Female Genital Cutting in the Context Ofislamic Bioethics by Erin Marie

Female Genital Cutting in the Context ofIslamic Bioethics

Erin Marie Rehel

Faculty ofReligious Studies and Biomedical Ethics Unit, Faculty of Medicine McGill University, Montreal

June 2005

A thesis submitted to McGill University in partial fulfillment of the requirements of the degree of Master of Arts, Bioethics Specialization.

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Female genital cutting (FGC) has received much attention since the early 1980s. Decried as both a human rights violation and a barbarie example of the patriarchal subjugation of women and girls in developing nations, FGC has oruy recently been examined within the cultural framework in which it takes place. This thesis will focus on the Muslim communities in Egypt and Sudan who continue to engage in FGC as a required Muslim practice. Starting from the notion that FGC has a limiting effect on a woman's overall health, this thesis will use three foundational notions from Islamic medical ethics to argue against the continuation of FGC. Specifically, it will elaborate and draw on the Islamic position in favor of organ transplantation, thus further illustrating the argument against FGC. By using principles and notions from Islamic medical ethics, this thesis will argue against FGC from within Islam.

L'excision génitale féminine (EGF) a reçu beaucoup d'attention depuis le début des années 1980. Exposée comme étant une violation des droits de la personne et un exemple barbare de la subjugation patriarcale des femmes et jeunes filles venant de nations en voie de développement, cette pratique n'à été examine que récemment dans le milieu culturel ou elle a cours. Cette thèse se concentrera sur les communautés Musulmanes d'Egypte et du Soudan qui continue à utiliser l'EGF comme une pratique Musulmane obligatoire. En se basant sur le fait que l'EGF affecte grandement la santé de la femme, cette thèse mettra de l'avant trois notions de l'éthique médicale islamique pour contester la continuation de la pratique de l'EGF. Plus spécifiquement, cette thèse élaborera, et s'appuyera sur la position islamique en faveur de la transplantation d'organe. Par conséquent, elle renforcera les arguments contre l'EGF. En faisant appel aux principes et notions de l'éthique médicale islamique, cette thèse contestera l'EGF à l'intérieur même de l'islam. Acknowledgements

While there are many individuals who deserve many thanks for their support during the thesis portion of my graduate work, none are more deserving of the most sincere thanks possible than my two wonderful supervisors, Professor Robert Crouch and Professor Lisa Sideris. Robert, your attentiveness to my many concems, comments and questions, many of which extended far beyond the scope of my thesis work, helped maintain my focus throughout and contributed significantly to the final product found here. Lisa, for reading countless pages, providing comments and suggestions each and every time and then permitting me the opportunity to discuss ideas with you further, l would not have taken as much from this process without you; From proposing the idea to submitting the final copy, the unwavering encouragement l received from bath ofyou was amazing. l could not imagine a more perfect experience as a graduate student than the one l had working with both ofyou. For this, l am extremely grateful.

l would further like to thank several other faculty members from across the university who provided assistance, expertise and personal support over the course of my time as a graduate student at McGill: Prof. Carolyn ElIs, Prof. Michelle Hartman, Prof. Patricia Kirkpatrick and Prof. Katherine Young.

To my friends, who listened patiently, debated rigorously, discussed at length and helped make my graduate experience a positive one, many, many thanks: Julia Carlton, Bonnie De Bruijn, Shawna Gutfrend, Mark Henderson, Toni Pascale, Devorah Ritter and Jonathan Sozek.

Finally, to my parents, without who none of this would have been possible. Your constant and unquestioning encouragement and support has allowed me to achieve so much, this thesis being but one of many examples.

11 Table of Contents

Abstract...... i

Acknowledgements ...... ii

Table of Contents ...... iii

Introduction ...... 1

Chapter 1: Islamic Bioethics and the Islamic Position on Organ Transplantation ...... 8 Islam: Sources ...... 9 Social Justice and Islam ...... 17 Basic Tenets of Islamic Bioethics ...... 21 Organ Transplantation and Islam ...... 26

Chapter 2: Female Genital Cutting in Egypt and Sudan ...... 34 Prevalence ...... 37 Egypt and Sudan: Studying FGC ...... 38 Types ...... 43 Health Consequences ...... ; ...... 46 .Justification and Rationale for FGC ...... ; .... 50 Islam and FGC ...... ·...... 55

Chapter 3: Arguing Against Female Genital Cutting- A Case from Within Islam ...... 66 Medicalization of a TraditionaVReligious Practice ...... 67 God's Unity, Notions ofCommunity and Public Interest ...... 72 Dignity of the Body and the Doctrine ofNecessity ...... 76 Maintenance ofHuman Life and the Imperative to Seek Remedies ...... ~ ...... 82

Conclusion ...... 88

Works Cited ...... 92 Introduction

"Ali related mutilations- the crippling of women in a much broader sense, both physical and psychological- must be confronted ... Genital and sexual mutilations, to be sure, are the most drastic and physical form. The contempt for the female of the species, which is the basic cause of ail forms offemale mutilations, must be challenged and dealt with everywhere, and at its source. ,,]

Female genital mutilation, a traditional practice that can have serious health consequences, is ofgreat con cern to the World Health Organization (WHO). In addition to causing pain and suffering, it is a violation ofinternationally accepted human rights. 2

