COMMENTARY

Ethical concerns in female genital cutting

Rebecca J. Cook

Description A WHO study critical of the procedure has An initial ethical concern is what properly to call conceded that: what the World Health Organization (WHO) in a society where there is little economic describes as: viability for women outside marriage, ensuring that a daughter undergoes genital mutilation all procedures that involve partial or total as a child or teenager is a loving act to make removal of the female external genitalia and/ certain of her marriageability.3 or injury to the female genital organs for 1 cultural or any other non-therapeutic reasons. This recognition separates harms resulting A name commonly applied, including by the from the procedure from intentions of parents WHO itself, is “female genital mutilation” but who seek it. Accordingly, they should not be this description may be ethically inappropriate. described as mutilators of their children. More Descriptively, the word “mutilation” may be ethically sensitive language, such as female genital exaggerated, because it fails to distinguish cutting (FGC), favours description over 4 between the four types of genital cutting evaluation and personal condemnation. recognized by the WHO. Evaluatively, the name is not a neutral description but a severely hostile Types and Extent judgment, since it condemns those who seek, The WHO has distinguished four types of FGC, authorize and perform such cutting as mutilators with some possible overlap in categories but of human beings. Culturally, the name is ranging from the minor to the more severe. They disrespectful, because it fails to respect the are: motivation with which those who request the Type I – Excision of the prepuce (equivalent procedure for their daughters are acting. to the male foreskin) with or without Personally, the name is again disrespectful, because excision of part or all of the ; it tells women who were subjected to procedures that they have been mutilated, by their parents or Type II - Excision of the prepuce and clitoris other family members. Among communities in together with partial or total excision which the practice has prevailed, it is described of the ; by the word that signifies purification.2 Purity in some communities is a condition for a young Type III - Excision of part or all of the external girl’s marriage, which is essential for daughters’ genitalia and stitching/narrowing of future where single women have no opportunities. the vaginal opening (infibulation); 8 African Journal of Reproductive Health Type IV - Unclassified: Pricking, piercing, or even more minor procedures can prove damaging, incision of the clitoris and/or labia; health-threatening, and not uncommonly life- stretching of the clitoris and/or labia; threatening when conducted with crude cauterization by burning of the clitoris instruments, in unhygienic, non-sterile conditions, and surrounding tissues; scraping and without anesthesia. (angurya cuts) of the vaginal orifice Milder forms of Type IV FGC and minor or cutting (gishiri cuts) of the ; forms of Type I, though presenting inherent risks, introduction of corrosive substances often from non-sterile practice, allow relatively into the vagina to cause bleeding, or speedy recovery and unimpaired urination, of herbs into the vagina with the aim menstruation and sexual intercourse in later years. of tightening or narrowing the vagina; In many settings, FGC is usually undertaken when any other procedure that falls under girls are young. However, it is found that the definition of female genital [g]irls are commonly circumcised between the 5 mutilation given above. ages of 4 and 10 years, but in some commu- nities the procedure may be performed on Accepting the broad coverage of these infants, or it may be postponed until just categories, it has been observed that “[w]orldwide, before marriage or even after the birth of the an estimated 130 million girls and women have first child.8 undergone (FGC). At least two million girls a year are at risk of undergoing some form of the Ethical concerns over parental use and misuse procedure”.6 Further, under the impact of of authority over their dependent children, immigration, the practice is now found in regions affecting the children’s health, are often reduced where it has not been prevalent. It has been noted when adolescents and adults reach capacity for that FGC autonomy. However, even autonomous adults can be subject to family and social pressure to is practiced in 28 African countries in the sub- agree to procedures they disfavour and reasonably Saharan and Northeastern regions…However, prevalence varies widely from country to understand as liable to prejudice their health, such country. It ranges from nearly 90 percent or as FGC, so that their capacity for freely given higher in Egypt, , Mali and to consent is negated or compromised. less than 50 per cent in the Central African All types of FGC present the risk of Republic and Côte d’Ivoire, to 5 per cent in immediate and often longer-term health the Democratic Republic of Congo and complications, including psychological pain- Uganda …Women who have undergone FGC related effects. The more immediate medical are also found among African immigrant complications include excessive bleeding, which communities in Europe, Canada, Australia may necessitate emergency medical care that is and the United States.7 not always available. Serious sepsis may occur, particularly where unsterile instruments are Consequences employed for even minor cutting, and infection Ethical concerns are raised not simply from the can lead to septicemia if the bacteria reach the inherent bodily insult of FGC, which ranges from bloodstream, which can be fatal. Acute urine minor cuts to major procedures, the more invasive retention can also result from the wound of which, such as infibulation, have caused all becoming swollen and inflamed.9 The most severe forms of FGC to be characterized as mutilation, long-term complications arise with FGC Types but from its known consequences. Some harmful II and III. Common complications of effects are due to the extent of interventions, but infibulation include repeated urinary tract infection

