“Cutting for love”: genital incisions to enhance sexual desirability and commitment in KwaZulu-Natal, South Africa

Abstract

Several studies have documented women's use of vaginal practices in South Africa to enhance their desirability to men. This article describes a little known practice of this kind among women in KwaZulu-Natal. It involves the use of small incisions in the genital area (and often abdomen and breasts) to introduce herbal substances, described as love medicines, into the body through the incisions. In-depth interviews were carried out with 20 key informants and 20 women, and eight focus group discussions with women and men, in a rural and urban site in 2005–06. A province-wide household survey was then conducted using a multi-stage cluster sample design among 867 women aged 18–60. Forty-two per cent of the women in the household survey had heard of genital incisions; only 3% had actually used them. The main motivation was the enhancement of sexual attractiveness and long-term partner commitment. It appears to be a very recent practice, but may be an extension of an older healing practice not involving the genitals. It was most prevalent among rural women aged 24–29 (although not significant), those with less education, and those who suspected their partners of having other partners. It is linked to the modern popularity of love medicines, which in turn illustrates the troubling state of gender relations in KwaZulu-Natal today.

Résumé

Plusieurs études ont documenté les pratiques vaginales utilisées par les Sud-Africaines pour se rendre plus désirables. Cet article décrit une pratique peu connue de ce type chez les femmes du KwaZulu-Natal. De petites incisions sont pratiquées dans la zone génitale (et souvent l'abdomen et les seins) afin d'introduire dans le corps des substances à base de plantes, décrites comme des médicaments de l'amour. Des entretiens approfondis ont été réalisés avec 20 informateurs clés et 20 femmes, ainsi que huit discussions par groupes d'intérêt avec des femmes et des hommes, dans un site rural et un site urbain en 2005–2006. Une enquête auprès des ménages dans l'ensemble de la province a ensuite été menée à l'aide d'un échantillonnage en grappes à plusieurs étapes chez 867 femmes âgées de 18 à 60 ans. Dans l'enquête auprès des ménages, 42% des femmes avaient entendu parler des incisions génitales ; 3% seulement y avaient eu recours. Leur principale motivation était d'accroître l'attirance sexuelle du partenaire et de s'assurer sa fidélité. Cette pratique semble très récente, mais elle prolonge peut-être une méthode plus ancienne de guérison qui ne concernait pas les organes génitaux. On l'a surtout observée chez les rurales âgées de 24 à 29 ans (mais non significative), les femmes moins instruites et celles qui soupçonnaient leur partenaire d'avoir une liaison. Elle est liée à la popularité moderne des médicaments de l'amour, qui illustre à son tour l'état troublant des relations entre hommes et femmes au KwaZulu-Natal aujourd'hui.

Resumen

Varios estudios han documentado el uso de prácticas vaginales en Sudáfrica para mejorar la deseabilidad de las mujeres por los hombres. En este artículo se describe una práctica poco conocida de este tipo entre mujeres en KwaZulu-Natal. Implica el uso de pequeñas incisiones en el área genital (y con frecuencia en el abdomen y los senos) para introducir en el cuerpo sustancias herbales, descritas como medicinas de amor, a través de incisiones. Se realizaron entrevistas a profundidad con 20 informantes clave y 20 mujeres, así como ocho discusiones en grupos focales con mujeres y hombres, en zonas rurales y urbanas, en 2005–06. Después, se realizó una encuesta domiciliaria en toda la provincia, utilizando un diseño de muestra de grupo, de múltiples etapas, entre 867 mujeres de 18 a 60 años de edad. El 42% de las mujeres en la encuesta domiciliaria habían oído hablar de incisiones genitales, pero sólo el 3% las había usado. La motivación principal fue mejorar su atractivo sexual y el compromiso de su pareja a largo plazo. Parece ser una práctica muy reciente, pero quizás sea una extensión de una práctica curativa más antigua que no implica los genitales. Era más prevalente entre mujeres rurales de 24 a 29 años (aunque no significante), aquéllas con menos educación y aquéllas que sospechaban que sus parejas tenían otras parejas. Está vinculada a la popularidad moderna de las medicinas de amor, que a su vez ilustra el penoso estado actual de las relaciones entre mujeres y hombres en KwaZulu-Natal.