"Arrogant perception is apparent in the West's horrified, condemnatory responses to practices such as the Indian tradition ofsati, Chinese foot binding, and A rab customs of veiling and purdah. It is apparent in Western facile insensitivity to the unfamiliar. Arrogant perception nourishes ethnocentrism even as it obscures visions of the multifaceted complexity of those characterized as oppressed 'others, ' ... 1 am convinced that the debates swirling around female circumcisionlfemale genital mutilation can and must move beyond troubling stances ofarrogant perception. ,,3

"The west has acted as though they have suddenly discovered a dangerous epidemic which they then sensationalize in international women 's forums creating a backlash of over-sensitivity in the concerned communities. They have portrayed it as irrefutable evidence of the barbarism and vulgarity of undeveloped countries ... It became a conclusive validation to theview of the primitiveness of Arabs, Muslims and Africans ail in one blow. ,,4

"We must focus mainly on the differences most responsible for creating or sustaining the conf/ict and the similarities most likely tofacilitate settlement. ,,5

Since the 1970s, few topics have gamered as much attention from such a variety of sources as the traditional practice of female genital cutting (FGC). Studied, analyzed and criticized by social scientists, attacked by feminist activists and academics from

nd 1 Fran Hosken, The Hosken Report: Genital and Sexual Mutilation ofFemales, 2 ed. (Lexington: Women's International Network News, 1979), 1. 2 World Health Organization, Female Genital Mutilation: An Overview (Geneva: World Health Organization, 1998). 3 Stanlie James, "Shades ofOthering: Reflections on Female CircumcisioniGenital Mutilation," Signs: Journal ofWomen in Culture and Society 23, no. 4 (1998): 1034. 4 Nahid Toubia, "Women and Health in Sudan," in Women of the Arab World: The Coming Challenge, ed. Nahid Toubia (London: Zed Books, 1988), 101. 5 Jeffery Stout, "On Having a Morality inCommon," in Prospects for a Common Morality, eds. Gene Outka and John P. Reeder, Jr., (Princeton: Princeton UP, 1993),217. across disciplines, opposed and condemned by the United Nations and its affiliate organizations, and legally banned in many nations in the developed world, FGC is still almost universally practiced in sorne communities in northern Africa. Valued by many of the members of the communities where it is practice, it is seen as an important, vital and often religiously mandated practice. As such, top down attempts to eradicate FGC that present the practice as unacceptable, barbaric and an example of the subordination of women have met with strong resistance, leading in sorne cases to increased incidences of genital cutting.

Two of the most dominant positions on FGC are what can be dassified as the feminist perspective and the human rights perspective. The Hosken Report, first published first in 1979, is said to mark the beginning of international attention to an issue that had been previously unknown to the Western world and dismissed by international organizations on numerous occasions.6 Hosken focused on how patriarchal social structures kept women in a subordinate position, one where they were unable to break free from this horrible tradition that mutilated their bodies and instilled a sense of inferiority in their minds. Hosken makes the daim that FGC aims "to control women's

sexuality and reproductive lives at the price of their health.,,7 By making this daim,

Hosken completely disregards the cultural importance and social function of this practice.

While she does list sorne of the reasons for FGC, this seems to be more to highlight the inherent backwardness of the cultures where FGC is practiced.

6 The World Health Organization refused to examine the issue ofFGC, despite several invitations to do so, claiming that such practices were of socio-cultural meaning and therefore outside their scope. This stance continued to be upheld until the late 1970s. 7 Hosken, The Hosken Report: Genital and Sexual Mutilation ofFemales, 1.

2 As with most early feminist theory, the subject of Hosken's work, the African

women who engage in FGC, is the dichotomized "other," the object of white, Western

feminist discourse.8 This objectification has created resentment and anger towards those

who have created the discourse. As such, there is a large gap between those who engage

in FGC, Hosken and her targeted Western audience. The result ofthis objectification in

sorne countries, Egypt and Sudan among them, is an increase in the nurnber of girls undergoing sorne form of genital cutting in recent years. This can be se en as a reactionary

increase, one spurred by an attempt to define and defend one's self and one's culture in

opposition to the 'other': "each group defines itself against the other, thus hardening whatever differences there are.,,9 While Hosken's work is one of the most weIl known and overt examples of ferninist discourse on the matter, she is hardly alone in this group.

However, it has only been in very recent years that the voice of African feminists has been heard on this matter. Despite the sensationalist style Hosken adopted, she was extrernely successful in attracting international attention to the subject of FGC.

The human rights discourse developed from the ferninist works, butwithin the context of the Universal Declaration of Human Rights. Works produced by the United

Nations and its affiliate organizations, such as the World Bank and the World Health

Organization (WHO), aIl fall into this category. Govemments of countries where FGC is common often create and adopt policies along these lines. There are three rights that form

8 Robyn Cerny Smith articulates this commonly discussed "shortcoming" of earlier feminist theory:" Feminist theories cannot be objective but are distorted in perspective ... [they were] 'developed by Western white women and are therefore 'insufficiently attentive to ... cultural diversity, and they falsely universalize features of the theorist's own era, society, culture, class, sexual orientation, and ethnie, or racial group.'" Robyn Cerny Smith, "Female Circumcision: Bringing Women's Perspectives into the International Debate," Southern California Law Review 65, no. 5 (1992): 2488. 9 Stout, "On Having a Morality in Common," 218.

3 the focus of human rights discourse: the right to be free from aH forms of discrimination against women, the right to health, and the rights of the child.

