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African Journal of Reproductive Health
Women's Health and Action Research Centre
ISSN: 1118-4841
Vol. 12, Num. 1, 2008, pp. 7-11
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African Journal of Reproductive Health,
Vol. 12, No. 1, April
2008, pp. 7-11
Commentary
Ethical
concerns in female genital cutting
Rebecca J. Cook
Code Number: rh08001
Description
An
initial ethical concern is what properly to call what
the World Health Organization (WHO) describes as:
all
procedures that involve partial or total removal of the
female external genitalia and/or injury to
the
female genital organs for cultural or any other
non-therapeutic reasons.1
A name
commonly applied, including by the WHO itself, is
female genital mutilation but this description may be
ethically inappropriate. Descriptively, the word
mutilation may be exaggerated, because it fails to
distinguish between the four types of genital cutting
recognized by the WHO. Evaluatively, the name is not a
neutral description but a severely hostile judgment,
since it condemns those who seek, authorize and perform
such cutting as mutilators of human beings. Culturally,
the name is disrespectful, because it fails to respect
the motivation with which those who request the
procedure for their daughters are acting. Personally,
the name is again disrespectful, because it tells women
who were subjected to procedures that they have been
mutilated, by their parents or other family members.
Among communities in which the practice has prevailed,
it is described by the word that signifies purification.2 Purity
in some communities is a condition for a young girl's
marriage, which is essential for daughters' future where
single women have no opportunities. A WHO study critical
of the procedure has conceded that:
in a society where there is little economic viability
for women outside marriage, ensuring that a daughter undergoes genital mutilation as a child or
teenager is a loving act to make certain of her marriageability.3
This recognition separates harms resulting from the procedure
from intentions of parents who seek it. Accordingly,
they should not be described as mutilators of their
children. More ethically sensitive language, such as
female genital cutting (FGC), favours description over
evaluation and personal condemnation.4
Types and Extent
The WHO
has distinguished four types of FGC, with some possible
overlap in categories but ranging from the minor to the
more severe. They are:
Type I
- Excision of the prepuce (equivalent to the male
foreskin) with or without excision of part or all of the
clitoris;
Type II
- Excision of the prepuce and clitoris together with
partial or total excision of the labia minora;
Type
III - Excision of part or all of the external
genitalia and stitching/narrowing of the vaginal opening
(infibulation);
Type IV
- Unclassified: Pricking, piercing, or incision of the
clitoris and/or labia; stretching of the clitoris and/or
labia; cauterization by burning of the clitoris and
surrounding tissues; scraping (angurya cuts) of the
vaginal orifice or cutting (gishiri cuts) of the vagina;
introduction of corrosive substances into the vagina to
cause bleeding, or of herbs into the vagina with the aim
of tightening or narrowing the vagina; any other
procedure that falls under the definition of female
genital mutilation given above. 5
Accepting the broad coverage of these categories, it has been
observed that [w]orldwide, an estimated 130 million
girls and women have undergone (FGC). At least two
million girls a year are at risk of undergoing some form
of the procedure.
Accepting the broad coverage of these categories, it has
been observed that [w]orldwide, an estimated 130
million girls and women have undergone (FGC). At least
two million girls a year are at risk of undergoing some
form of the procedure.6 Further,
under the impact of immigration, the practice is now
found in regions where it has not been prevalent. It has
been noted that FGC is
practiced in 28 African countries in the sub-Saharan and
Northeastern regions
However, prevalence varies widely
from country to country. It ranges from nearly 90
percent or higher in Egypt, Eritrea, Mali and Sudan to
less than 50 per cent in the Central African Republic
and Côte d'Ivoire, to 5 per cent in the Democratic
Republic of Congo and Uganda. Women who have undergone FGC are also found among African immigrant communities
in Europe, Canada, Australia and the United States.7
Consequences
Ethical
concerns are raised not simply from the inherent bodily
insult of FGC, which ranges from minor cuts to major
procedures, the more invasive of which, such as
infibulation, have caused all forms of FGC to be
characterized as mutilation, but from its known
consequences. Some harmful effects are due to the extent
of interventions, but even more minor procedures can
prove damaging, health-threatening, and not uncommonly
life-threatening when conducted with crude instruments,
in unhygienic, non-sterile conditions, and without
anesthesia.