Key Words:

• vaginal practices
• genital incisions
• sexual behaviour and practices
• gender issues
• love medicines
• South Africa

Several studies in Africa have documented women's use of vaginal practices to enhance their desirability to men.^1–3 Recent qualitative research has tried to further improve our understanding of these practices by classifying them as follows: intravaginal cleansing or douching, application of substances to the vulva, intravaginal insertion of substances, oral ingestion of substances, and anatomical modification, including genital incisions.⁴ Some of these practices have been linked with increased transmission of sexually transmitted infections (STIs), including HIV.⁵⁶

In South Africa, many vaginal practices are motivated by hygiene, but a substantial proportion are for introducing love medicines into the body, as a way to cement relationships and increase sexual pleasure.³ Genital incisions were documented in the late 1990s among female sex workers at truck stops in KwaZulu-Natal, in the context of HIV-related research.⁷ These women reported the practice of ukugcaba – making small incisions in the genital area close to the labia with a razor blade, after which herbal substances were rubbed into the wounds, allegedly to attract men and keep them sexually satisfied.

Ukugcaba, which has a long history in Nguni indigenous healing, is one of several techniques commonly used by Zulu traditional healers to relieve ailments and afflictions.^8–10 The incisions themselves (called izingcabo) are shallow, and commonly made on several sites, including the head, abdomen, breasts and joints.¹¹ The practice is considered a form of “protective” medicine, classically used to strengthen small children against the effects of witchcraft and bad spirits.¹² Adults affected by ancestral anger, interpersonal conflict, witchcraft or ordinary misfortune may also be treated in this way.¹⁰¹¹ Some have classified izingcabo as akin to injections or immunisation in Western medicine, since the aim is the introduction of small quantities of traditional medicines (umuthi, pl. imithi) into the body rather than the incisions themselves.⁹

Importantly, the traditional literature on ukugcaba makes no mention of the use of love medicines nor does it describe the incisions being performed on the female genitalia.^10,11,13 The latter practice has escaped the notice of researchers and activists concerned with female genital cutting/mutilation, possibly because much of southern Africa falls outside the geographical areas where these are traditionally practised. Yet various iterations of genital incisions and/or anatomical modification appear in historical and ethnographic records on sexual practices in this region in the early 20th century. These are documented largely as components of puberty rites in some female initiation schools at the time. Practices included the ritual breaking of the hymen with a finger or animal horn (South Sotho), the making of a tiny cut above the clitoris (Lobedu)¹⁴, and labial-pulling to elongate the labia majora. The latter was practised by the Kgatla of Botswana,¹⁵ the Venda of South Africa,¹⁶ and in urban settlements around Johannesburg in the late 1950s.¹⁷ More recently, labial-pulling has been described in Zimbabwe,¹⁸ Uganda¹⁹ and Mozambique²⁰ as central to contemporary adult female sexual identity.

Indeed, the patriarchal construction of femininity via the deliberate moulding of the female body appears to motivate many forms of genital modification in southern Africa. This is certainly true of female genital cutting/mutilation in many parts of the world, which – despite diverse cultural meanings – is generally seen as necessary to make a woman fully female and feminine, and conform to cultural notions of propriety and beauty.²¹ All these practices are arguably historical precedents for the newer forms of female genital surgery (such as ‘labiaplasty’), performed in modern biomedical contexts largely for cosmetic purposes.²²²³

It is uncertain, however, whether similar motivations underlie the practice of genital incisions in South Africa today, such as the genital izingcabo reported in the sex worker study, reports of which we also encountered during research in KwaZulu-Natal on vaginal practices more broadly.³

This article reports the findings from a sub-study of genital ukugcaba, its meanings and prevalence and the related use of contemporary love medicines, which formed part of a larger World Health Organization (WHO) study of gender, sexuality and vaginal practices in one province each of South Africa, Mozambique, Thailand and Indonesia.