FGC is seen as an example of discrimination against women in so far as it is

significantly more severe than the male counterpart and there is often no male equivalent in many communities. lO Any practice that singles women out and causes harm to their bodies, their minds or their personal integrity in any way is a form of gender-based discrimination. The second right that FGC is thought to be in violation of is the fundamental right to health. While the WHO defines health as "a state of complete

10 Questions surrounding male circumcision inevitably arise from almost any discussion of FGC. Male circumcision is universally practiced by Muslims for a variety of reasons. Although it is also not specifically outlined in the Qur'an, it is accepted as a religious requirement. While male circumcision carries sorne health risks, even in the hospital setting of the developed world, these pale in comparison to the number and severity of those associated with female circumcision. The foreskin of the penis functions very differently in the overall physiology of the human body than the clitoral system. Integral to a woman's overall sexual experience, the clitoris and surrounding tissue do have a profound impact on a woman's sexuality in a way that the foreskin does not for a man. However, as Boyle points out, both practices "are considered medically unnecessary" and involve removing "healthy tissue from a child's genitals, often without anesthesia." (Elizabeth Heger Boyle, Female Genital Cutting (Baltimore: John Hopkins University Press, 2002), 37.) Contradictory medical evidence on male circumcision exists. Sorne studies demonstrated lower rates of infection for circumcised males, while other studies show the opposite, leaving many parents at the mercy of their doctors preference or with a difficult decision experience pleasure from sexual relations. (See Hanny Lightfoot-Klein, Prisoners of Ritual: An Odyssey into Female Genital Circumcision in Africa, (New York: Haworth Press, 1989). Hanny Lightfoot-Klein is one of the many researchers to discover that, contrary to preconceived notions about post-FGC sexuality, many women who have undergone FGC enjoy sex. Several other works have discussed similar fmdings. Discrepancies such as this one between perceived problems of FGC from Westerners and the actual lived experience of women who practice FGC form the basis of Carla Obermeyer's argument in her article "Female Genital Surgeries: The Known, the Unknown, and the Unknowable." Projections of what the effects of FGC have played a large role in what surveys attempt to ascertain; as such, results from these surveys serve to support Western understandings of FGC, understandings that might not match how the women and men in these communities view FGC. Sexuality is perhaps the area in which Western ideas diverge most significantly from those held in both Egypt and Sudan. Male circumcision has come under criticism in recent years, including those done for religious reasons. Margaret Somerville considers this issue in her recent book The Ethical Canary. While she concluded that male circumcision performed for non-religious reasons could not be justified under any circumstance, those carried out in the name of religion posed a different set of issues. In this context, she finds male circumcision permissible for those "who believe they have a fundamental, absolute religious obligation to carry out infant male circumcision." (Margaret Somerville, The Ethical Canary: Science. Society and the Human Spirit, (Toronto: Penguin Books, 2000), 216.) However, she also insists that harm reducing measures should be enacted to alleviate sorne of the pain and suffering caused by this form of surgical intervention. (Ibid., 216) This exemption becomes problematic in a discussion ofFGC for groups that uphold it as a religious requirement. However, given that FGC is not universally practiced by any religious group and tremendous variation exists, Somerville's argument does not leave an opening for FGC.

4 physical, mental, and social well-being, not merely the absence of disease or infirmity,,,ll

this does not mean that this right guarantees perfect health to all. With the CUITent

inequality that exists between nations in the developing world and developed nations, this

right is problematic in and of itself. However, FGC does violate this right in that it is a

practice with known physical and psychological consequences that is still carried out.

Finally, since FGC is most commonly a childhood ritual, it falls under the rubric of the

rights of the child. Children, due to their vulnerable social, economic and physical

position, require and de serve additional protection from harm. 12 That they rarely consent

freely to this practice, nor do they always understand the potential negative repercussions

of FGC, means that their rights are being violated.

Critics ofhuman rights claim that the Universal Declaration ofHuman Rights was

conceived by the powerful nations who emerged from the destruction of World War II.

As such, the Declaration takes into consideration Western values, customs and norms, with little consideration for alternatives from other value systems. In particular, the

Western notions of individualism and autonomy inform the overall orientation of the

Declaration, notions that are quite foreign in many non-Western communities. The rights

stipulated in the Declaration are then foisted upon the international community; smaller, less powerful nations and those attempting to rebuild in the post-colonial period have little choice but to accept these rights and the accompanying values and norms or risk political and economic isolation. This discourse is still often developed from the top down, meaning there is not necessarily a respect for culture or a real attempt to

11 Nahid Toubia, Female Genital Mutilation: A CalI for Global Action (New York: RAINBO, 1995),26. 12 Toubia, Female Genital Mutilation: A CalI for Global Action, 28.

5 understand cultural differences. As such, human rights dis course also has significant

problems associated with it.

Despite the successful eradication of FGC in certain communities as a result of

intervention based on either feminist or human rights discourse, the need for culturally

based intervention is plainly apparent. The inspiration and purpose of this paper is born

out of this need. Recognizing the limiting effects of FGC on women's health and the

place FGC occupies in many communities, l will construct an argument that not only

takes the socio-religious meaning of FGC into consideration, but one that is firmly based

in this socio-religious context. By beginning from the more neutral position of health and

focusing specifically on the Muslim communities that practice FGC in Egypt and Sudan,

l will use Islamic bioethics in general, with a particular appeal to the position on organ transplantation, to refute the daim that this practice is mandated by or consistent with

Islam.