African Journal of Reproductive Health Vol. 12 No.1 April, 2008 Ethical concerns in female genital cutting 9 and chronic pelvic infections, which may cause violation, robs their families of honour, status irreparable reproductive organ damage and and respect in their communities. The purpose infertility. Excessive growth of scar tissue may of FGC, especially Types II and III, is to reduce result, which can be disfiguring, and cysts the female drive for sexual satisfaction, and reduce (implantation dermoids) may also occur. their vulnerability to . This explanation reflects Complications of pregnancy include difficulties gender stereotyping, which enhances men’s before, during and after delivery,10 such as pain reputations if they are sexually adventurous, but during and following deinfibulation. Infibulation- condemns women for sexual immodesty or being related complications can arise in early labour, sexually provocative or experimental. and from prolonged and obstructed labour, This explanation fits into a wider framework including creation of obstetric fistulae, which can of male hostility to females exhibiting or have devastating effects in women’s domestic indulging their sexuality. In the latter half of the circumstances and family lives.11 19th century in Europe, including the U.K., and Fetal distress and stillbirth or early neonatal in the United States, gynecological surgeons death may result, fetal deaths apparently being performed many , on what were related to obstruction of delivery presented by claimed to be medical indications for conditions scarring in Type III procedures or the extra related to sexual disorder, such as hysteria, scarring sometimes associated with complicated epilepsy, melancholia, the psychiatric disorder of Types I and II procedures.12 Postpartum nymphomania, and the psycho-social disorder of hemorrhage is significantly more common in seeking or deriving pleasure from sex.14 By this women with FGC, usually associated with scarring explanation, FGC appears to be continuation of that may result from all types of FGC, and a history of social control of female sexuality, a scarring can contribute to and even cause maternal feature of many traditional societies of various death, often resulting from unattended or religious faiths. Consistently with this explanation, improperly treated obstructed labour.13 the practice has been seen to decline among daughters of urban, educated women, and, for Contexts instance, among Ibo girls in Nigeria, largely In view of the risks and harmful consequences attributed to the rising rate of women’s formal 15 that societies in which FGC is prevalent know to education. be associated with and often directly due to the practice, its continuing acceptance and even Professional Responses requirement raises the ethical question of why Choice of ethical response among physicians the practice persists. One explanation is religiosity, brings out the ambivalence of the historical since the practice has historically been followed medical ethic, Do No Harm. In the language of out of a sense of devout duty in Islamic, Christian modern bioethics, this is embodied in the and Jewish communities, although nothing in the principle of non-maleficence. FGC is no doubt sacred texts or doctrines of these religions safer in medical than in unskilled hands, so that, mandates it, unlike male circumcision in Islam for instance, excessive bleeding can be better and Judaism. Another explanation is the cultural contained, but at best the procedure bears an requirement of female purity, exhibited in the irreducible minimum risk of injury, and in almost virginity of brides and fidelity of wives. A family’s all cases is demonstrably non-therapeutic. A direct females are the focus and token of its honour, application of the Do No Harm principle so that females are guardians of their families’ therefore indicates that physicians should not virtue. Females’ sexual enterprise, or their sexual undertake FGC. Another aspect of non-