Methods

Full details of the study methodology in all four countries are described elsewhere.²⁴ The sub-study drew on data about genital incisions from both the qualitative phase and quantitative household survey in South Africa. In the latter, some women mentioned genital incisions when asked to describe “surgical procedures used for modifying the vagina”. In all instances these procedures were described as ukugcaba, izingcabo zothando (love incisions), or ukugcabela indoda (to cut and insert traditional medicines for a man).

Ethical approval for the study was obtained from the Social Science Specialist Panel, UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, and the Human Research Ethics Committee, University of the Witwatersrand, Johannesburg.

Qualitative design

There were two study sites for this phase which involved 97 people: Umlazi, a large township in the coastal city of Durban, and a cluster of rural villages in Centocow, southern KwaZulu-Natal. Ten key informants were interviewed in each site: a total of 14 women (members of local women's organisations, herbalists, diviners and health workers such as HIV counsellors, nurses and doctors) and six men (traditional medicine traders, herbalists, diviners and a doctor). In-depth interviews were conducted with a further 20 women from the general population (ten in each site). They were aged 19–63 years old (mean age 35). Five were married or cohabiting, nine were in relationships but not cohabiting, while the rest were either divorced, widowed or single. Nine women were unemployed, three were students, five worked in semi-skilled occupations, two were retired, and one was a commercial sex worker. In each site, four focus group discussions (FGDs) were held with women, three with men and one mixed sex (33 women and 24 men in total). The groups, each with four to nine participants, were from the general population, with women aged 18–34 years and men 18–40.

All interviews were conducted by trained facilitators, audio-recorded and transcribed. In-depth interviews and FGDs were in isiZulu with a translator present where needed, while key informant interviews were mostly in English. Data were collected on vaginal practices, procedures and products used; timing and desired effects; and societal and gendered norms shaping these practices. Following identification of main themes, manual coding was undertaken and the research team formed consensus on a final set of themes.

Quantitative design

Following the qualitative phase, a household survey between April and July 2007 sampled the whole province using a multi-stage cluster design. A structured questionnaire was used in face-to-face interviews with 867 women aged 18–60 to explore the prevalence and patterning of vaginal practices throughout women's life-course. For most questions, participants could select from a list of categories, but open-ended questions were also used to gather more detailed information.

From a list of all census enumeration areas (EAs) in the province, 28 were selected with a probability proportional to size. Within each selected EA, 36 households were chosen using simple random sampling (one woman interviewed per household). Study tools were translated into isiZulu, back translated and pre-tested. To minimise non-response and social desirability bias, female interviewers were trained to interview sensitively, while optimising privacy and safety. Validity and range checks were included in the questionnaire and study database. Survey data were double entered, using Epidata 3.1, and analysis done with STATA V10 (College Station TX, USA). Survey data were weighted, as is commonly done in household surveys, as response rates varied between EAs and because the sampling design meant that participants had an unequal probability of inclusion.^*

Nearly 90% of eligible women were interviewed (867/972); 36 of the selected households had no eligible women. About a third of those interviewed (36.4%) were under 24 years, a further quarter between 24 and 30 years, and 14.4% were 45 to 60 years. Most women were first-language isiZulu speakers (81.4%), with the remainder predominantly isiXhosa or English. The majority were Catholic or Protestant (49.0%), while just under a third attended Zionist (African Independent) churches (29.8%). Most lived in urban areas (63.5%) and had completed secondary school education (62.4%), but only a further 9.7% had entered tertiary education. Only 18.3% were married; 60.4% described themselves as in a stable relationship but unmarried, consistent with figures from other research in the province.²⁵²⁶ One-third of women felt able to say with certainty that their male partner had no other partners (35.9%), while conversely, 15.8% believed their partner had other informal relationships, and a substantial proportion (42.5) expressed uncertainty about this. Polygamous relationships were reported by 5.8% of women. Slightly more than half of the study population described their overall health status as average (42.5%) or poor (9.6%), with almost a quarter concerned they had a genital illness (23.0%).