In Chapter 1 l begin with a brief exploration of the orientation towards social justice found in Islam and then proceed through an examination of three major ideas

found in Islamic bioethics. Once this foundation has been established, l will articulate the

dominant Islamic position in favor of organ transplantation. In Chapter 2 l will focus on

female genital cutting, providing information about the history, geographic distribution, prevalence, types and health effects of FGC. The focus of this chapter will be on FGC

and Islam, and therefore will expand on the Islamic justification and basis for the practice. Finally, in Chapter 3, l will synthesize the information provided in the preceding two chapters, illustrating how a bioethical argument against FGC can be constructed from within Islam.

6 This approach will use sorne of the very values and ideals used to justify FGC to challenge this position. It is hoped that a position such as this can be used as part of public health or sirnilar education carnpaigns as a starting point towards eliminating FGC in Egypt and Sudan.

7 Chapter 1: Islamic Bioethics and the Islamic Position on Organ Transplantation

"Therefore We prescribe for the Children of Israel that whoso slays a soul not to retaliate for a soul slain, nor for corruption done in the land, shall be as if he had slain mankind altogether; and whoso gives life to a soul, shall be as if he had given life to mankind altogether" (Qur 'an 5, 35).

This Qur'anic verse, referring to the Old Testament story of Cain and Abel,

reveals much about Islam, particularly with regard to ethics. The individual human is of

paramount importance, but this importance is very much in relation to the community at

large. It is this community-centered stance that is often viewed as a clear line dividing

Islam from the more individualistic West. While the individual is given numerous rights

in most Western nations, many of which prote ct and preserve individual autonomy, this

emphasis is not always found in countries where Islam has guided social and legal

development. This marked difference is especially apparent in the area of bioethics,

where the Islamic judicial notion of public interest or community concern, maslaha, is

often invoked. 1 Furthermore, ingrained in the very core of Islamic orthopraxy is the

importance of almsgiving, zakat, one of the five pillars of Islam. In addition to highlighting the community aspect of Islam, this verse clearly illustrates the importance

ascribed to human life and its protection. In this chapter, l will discuss this emphasis on

community and social justice as a means of establishing a solid context for a more

detailed discussion of Islamic bioethics generally. This, in turn, will lead to an

1 Nanji asserts that the concept ofpublic interest has a long history in Islamic medicine. "The message of social justice proclaimed by the Qur' an through regular ritual and other acts of charity" (268) led to the establishment ofhospitals for the poorer members of society. Although slightly different than the legal concept of public interest, this shows how important the well-being of the community is in Islam. Azim A. Nanji, "Medical Ethics and the Islamic Tradition," Journal of Medicine and Philosophy 13, no.3 (1988): 257-75.

8 elaboration of the Islamic position on organ transplantation, thus enabling a comparison,

firmly based in Islam, between female genital cutting and organ transplantation.

Islam: Sources

More than a religion, Islam is often understood as an all-encompassing way of

life, providing answers to questions ranging from the very mundane to the highly sacred.

"Islam differs from many other religions in providing a complete code of life.,,2 The

legalistic orientation of Islam3 creates an interesting space for ethical discourse. While

there is much discussion of the relationship between law and ethics in the Western world,

Islamic law, the Shari 'a, is understood to be as much a legal system as it is an ethical

one.4 As such, a clean separation between ethics and law in Islam is simply not possible.

Furthermore, it is impossible to write about ethics without reference to jurisprudence and

vice versa. 5 This is clearly seen in the development of Islamic bioethics.

In recent decades, Islam has had to evaluate the advances of modern biomedicine

and biotechnology as Muslims all over the world are confronted with a variety of health

care decisions. The positions adopted by the ulama have drawn on the rich legal and

ethical discourse present in Islam, synthesizing elements from the Qur'an and Sunna with

medical knowledge. In what follows, I explore in greater detail how each of the

2 Mohammed Ali Albar, Contemporary Topics in Islamic Medicine (Jeddah: Saudi Publishing House, 1995),3. 3 Judaism and Islam are often paraUeled as being legalistic in orientation. As with Islam, Jewish law, Halakha, is a complete code oflaw that provides guidance on aU matters oflife. 4 Hourani described the two-way relationship between ethics and divine law, shari'a, as one of mutual influence. While he asserts that "the whole range of ethics was absorbed into the shari'a, so that aU conduct was judged as obedience or disobedience to divine law the purpose ofthis vast legal structure was ethical in the modem sense" (1). Law, therefore, was the means to an ethical end. George F. Hourani, Reason and Tradition in Islamic Ethics, (Cambridge: Cambridge UP, 1985). 5 Muhammed Kanju Salim, Islam, Ethics and Teachings (New Dehli: Kitab Bhavan, 1991), 19.

9 authoritative sources and methods used in Islamic jurisprudence are used in Islamic

bioethics.

As with everything in Islam, the primary source for medical ethics is the Qur' an.