Milder forms of Type IV FGC and minor forms of Type I,
though presenting inherent risks, often from non-sterile
practice, allow relatively speedy recovery and
unimpaired urination, menstruation and sexual
intercourse in later years. In many settings, FGC is
usually undertaken when girls are young. However, it is
found that
girls
are commonly circumcised between the ages of 4 and 10
years, but in some communities the procedure may be
performed on infants, or it may be postponed until just
before marriage or even after the birth of the first
child.8
Ethical concerns over parental use and misuse of
authority over their dependent children, affecting the
children's health, are often reduced when adolescents
and adults reach capacity for autonomy. However, even
autonomous adults can be subject to family and social
pressure to agree to procedures they disfavour and
reasonably understand as liable to prejudice their
health, such as FGC, so that their capacity for freely
given consent is negated or compromised.
All types of FGC present the risk of immediate and often
longer-term health complications, including
psychological pain-related effects. The more immediate
medical complications include excessive bleeding, which
may necessitate emergency medical care that is not
always available. Serious sepsis may occur, particularly
where unsterile instruments are employed for even minor
cutting, and infection can lead to septicemia if the
bacteria reach the bloodstream, which can be fatal.
Acute urine retention can also result from the wound
becoming swollen and inflamed.9 The
most severe long-term complications arise with FGC Types
II and III. Common complications of infibulation include
repeated urinary tract infection and chronic pelvic
infections, which may cause irreparable reproductive
organ damage and infertility. Excessive growth of scar
tissue may result, which can be disfiguring, and cysts
(implantation dermoids) may also occur. Complications of
pregnancy include difficulties before, during and after
delivery,10 such
as pain during and following deinfibulation.
Infibulation-related complications can arise in early
labour, and from prolonged and obstructed labour,
including creation of obstetric fistulae, which can have
devastating effects in women's domestic circumstances
and family lives.11
Fetal distress and stillbirth or early neonatal death
may result, fetal deaths apparently being related to
obstruction of delivery presented by vulva scarring in
Type III procedures or the extra scarring sometimes
associated with complicated Types I and II procedures.12 Postpartum
hemorrhage is significantly more common in women with
FGC, usually associated with scarring that may result
from all types of FGC, and scarring can contribute to
and even cause maternal death, often resulting from
unattended or improperly treated obstructed labour.13
Contexts
In view
of the risks and harmful consequences that societies in
which FGC is prevalent know to be associated with and
often directly due to the practice, its continuing
acceptance and even requirement raises the ethical
question of why the practice persists. One explanation
is religiosity, since the practice has historically been
followed out of a sense of devout duty in Islamic,
Christian and Jewish communities, although nothing in
the sacred texts or doctrines of these religions
mandates it, unlike male circumcision in Islam and
Judaism. Another explanation is the cultural requirement
of female purity, exhibited in the virginity of brides
and fidelity of wives. A family's females are the focus
and token of its honour, so that females are guardians
of their families' virtue. Females' sexual enterprise,
or their sexual violation, robs their families of
honour, status and respect in their communities. The
purpose of FGC, especially Types II and III, is to
reduce the female drive for sexual satisfaction, and
reduce their vulnerability to rape. This explanation
reflects gender stereotyping, which enhances men's
reputations if they are sexually adventurous, but
condemns women for sexual immodesty or being sexually
provocative or experimental.
This explanation fits into a wider framework of male
hostility to females exhibiting or indulging their
sexuality. In the latter half of the 19th century
in Europe, including the U.K., and in the United States,
gynecological surgeons performed many clitoridectomies,
on what were claimed to be medical indications for
conditions related to sexual disorder, such as hysteria,
epilepsy, melancholia, the psychiatric disorder of
nymphomania, and the psycho-social disorder of seeking
or deriving pleasure from sex.14 By
this explanation, FGC appears to be continuation of a
history of social control of female sexuality, a feature
of many traditional societies of various religious
faiths. Consistently with this explanation, the practice
has been seen to decline among daughters of urban,
educated women, and, for instance, among Ibo girls in
Nigeria, largely attributed to the rising rate of
women's formal education.15
Professional Responses
Choice
of ethical response among physicians brings out the
ambivalence of the historical medical ethic, Do No Harm.
In the language of modern bioethics, this is embodied in
the principle of non-maleficence. FGC is no doubt safer
in medical than in unskilled hands, so that, for
instance, excessive bleeding can be better contained,
but at best the procedure bears an irreducible minimum
risk of injury, and in almost all cases is demonstrably
non-therapeutic. A direct application of the Do No Harm
principle therefore indicates that physicians should not
undertake FGC. Another aspect of non-maleficence,
however, is to minimize harm. The case for medical
involvement is that when parents feel compelled to have
FGC for their daughters, and unskilled practitioners
such as family members are available to undertake
procedures in non-sterile conditions and by crude means,
harm will be minimized if physicians agree to conduct
procedures and can do so by minimally invasive means.