Findings

Almost half the women (42.0%) interviewed in the household survey had heard of surgical procedures to modify or cut the vagina. Fifty-two women reported having used these procedures (5.9% of women interviewed; 3.0% overall weighted prevalence). Most of those who had heard of them said they had not considered using them, because it was unnecessary (38.4%) or they did not like the idea (31.8%). Interestingly, 12.9% of those who had heard of genital incisions considered trying them, but had not done so because of concerns that it was dangerous (39.5%) or counter to their religion (35.4%).

Which women practised genital incisions?

The characteristics of women who reported ever-use of genital incisions in the survey were strikingly different from those who did not (Table 1) . One in 20 women aged 24–29 had ever practised genital incisions, while fewer older women had tried this. The low levels of genital incisions among older women imply that the practice is historically recent. This was confirmed at interview by an older woman in the rural site:

short-legendTable 1

“…but I was already married when people started using this umuthi… They cut here [points to genitals] and then they put the umuthi there. This thing arrived when we were already old, grandmothers.” (Married woman, age 63)

Prevalence of incisions in the survey was 6.4% in women with incomplete primary schooling (or no education), and decreased with increase in education, to a low of 0.7% in women with tertiary education. Incisions were also 4.22 times more common among Zionist women than women in mainstream churches (95% CI, odds ratio 1.49-12.0, p=0.009 [data not shown]). Prevalence was two-fold higher in rural areas, though this difference was not significant (p=0.09). Genital incisions were more common among women who had a poorer overall sense of health and current concerns about genital health, and were higher among the 8.5% of women who had previous experience of genital ulcers or warts.

Procedures

Women described making cuts a few millimetres long with a small razor blade, nicking the skin until blood was drawn and a sufficient opening created for the insertion of substances into the wound. Descriptions of the precise location of these cuts were generally quite vague, ranging from “right inside the vagina”, “on top of your private parts”, “on the clitoris” to “on the sides of the vagina”.

“You make small cuts on the sides of the vaginal lips and on the clitoris, just once, and rub in the black powder.” (Unmarried woman, age 30)

At the time of these incisions, women also commonly made similar “love incisions” elsewhere, including on top of the head, on the forehead, above the eyebrows, at the base of the neck, between the breasts, at all joints, around the navel, on the thighs, and between the first and second toes. Women explained that these areas would most likely come into contact with a partner during sex. Some also made incisions only on the left-hand side, following a local convention of holding a man in the left arm during love-making. One traditional healer in an in-depth interview said she advised her patients as follows:

“You cut eight around your belly-button, two on top of your breasts, eight on your vagina (inkomo) and one on your back.” (Traditional healer, age 58)

The incisions themselves were mostly made by traditional healers or a trusted friend. Frequency of the practice was variable: some women in the household survey made incisions monthly or even more frequently (15%), while most had done it only once (37%) or between two and five times ever (25%). Some could not remember how many times they had made incisions.

“It stays [in the body] for a longer period and I will renew it after four years.” (Married woman, age 21)

“You do not cut all the time, you only cut once because a man takes them (medicines) just once and it stays forever.” (Unmarried woman, age 37)

Women confirmed that the purpose of the procedure was essentially to allow direct entry of these products into the body. A range of products were mentioned and that it was the combination of these two processes that made it effective.

Although no women mentioned scarring from repeated incisions in the same area, a female physician at a rural district hospital said:

“I've seen women with scarification on their clitoris... And then I've thought to myself, ‘the only thing that could cause these scars is if they have cut themselves with razor blades’. This scarification can sometimes cause problems because the scar pulls at the clitoris, which in turn pulls the urethra and that can cause complications like urinary tract infections.”

Only four women in the survey said that the procedure had caused an adverse health effect, three reporting genital irritation and one genital itchiness. In the in-depth interviews, however, all the women who had knowledge or experience of the practice acknowledged that the wound “burns” when umuthi is rubbed into it, but stressed this pain was acceptable given its benefits:

“…because you know you will gain something, it doesn't matter” (Unmarried woman, age 33)

Love medicines

Products inserted into the fresh incisions were all traditional medicines (imithi), generally consisting of roots, bark and leaves, animal parts or ground minerals (or a combination thereof). These were mostly powders or oils, and either black, brown or red in colour. Snuff (ground tobacco) was also mentioned, as was a compound of saltpetre and ammonium chloride. Products were sourced either from traditional healers or homemade; two women said they purchased theirs in a market. It was, however, rare for traditional healers to initiate women into the practice. Half the women (52.4%) said their use of genital incisions was influenced by a friend or neighbour, while the remainder mentioned relatives such as mothers, sisters and grandmothers.