As the revealed word of God, the basis of the Muslim way of life and the most basic

source of law, it is Imperative to refer to the Qur' an above aIl else; it must "serve as the

basis of aIl inquiry.,,6 Although it contains sorne explicit legal prescriptions, the Qur'an is

comprised predominantly of "broad, general moral directives- what Muslims ought to

dO,,,7 and must therefore be explored for paraIlels to modem bioethical concems. As

Rahman daims, "the Qur'an, from its very beginning, has been very emphatic regarding

the amelioration of conditions for the po or and the deprived and has strongly advocated

socioeconomic justice ... these are the comerstones of the entire Qur' anic teaching.,,8

This emphasis on justice is manifest throughout the Qur' an, as demonstrated in the according of additional rights to women, prohibiting usury, condemning of slavery,

endorsing charitable acts and the protecting of orphans. Many of these were problematic

areas in pre-Islamic Arabia that the Qur'an sought to rectify; although sorne practices,

such as slavery, that perpetuate social inequality were not banned outright in the Qur'an, they were strongly advocated against or significantly limited.9 It was recognized that the

social injustice and inequality present in pre-Islamic Arabian society were the roots of the

divisions in the community; these divisions would never lead to a strong, unified society.

The Qur'anic emphasis on unity, achieved through brotherhood and cooperation, would

6 Jonathan E. Brockopp, ed., Islamic Ethics ofLife: Abortion, War, and Euthanasia (Columbia: University of South Carolina Press, 2003), 3. rd 7 John L. Esposito, Islam: The Straight Path, 3 Ed., (Oxford: Oxford UP, 1998), 79. 8 Fazlur Rahman, "Law and Ethics in Islam," in Ethics in Islam, ed. Richard G. Hovannisian (Malibu: Undena Publications, 1983),7. 9 Esposito, Islam: The Straight Path, 79.

10 break down the divisions that keep sorne members of society marginalized. It is evident

that the less fortunate are very much a concem in the Qur' an and hence are a very real

concem for the later Muslim communities.

Most of the questions and problems raised by biomedicine today are not dealt

with in the Qur' an, but its preeminence in Islam requires that it be considered first and

foremost. Medical ethics is not the only field to draw on Qur'anic material in the absence

of overt references and statements. Brockopp highlights two ways in which the Qur' an is

traditionally accessed: through careful textual analysis, whereby passages on related

themes are "probed for ... possible relevance to the case at hand,,,l0 and through the vast

literature of commentary that has developed over the centuries.

Both of these methods of using the Qur' an reveal that while it is considered a

sacred, revealed text, those who study and analyze it bring meaning to the text. 11 A single

Qur'anic verse can be taken to mean one thing to one scholar, while simultaneously being

taken for a slightly different purpose by another. The scholars who have studied and

continue to study the Qur'an provide valuable insight into the text itself. This, in part,

explains the variation found across the Muslim world in terms of dress, social norms,

customs, and even law. 12 In the area of ethics, and perhaps more so in bioethics, the

interpretation of the Qur' anic text by scholars is of paramount importance. Scholars must

find the most salient passages, with the proper context, to be used in ethical decision-

making.

JO Brockopp, Islamic Ethics ofLife: Abortion, War, and Euthanasia, 3. 11 Ibid, 4. 12 The four dominant schools of law in Sunni Islam often put forward different legal opinions on matters of concem. Because a country or particular region will ascribe to a certain law school, this often accounts for region differences among Muslims. However, local customs also influence Islam and it is therefore impossible to attribute all differences to law.

11 The second major source of Islamic law, and hence medical ethics as weU, is the

Sunna, or Tradition, of the Prophet. Viewed as complementary to the Qur'an, it is the

Sunna that aUows for further understanding of the Qur'an. Transmitted and recorded in

the form of hadith, a term meaning "story, a narration, a report,,,13 the authority of this

body of literature is based on several Qur' anic verses. "Obey God and obey the

Messenger ... .If you should quarrel over anything refer it to God and the Messenger"

(4:59) and "In God's messenger you have a fine model for anyone whose hope is in God

and the Last Day" (33:21): taken together, these two verses, among many others, give a

clear indication that while God is supreme, his messenger Muhammad is to be venerated

as weIl. As the seal of the prophetic line and the one chosen to receive the Qur'an, it is

believed that "Muhammad was inspired by God to act wisely, in accordance with God's

Will.,,14 His words and behavior, therefore, should continue to serve as an example to be

emulated, even without his presence.

Sunna, meaning custom or "trodden path,,,15 was a commonly used term during

the time of Muhammad; after his death, it became a specific, special term denoting his 16 customs. However, there are several problematic aspects to the ahadith, aU stemming 17 from the same source. The ahadith were recorded over a hundred years after

Muhammad died, "remembered and transmitted by many different people in a wide

variety of contexts and regions.,,18 Consequently, ahadith of questionable authority or

content were recorded along with authentic ones. Towards the beginning of the 9th

nd 13 Fazlur Rahman, Islam, 2 ed. (Chicago: University of Chicago Press, 2002), 53. 14 Esposito, Islam: The Straight Path, 80. 15 Rahman, Islam, 55. nd 16 Frederick Mathewson Denny, An Introduction to Islam, 2 ed. (New York: Macmillan Publishing, 1994), 159. 17 Hadith is the singular term for the format of the stories and sayings of the Sunna, while ahadith will be used to denote the plural. 18 Denny, An Introduction to Islam, 159.

12 century a science was developed to separate authentic from forged ahadith, a SCIence focusing on the chain of transmission and the subject matter. 19 Despite the high level of sophistication of this science, ahadith are used today that are not accepted by aIl

Muslims. l give examples ofthis in the following chapter.

