

So, the patriarchy argument is just not a simple one. Female circumcision is part of demarcating insider and outsider status. Are you part of this group of elder women who have power in their society?

Khazan: What, medically, are the harms? Why are people trying to stop this?

Shell-Duncan: The WHO was able to show a statistically significant association between FGC and certain risks from obstetrical outcomes. Things like infant death, hemorrhage.

There was a study that was done in Gambia—they were looking at the chances of having sexually transmitted infections and pelvic inflammatory disease, and it was positive, but of course, you can't prove that being circumcised is causal.

Khazan: Do these communities know about the medical consequences?

Shell-Duncan: One of the things that is important to understand about it is that people see the costs and benefits. It is certainly a cost, but the benefits are immediate. For a Rendille woman, are you going to be able to give legitimate birth? Or elsewhere, are you going to be a proper Muslim? Are you going to have your sexual desire attenuated and be a virgin until marriage? These are huge considerations, and so when you tip the balance and think about that, the benefits outweigh the costs.

Early on in the campaigns, one of the strategies was to educate people about the medical risks, which were, by and large, not really news to them.

Some of the campaigns talked about infibulation, which was not the most common form of FGC. Infibulation is the most severe form. That’s when they cut the labia minora, and they take the cut edges together and stitch it together and leave a pinhole opening for urine and menstrual blood. They partially open it for intercourse and to give birth. But that’s about 15 percent of cases.

So activists were saying, “Look how terrible this is.”

And the people in these communities were like, “Well, that might be true in Somalia, but we don’t do that here.”

There was a real credibility gap.

The other thing that can happen is that increasingly, one of the big trends in West Africa is to go to healthcare providers and have the circumcision performed there. They think, “let’s go to the doctor to make this safer.”

In certain places, it was banned in healthcare facilities. So then, nurses would take their annual leave and go to their home communities and perform it.

Khazan: Do you think it’s a global-health imperative that we work to stop this?

Shell-Duncan: There's no question this is a global-health issue. In the U.S., adult women are capable of giving consent for surgical procedures. But what would it take to get a woman in an African country to the same position of being able to give consent? Social pressures [in the nations that practice FGC] are so strong that no woman could ever opt out. Everybody would come down on her. That’s the problem. Why can we give consent and they can’t?

Khazan: So the health-impact messaging doesn’t necessarily work. What else do we know doesn't work?

Shell-Duncan: Well, the big new strategy is legal prohibitions. Now, prohibitions have been put into law in many African countries—22 countries have specific laws. A couple of countries also have constitutional decrees banning it. The shift from the medical argument to the human-rights argument means that a woman can turn to the state for protection. That’s a big difference.

The results have been mixed. Where we were working, we were at the border with Senegal. People had gone to visit relatives in Gambia, and they weren’t sure if what they had done was illegal or not. And it wasn’t, but they didn’t know. I asked if they knew specific cases of prosecution. Nobody knew of any cases of prosecution. They couldn’t tell us anything.

Khazan: I also read that in surveys, large numbers of women and men no longer favor the practice, but they have their daughters cut regardless. Why do they keep doing it?

Shell-Duncan: This is not an individual behavior. For example, if I decide I want to lose weight, and that I'm going to start exercising on a daily basis, I can decide that all by myself. If I decide I don't want to circumcise my daughter, that’s not an individual behavior. I would have to answer to my husband, to my mother-in-law, my mother-in-law would have to answer to her friends throughout the community, my father-in-law would have to answer to people in the community, so there's societal pressure. So understanding what is a collective decision versus individual is really important. You can go and tell an individual mother what the health risks are and she can believe you, but it doesn’t mean, first of all, that she has the power to make that decision, or even that she has the authority to impart that information to her mother-in-law and other senior people in the society who are the decision-makers. Who wants to be the first one to change? Who wants to be the odd man out?

Khazan: What seems like an eradication strategy that might work, given those pressures?

Shell-Duncan: What we're coming to realize is that programs that target individual mothers are completely ineffective. Mothers are not solely in charge of the decisions for their daughters. We need to be targeting people who are in the extended family, and we know that we need to figure out who are the figures of authority in these families, and who are the influences on them in the community. We need to do male elders, but also female elders.

Khazan: And what do you tell them?

Shell-Duncan: This is part of what our research project is about. First and foremost, what we need to understand is that people are doing this because they want to assure the future for their girls, like every parent everywhere. They want to make sure their children are going to be okay moving forward. When they come to Europe or the U.S., a lot of the refugees very quickly realize that the well-being of their girls is not best assured by continuing female circumcision, that it doesn’t make any sense in that setting. They want them to go to college.

It’s about a conversation about, What is the best way to secure the future for your children? The future for their girls might not be best secured by being circumcised any longer.