Women in both interviews and survey referred to the need for the wound to heal in such a way that the umuthi was sealed up inside it, so it remained in the body for some time. One woman, who was not a traditional healer but nonetheless provided many such love medicines to young women in her community, described the full procedure as follows:

“…another snip on the clitoris, and then there is that stuff [medicine], you put it in there. As the wound heals, it closes so that it stays inside. It's sort of like a ground stuff, like a powder. And over your belly-button too. You rub it into the cuts. You don't get into the bath because it [the wound] has got to close first.” (Unmarried woman, age 57)

The context of love medicines: commercialised traditional medicines in a store in Ixopo, KwaZulu-Natal, South Africa

Motivations for genital incisions

The desire to increase their sexual appeal and attractiveness to their partner(s) was a dominant motive for making these incisions and closely tied to aphrodisiacal effects. The umuthi folded up inside the incision is believed to be transferred during sex.

“By sleeping with you, he takes that umuthi. And he will love you more. Even if he kisses you, he takes it.” (Traditional healer, age 58)

“They say there is a cut you make on a woman so that her man will be interested in her. You are cutting for love.” (Unmarried woman, age 42)

“It makes a person to be lovely, to feel hot, you see… so that a man will love her more.” (Unmarried woman, age 24)

Enhancement of sexual desirability was often described as “preparing the vagina” (ukulungisa ingaphansi) or, less frequently, as “bringing back your virginity”. References to “sexual pleasure” were somewhat more ambiguous, with slightly more women (in the survey) citing their own rather than their partners' pleasure as a motivation (65.5% versus 49.2%). The majority of genital incisions were done for sexual purposes, and almost all were made before (89.2%) rather than after sex.

Closely related to these descriptions was the notion of incisions enhancing intimacy and harmony in sexual relationships and reducing conflict. It was said to make couples “like bread and butter. So close.” One of the traditional medicines used for love incisions, isibambelelo (something that holds tight) neatly captures the desire for a partner's long-term commitment and to get him to treat you better, to “love you and listen to you”. These motivations were reported by 79.6% of women in the survey who had performed vaginal incisions:

“To make him stay with you forever, till death us do part.” (Unmarried woman, age 24)

“[The husband] will now know and respect her, he will stay at home.” (Traditional healer)

One woman even described a practice in which love medicines are inserted into an inanimate object such as a pillow or mattress – instead of the body:

“Then you cut your pillow, you stuff it (umuthi) in there, you sew it back. And then every time you get into that room you just bang the pillows, you call his name, and say: ‘This is where you belong!’ He will stay. He doesn't know! Who can suspect a pillow?! [laughs] Oh, how the women work! To keep your man… [laughs].” (Unmarried woman, age 57)

Genital incisions were higher among those who believed that their husband/boyfriend had other sexual partners besides themselves (9.1%). Many women made reference to the value of umuthi as a way to “decrease the number of your partner's girlfriends”. Indeed, as an ongoing effect of love medicines, there was mention of the perceived harm that would befall a man who strays beyond the boundaries of a relationship.

“Compared to his girlfriend, you'll be the one who is nicer than her, nicer than the others. So then maybe he can just come to you alone.” (Unmarried woman, age 19)

“A man will love you and leave the other woman. He won't enjoy sex with anyone else but you.” (Married woman, age 49)

“If your partner cheats or slept with other girls he would feel a sharp pain, a pain which feels like you have a hole in your body.” (Unmarried woman, age 34)

Importantly, competition was not only perceived to be from other potential sexual partners. One of the traditional products, delunina, translates literally as “forsake your mother”. A woman could not only use delunina to make a man leave his other sexual partners, but also to make him desert his own mother and follow her. In part, the rationale for desiring exclusive affection and love was economic. One married woman explained that delunina was popular “because mothers-in-law are cruel to new brides”, and “if a man has money then everyone wants a piece of him”.