As with the Qur'an, the Sunna does not always deal with issues being discussed in the contemporary world, and therefore calls for interpretation. One of the primary considerations when using a hadith is the context; a contemporary issue cannot be related to a hadith if no parallel to their context exists. An evaluation of context requires extensive knowledge of the hadith under consideration and the contemporary situation being studied. In terms of bioethics, the most obvious example is the Islamic prohibition on suicide and murder. The hadith that furthers the Qur' anic prohibition on these two actions is used to formulate a position against euthanasia?O The Qur' an remains the most authoritative, but the Sunna serve to confirm, extend, elaborate or supplement what is contained in the Qur'an.21 The existence of a hadith that is believed authoritative can influence the actions of a community almost as much as a Qur' anic verse. This will

19 The authenticity of a hadith is ascertained by evaluating the isnad, the chain of transmission, and the maIn, the main text. However, as Denny discusses, because it is very possible to fabricate a plausible-sounding text, the chain of transmission "came to be regarded as a crucial index ofauthenticity" (Denny, An Introduction to Islam, 161). Evaluating the isnad involves several different aspects. Not only should this chain be unbroken, right back to the Prophet or one ofhis close associates, but those who have passed the hadith down should be reliable, pious and upstanding individuals (Rahman, Islam, 64). Countless number of ahadith were found to be spurious or fraudulent by the men who complied the flfst authoritative collections. Ofthese, the Sahih ('The Genuine') of Muhammad ibn Isma'il al-Bukhari is considered the most important, followed closely by that of Muslim ibn al-Hajjaj (Rahman, Islam, 63-64). 20Although it would be impossible to do justice to the intricacies of and debates surrounding the Islamic position on euthanasia here, briefly the dominant position is as follows: based on the Qur'anic verses that prohibit suicide (2: 195 and 4:29), euthanasia is taken to be similar and therefore also prohibited. Ultimately, God is the giver and taker of life and human beings should not attempt to play this role. This view is reinforced in the Islamic Code of Medical Ethics, discussed further in this chapter,: "Mercy killing, like suicide, finds no support except in the atheistic way ofthinking that believes that our life on this earth is followed by a void. The claim that killing for painful, hopeless illness is also refuted, for there is no human pain that cannot be largely conquered by medication or by suitable neurosurgery" (65). 21 Denny, An Introduction to Islam, 159.

13 become evident in the discussion of FGC found in the following chapter, where a hadith

is discussed as the basis of the practice for sorne Muslims.

The next two sources fall somewhere between method and source. As stated by

Esposito, "throughout the development of Islamic law, reason had played an important

role ... where no clear, explicit revealed text or general consensus existed.,,22 Legal

reasoning is called ijtihad, "a method of creative intellectual effort to find a solution to

problems not resolved or not mentioned by the Koran or the sunna. ,,23 Derived from the

same root as the terrnjihad, "to strive or struggle in God's path," ijtihad means "to strive

or struggle intellectually.,,24 This intellectual endeavor took on two main forrns, one

individually based, qiyas, and the other community oriented, ijma. Ijtihad reflects the

truly organic nature of Islam, as it allows for flexibility and adaptation to new

situations.25

Those who use qiyas, meaning analogical, deductive or syllogistic reasoning, take

a verse from the Qur' an, or principle or case from the Sunna, and argue a position on an

issue that is not explicitly dealt with in either source?6 This can lead to the development

of a religious, moral or legal rule.27 The selection of passages from the Qur' an or Sunna

is not arbitrary; great care is taken to select something similar in context, social function

and reason or cause.28 Suicide/euthanasia once again offers an excellent example.

Although qiyas differs from both the Qur'an and the Sunna in that it is more of a method,

22 Esposito, Islam: The Straight Path, 82. 23 Fakhereddine Ben Hamida, "Islam and Bioethics," The Human Rights, Ethical and Moral Dimensions ofHealth Care (Strasbourg: Council of Europe Publishing, 1998),83. 24 Esposito, Islam: The Straight Path, 82. 25 Ben Hamida, "Islam and Bioethics," 83. 26 Rahman, Islam, 71. 27 Ben Hamida, "Islam and Bioethics," 83. 28 Esposito, Islam: The Straight Path, 82.

14 it nonetheless has produced material that is another key source in Islamic law and subsequently Islamic medical ethics.

1jma, meaning consensus or agreed practice,29 is another important source of law and ethics. In the absence of guidance following the death of the Prophet, community consensus became important in legal decision making.30 The authoritativeness of ijma is derived from the hadith of the Prophet: "my community does not agree on an error.,,31

With this method, new rules can be created through community consensus.32 While

'community' was originally taken to encompass the entire Muslim community, with the development of Islamic jurisprudence, 'community' became defined narrowly to include only legal scholars and religious authority and not the community at large.33

Rahman accords enormous significance to ijma, asserting that "it was ijma that determined what the Sunna of the Prophet has been and indeed what the right interpretation of the Qur'an was.,,34 Interestingly, he also connects the Sunna and ijma through qiyas, equating qiyas to a "bridge" between these twO. 35 An "organic process," ijma connects the past to the present, shaping Islam as it expands and changes.36 Muslim societies influence ijma formation just as ijma influences the formation of these societies.

This exchange takes place within the confines of the doctrines and principles laid out in the Qur'an and the Sunna, hence its association to qiyas.

29 Rahman, Islam, 72. 30 Esposito, Islam: The Straight Path, 83. 31 Majid Khadduri, The Islamic Conception of Justice (Baltimore: The John Hopkins UP, 1984), 190. 32 Ben Hamida, "Islam and Bioethics," 83. 33 Esposito, Islam: The Straight Path, 83. 34 Rahman, Islam, 74. 35 Ibid., 75. 36 Ibid., 75.