African Journal of Reproductive Health Vol. 12 No.1 April, 2008 10 African Journal of Reproductive Health maleficence, however, is to minimize harm. The about risks of procedures in unskilled hands, and case for medical involvement is that when parents the violation of women’s bodily integrity due to feel compelled to have FGC for their daughters, these practices. Physicians can also explain decline and unskilled practitioners such as family in use of the practice, and that it is decreasing as members are available to undertake procedures an expectation in more educated communities. It in non-sterile conditions and by crude means, may also be essential to point out, where laws harm will be minimized if physicians agree to prohibit FGC, that its performance is an offence[19] conduct procedures and can do so by minimally and its very request bears risks of legal liability. invasive means. Physicians’ responses may give less emphasis to There is strong medical professional punitive aspects of FGC, however, than to aiding objection, however, to seeming to medicalize parents, families and communities to understand FGC, and to making it appear to be part of the the protective purpose the medical profession legitimate practice of medicine. The objection is advances in eliminating such procedures. Medical analogous to physicians’ non-participation in associations and individual physicians are also judicially-ordered amputation, corporal or capital urged to collaborate with national authorities, punishment, and governmentally permitted non-governmental organizations and, for instance, torture. For instance in 1994, the General religious leaders, to support measures aimed Assembly of the International Federation of at elimination of this harmful traditional Gynecology and Obstetrics resolved that practice.20 gynecologists should “oppose any attempt to medicalize the procedure or to allow its Notes performance, under any circumstances, in health 1. Department of Women’s Health, Family and [16] establishments or by health professionals.” Community Health, WHO. A systematic review Accordingly, practitioners should not succumb of the health complications of female genital to inducements, threats of unskilled alternatives, mutilation including sequelae in childbirth. WHO/ or manipulation, to give the esteem of their FCH/WMH/00.2. Geneva: World Health Organi- medical professional status to FGC. This zation, 2000, p.11. prohibition is reinforced by the ethical codes of 2. L. Brown (editor). The New Shorter Oxford many national medical associations, and by an English Dictionary. Oxford Clarendon Press, 1993, increasing number of national laws, several of p. 405. which are vigorously monitored for compliance. 3. N. Toubia, S. Izett. Female genital mutilation: an Underpinning these is the UN Convention on overview. Geneva: World Health Organization, the Rights of the Child, ratified by all countries 1998, p. 2. of the world except and the U.S. Article 4. R.J. Cook, B.M. Dickens, M.F. Fathalla. Female 19(1) requires that all states apply “measures to genital cutting (mutilation/circumcision): ethical protect the child from all forms of physical or and legal dimensions. International Journal of mental violence, injury or abuse,” and Article 24(3) Gynecology and Obstetrics 2002; 79: 281-7. requires abolition of “traditional practices 5. Note 1 above, p. 11. prejudicial to the health of the child.”[17] Harmful 6. A. Rahman, N. Toubia (editors). Female genital traditional practices may change under the impact mutilation: a guide to laws and policies worldwide. of internationally respected human rights London and New York: Zed Books, 2000, p. 6. principles.18 7. Ibid., p. 7. A key role of physicians requested to 8. N. Toubia. Female circumcision as a public health undertake FGC is to explain why they cannot, issue. New England J. Medicine 1994; 331: 712- and to educate requesting parents and others 716 at p. 712. African Journal of Reproductive Health Vol. 12 No.1 April, 2008 Ethical concerns in female genital cutting 11 9. Note 3 above, p. 26. 17. See R.J. Cook, B.M. Dickens, M.F. Fathalla. 10. Note 1 above, p. 11. Reproductive Health and Human Rights: Integrating Medicine, Ethics and Law. Oxford: 11. R.J. Cook, B.M. Dickens, S. Syed. : Oxford University Press 2003, Case Study No. 2, the challenge to human rights. International pp. 262-275. Journal of Gynecology and Obstetrics 2004; 87: 72-7. 18. C.A.A. Packer. Using Human Rights to Change Tradition: Traditional Practices Harmful to 12. Note 1 above, p. 51. Women’s Reproductive Health in sub-Saharan 13. Ibid., p. 48. Africa. Antwerp, Oxford and New York: Intersentia 14. M.F. Fathalla. The girl child. International Journal 2002. of Gynecology and Obstetrics 2000; 70: 7-12. 19. Note 17 above, pp. 268-272. 15. P.O. Nkwo, H.E. Onah. Decrease in female genital 20. A.J. Gage, R. Van Rossem. Attitudes toward the mutilation among Nigerian Ibo girls. International discontinuation of female genital cutting among Journal of Gynecology and Obstetrics 2001; 75: men and women in Guinea. International Journal 321-2. of Gynecology and Obstetrics 2006; 92: 92-6. 16. Resolution in Female Genital Mutilation, FIGO General Assembly, Montreal, Canada, 1994. See note 14 above, p. 7.

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