Men's perspectives

While none of the men interviewed made reference to women's genital incisions per se, they said much about love medicines in general. These were characterised in largely negative terms, as a way in which women could illicitly wield control over them in somewhat nefarious and humiliating ways.

“There are even men who leave, desert their own home and then go and live with their girlfriends, and forget about their parents and their homes.” (FGD with rural men age 19–30)

“…If the umuthi is on me then I don't see that. She can give me washing, even panties, even socks, I can even wash her feet, and I don't see that. Even if your parents tell you that you have been bewitched, you won't listen. You see, girls are witches.” (FGD with rural men age 18–22)

Almost all women in the survey reported non-disclosure of genital incisions (94.4%). When asked what their partner would do if he found out, 37.7% said he would be angry while 32.3% believed discovery would result in violence or abandonment. Violence as a theme appeared repeatedly in focus group discussions with men, and was cited as a likely response if they “caught” their girlfriends using love medicines, but also, paradoxically, if their girlfriends decided at some point to cease these practices.

“If she stopped using it [after long-term use], you will feel like beating her and asking who she has been sleeping with.” (FGD with rural men age 19–30)

Discussion

Genital incisions were reported by about one in 30 women in KwaZulu-Natal, though at much higher levels in some population sub-groups, such as women belonging to Zionist Churches. This may relate to the fact that sorcery is a central concern of these churches, which generally promote traditional forms of healing over western biomedicine.²⁷ Our finding that women who practised genital ukugcaba were mainly those who suspected unfaithfulness in their partners is consistent with qualitative reports that the desire for partner fidelity is a strong motivator for the practice. Although there was an association with having experienced genital infections and a sense of poor health, this is unlikely to be causal, since genital incisions were never reported to be specifically for addressing these symptoms. More likely these links reflect the underlying vulnerability of this group of women, conferred by their low education levels, rural dwelling and insecure relationships, which in turn is perhaps a proxy for exposure to men's high-risk sexual behaviour in this setting.

A limitation of our research is that we did not investigate why the traditional (non-genital) ukugcaba, originally used as a form of healing and protection from supernatural forces, appears to have been adapted for genital administration of love medicines. We can only speculate that the medicines are seen as more potent when transmitted via the genitals during sex. Women in this setting are also already using other vaginal practices – such as insertion and application of products, both traditional and modern, for hygiene and sexual purposes.³ Perhaps it is only a small leap, then, to appropriate ukugcaba in this way, thus adding a new technique to the existing repertoire of methods for administering love medicines, which include, for example, ingestion in food and smearing on the body. That women appear to be using love medicines at all is itself interesting, given the suggestion in some literature that these medicines were originally the preserve of men alone.¹³²⁸

Women's economic and other forms of dependence on men, in the broader context of multiple and concurrent partners²⁹ perhaps provide the rationale for the use of love medicines today. Their alleged ability to secure commitment and fidelity from male lovers or husbands may make them appealing in situations where women are otherwise disempowered.^3,30 This point is underscored by women's expressed need to keep the practice secret and the fear of violence if use of love medicines is discovered, borne out by men in the focus group discussions.

In conclusion, while the actual prevalence of genital izingcabo among the general population in KwaZulu-Natal is relatively low, it is perhaps significant that almost half the women were aware of this practice. Genital incisions appear to be historically quite recent – or possibly an extension of an older practice that did not initially involve the genitalia. They are largely linked to the modern popularity of love medicines, which in turn reflects the troubling state of gender relations in KwaZulu-Natal today.

Acknowledgements

The Gender, Sexuality and Vaginal Practices study was a project of the UNDP/UNFPA/WHO/World Bank Special Programme on Research, Development, and Research Training in Human Reproduction (Protocol Numbers MO41125; MO60442). Support was provided by AusAID, Australian Research Council, Flemish Government, Ford Foundation, International Partnership on Microbicides, UNAIDS and WHO. The authors acknowledge the input of the study participants and the South African study team.

Notes

* As weighted percentages are presented, actual numerators and denominators are not shown.