15 These final two sources are related to a type ofliterature known asfatwas. Fatwas

are formaI legal opinion or decision produced by a mufti, a specialist in Islamic law.

Although "inherently personal and nonbonding" and "only a rough guide to Muslim

morality,,,37 they nonetheless are influential on a community level. Throughout history

however, fatwas have also been issued by influential people in the Muslim world on

controversial matters, not merely by religious authorities on religious matters. A fatwa

issued by a Grand Mufti is a decree, a highly authoritative statement that is most often

followed by most Muslims.38 Thoughfatwas do have a personal element to them, they

often have a significant impact on the community in question because judges and litigants

consult muftis on legal matters.

Fatwas are one of the primary sources of Islamic bioethics, as will be illustrated

in the discussion of organ transplantation. Since they allow the scholar or religious

authority to apply classical sources to modem problems, they have become fundamental to Islamic medical ethics. Drawing on these classical sources and applying them to

contemporary situation, they represent the body of legal material that demonstrates the

greatest amount of development within Islamic law. They are, on the other hand, very

subjective and subject to the biasof time and place. As the context out of which they

develop is often extremely patriarchal, this can have, and has had, dangerous

consequences, particularly on the lives and health of women. An excellent case in point is

that of female genital cutting.

A final text that has, since its formalization, been greatly influential in Islamic medical ethics is the Islamic Code of Medical Ethics, also referred to as the Declaration

37 Broekopp, Islamie Ethies of Life: Abortion. War. and Euthanasia, 7. 38 Albar, Contemporary Topies in Islamie Medicine, 7.

16 of Kuwait. Written in 1981, this document was produced by Muslims physicians from

different parts of the world at the International Conference in Islamic Medicine, held in

Kuwait. The Declaration deals with a broad spectrum of issues, ranging from the proper

conduct of a physician to explicit positions on particular ethical issues. This document

attempts to reconcile the advances of biomedicine and the influx of Western technology

and knowledge into the Muslim medical world with the precepts and principles of Islam

and Islamic medicine.

How each of these sources is employed will become apparent throughout the

discussion of Islamic bioethics and the position on organ transplantation. But 1 will first

consider the overarching theme of social justice as found in Islam. The overall Islamic

orientation towards justice and unity, stemming from the belief in the unit y and

sovereignty of God, will be outlined as a means of establishing a framework for a further

discussion of Islamic bioethics.

Social Justice and Islam

The belief in the unit y and sovereignty of God is one of the main tenets of Islam.

The belief in God's unity, tawhid, is one of the five foundational articles of faith in

Islam. 39 This divine unity and justice, however, represents more than a belief in God; it

represents the overall orientation of Islam as a religion. Just as God is One, and is

believed to be just, so too must the Muslim community be unified and just. "The unit y of

God is to be reflected in the unity and uniformity of his religion and in the unanimity in

39 Jacques Waardenburg, Islam: Historical, Social and Political Perspectives, (Berlin: Walter de Gruyter, 2002), 64.

17 his community of worshipers. AIl that the Muslim does is to reflect God's greatness and

unity.,,40 As God's chosen representatives on earth, human beings are given the

responsibility of carrying out God's work; this work must be just, merciful and

compassionate. "The essence of the obligation to Allah is to act as his vicegerent on

earth, ordering the good and forbidding wrong ... it is a dut y to accept responsibility for the establishment of proper public order.,,41 This proper public order differed

significantly from the tribal ways of pre-Islamic Arabia; the sense of solidarity to one's

tribe was replaced with a much larger solidarity towards aIl believers, reflecting God's

indisputable unity. This is evident in the reforms introduced by the Qur'an and the Sunna.

The advent of Islam marked a significant shift in many of the social practices of

7th century Arabia. Slavery, female infanticide, uncontrolled polygamy and usury were

among the many practices that perpetuated deep social divisions and maintained the preeminence of certain social groups over and above others. However, many of these practices were either mitigated or abandoned altogether with the Qur' anic revelation and the establishment of a Muslim community. Of aIl the reforms brought about with the

dawn of Islam, changes to the status of women are perhaps the most significant. These

reforms constitute the body of classical family law in Islam.42 Family law in Islam is

exceedingly important: "the centrality of the community in Islam and the role of the

family as the basic unit of Muslim society,,43 brings family law to the forefront of Islam.

Women were given property and inheritance rights (Qur'an 4:4, 7, 11-12, 176), thus providing them with a degree of freedom, making them less dependent on male

40 Denny, An Introduction to Islam, 65. nd 41 David Waines, An Introduction to Islam, 2 ed. (Cambridge: Cambridge UP, 2003), 63. 42 Esposito, Islam: The Straight Path, 94. 43 Ibid., 93.

18 favor. Marriage, although still understood as a umon of two families, underwent

significant changes. The Qur' an extended the right to contract a marriage to the woman herself; furthermore, the dower went to the woman and not to her new husband or her

father. This made marriage less of a property exchange and extended ever so slightly a woman's autonomy in the patriarchal society maintained in Islam.44 FinaUy, the Qur'an

limited polygyny to four wives for any one man, on the condition that aU were to be treated equaUy in aU respects: "if you fear that you will not act justly towards the

orphans, marry such women as seem good to you, two, three, four; but if you fear you will not be equitable, then only one" (Qur'an 4:3). However, this condition was foUowed with a further statement that aU but established monogamy as the norm in Islam: "You will not be able to be equitable between your wives, be you ever so eager" (Qur'an

4:129). Given that the condition for taking more than one wife is equal treatment among them, and it is stated in the Qur' an that this type of equal treatment is impossible regardless of intention, monogamy must be the appropriate marital arrangement.