There is strong medical professional objection, however,
to seeming to medicalize FGC, and to making it appear to
be part of the legitimate practice of medicine. The
objection is analogous to physicians' non-participation
in judicially-ordered amputation, corporal or capital
punishment, and governmentally permitted torture. For
instance in 1994, the General Assembly of the
International Federation of Gynecology and Obstetrics
resolved that gynecologists should oppose any attempt
to medicalize the procedure or to allow its performance,
under any circumstances, in health establishments or by
health professionals.16 Accordingly,
practitioners should not succumb to inducements, threats
of unskilled alternatives, or manipulation, to give the
esteem of their medical professional status to FGC. This
prohibition is reinforced by the ethical codes of many
national medical associations, and by an increasing
number of national laws, several of which are vigorously
monitored for compliance. Underpinning these is the UN
Convention on the Rights of the Child, ratified by all
countries of the world except Somalia and the U.S.
Article 19(1) requires that all states apply measures
to protect the child from all forms of physical or
mental violence, injury or abuse, and Article 24(3)
requires abolition of traditional practices prejudicial
to the health of the child.17
Harmful traditional practices may change under
the impact of internationally respected human rights
principles.18
A
key role of physicians requested to undertake FGC is to
explain why they cannot, and to educate requesting
parents and others about risks of procedures in
unskilled hands, and the violation of women's bodily
integrity due to these practices. Physicians can also
explain decline in use of the practice, and that it is
decreasing as an expectation in more educated
communities. It may also be essential to point out,
where laws prohibit FGC, that its performance is an
offence19 and
its very request bears risks of legal liability.
Physicians' responses may give less emphasis to punitive
aspects of FGC, however, than to aiding parents,
families and communities to understand the protective
purpose the medical profession advances in eliminating
such procedures. Medical associations and individual
physicians are also urged to collaborate with national
authorities, non-governmental organizations and, for
instance, religious leaders, to support measures aimed
at elimination of this harmful traditional practice.20
Notes
- Department of Women's Health, Family and Community
Health, WHO. A systematic review of the health
complications of female genital mutilation including sequelae in childbirth. WHO/FCH/WMH/00.2. Geneva: World
Health Organi-zation, 2000, p.11.
- L.
Brown (editor). The New Shorter Oxford English
Dictionary. Oxford Clarendon Press, 1993, p. 405.
- N.
Toubia, S. Izett. Female genital mutilation: an
overview. Geneva: World Health Organization, 1998, p. 2.
-
R.J. Cook, B.M. Dickens, M.F. Fathalla. Female genital
cutting (mutilation/circumcision): ethical and legal
dimensions. International Journal of Gynecology and
Obstetrics 2002; 79: 281-7.
- Note 1 above, p. 11.
- A.
Rahman, N. Toubia (editors). Female genital mutilation:
a guide to laws and policies worldwide. London and New
York: Zed Books, 2000, p. 6.
- Ibid., p. 7.
- N.
Toubia. Female circumcision as a public health issue.
New England J. Medicine 1994; 331: 712-716 at p. 712.
- Note 3 above, p. 26.
- Note 1 above, p. 11.
- R.J. Cook, B.M. Dickens, S. Syed. Obstetric fistula:
the challenge to human rights. International Journal of
Gynecology and Obstetrics 2004; 87: 72-7.
-
Note 1 above, p. 51.
- Ibid., p. 48.
- M.F. Fathalla. The girl child. International Journal of
Gynecology and Obstetrics 2000; 70: 7-12.
- P.O. Nkwo, H.E. Onah. Decrease in female genital
mutilation among Nigerian Ibo girls. International
Journal of Gynecology and Obstetrics 2001; 75: 321-2.
- Resolution in Female Genital Mutilation, FIGO General
Assembly, Montreal, Canada, 1994. See note 14 above, p.
7.
-
See R.J. Cook, B.M. Dickens, M.F. Fathalla. Reproductive
Health and Human Rights: Integrating Medicine, Ethics
and Law. Oxford: Oxford University Press 2003, Case
Study No. 2, pp. 262-275.
- C.A.A. Packer. Using Human Rights to Change Tradition:
Traditional Practices Harmful to Women's Reproductive
Health in sub-Saharan Africa. Antwerp, Oxford and New
York: Intersentia 2002.
- Note 17 above, pp. 268-272.
- A.J. Gage, R. Van Rossem. Attitudes toward
the discontinuation of female genital cutting among men
and women in Guinea. International Journal of Gynecology
and Obstetrics 2006; 92: 92-6.
Copyright 2008 - Women's
Health and Action Research Centre, Benin City, Nigeria
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