Establishing monogamy as the ideal raises women's status significantly, making them an equal party in the marital relationship. Not only does this have positive repercussions for women, but the whole community benefits from this change. Women became less like dependent children and more like autonomous adults under Islam, aUowing for the community of believers to develop as a whole, not just one half. That these changes to the status of women were affected by the development of Islam is taken by many scholars to be one of many indications of an underlying ethical concem for equity and justice in Islam. Although Islam undoubtedly established a patriarchal

44 Esposito, Islam: The Straight Path, 95.

19 community, women were taken to be important members of this society, with similar responsibilities towards God and the Muslim community.45

Often seen as a parallel development to alterations in the status of women, slavery as a social institution underwent significant reform as weIl. Although not completely banned, given the perceived social necessity of such arrangements, slave owners were encouraged to free their slaves or allow them to enter into freedom-purchasing contracts leading to their eventual emancipation.46 The ultimate end of such amendments was "to create a milieu where slavery ought to disappear.,,47

Finally, although not a reform, the introduction of the practice of zakat, or legal almsgiving, as one of the five pillars of Islamic orthopraxy clearly demonstrates the priority of social justice in Islam. Often associated with the second of the five duties,48 that of salat, prayer, Muslims are "dutybound to attend to the social welfare of their community by redressing economic inequalities through payment of an alms tax or po or tithe.,,49 Similar to prayer, almsgiving serves both an individual and communal purpose: giving to those less fortunate reminds Muslims that God is the ultimate provider, thus strengthening one's relationship with God, while simultaneously meeting the needs ofthe

45 One of the most important requirements ofMuslims is to command right and forbid wrong. Explicitly stated in several different Qur'anic verses (3:104, 3:110), one verse in particular addresses both men and women: "And the believers, the men and the women, are friends one ofthe other; they command right, and forbid wrong" (9:71). This verse is notable not only in the context ofIslam, but in the broader context of the Abrahamic traditions, where scripture is almost always addressed to men (Karen Armstrong, A History of God: The 4000-Year Ouest of Judaism. Christianitv and Islam (New York: Alfred A. Knopf, 1994) 158). Furthermore, the five pillars ofIslam are equally required of men and women. 46 Rahman, Islam, 39. 47 Ibid., 38. Rahman discusses the changes to family law and slavery as the product ofprogress in the context of certain social limitations. Truly radical reforms would not have taken hold and the injustices present at the time would have continued. The general moral principles ofthe Qur'an, coupled with specifie reforms such as those mentioned above, would eventually lead to a more just society in future generations. 48 The five required duties in Islam, the core ofIslamic orthopraxy, are also referred to as the five Pillars of Islam. They are prayer five times a day (salat), almsgiving (zakat), fasting during the holy month of Ramadan (saum), pilgrimage to Mecca (hajj), and profession offaith (shahada). 49 Esposito, Islam: The Straight Path, 90.

20 less fortunate, bringing the community closer together. This practice will be explored

further in connection to charity in the discussion of organ transplantation.

Although brief, this discussion of sorne of the social aspects of Islam has served to highlight the fact that social justice is a primary concem of Islam. Sorne of these themes will be elaborated throughout the remainder of the chapter.

Basic Tenets of Islamic Bioethics

In what follows, the discussion of Islamic medical ethics will be organized around three basic princip les, each based firmly in the religious tradition itself. These three principles are (1) God's supremacy in worldly affairs, (2) the requirement to maintain human life, and (3) the dignity of the human body. Each of these three will be explored briefly, followed by an in depth consideration of the Islamic position on organ transplantation. This sequence will demonstrate how these three princip les inform more

concrete positions on specific issues within Islamic medical ethics.

The Islamic conception of God plays a significant role in their ethics generally; bioethics is no exception. As in Judaism and Christianity, God is viewed as a supreme being, a being outside the realm of human knowledge. As such, the nature of God is not a topic of discussion in the Qur' an, although theological debate on this issue dominated much of Islamic scholarship during the Middle Ages. God is understood as the creative

force behind everything experienced in the finite world, including our own embodied experience. God is "the transcendent, all-powerful and all-knowing Creator, Sustainer,

21 Ordainer, and Judge of the universe.,,50 Although God is described in this way throughout the Qur'an,51 this is understood as an analogical description. God cannot be understood in human terrns, for God far exceeds such human limitations. Rahman sums this position up weIl: "God alone is infinite and original being; aIl else is created by him and necessarily suffers from finitude.,,52

Moreover, despite the many attributes ascribed to God, Islam is premised on the unit y and sovereignty of one transcendent God: "Your God is One God; there is no god but he, the All-merciful, the All-compassionate" (Qur'an 2: 157). The Qur'an dissociates the God of Islam from aIl other conceptions of God found in Arabia at the time of revelation, particularly the Christian Trinitarian God and the polytheistic gods of Arabia:

"God is not a Trinity (5:76); He has no begotten son (2:116) or daughters nor consorts

(6:100-101); and finaIly, unlike the religion ofpre-Islamic Arabia, God has no partners or associate deities (6:22-24).,,53

This notion of the unit y of God is intimately related to the divine justice that will be carried out by God during the Last Judgment. This idea of God as sovereign and judge reveals the highly eschatological, yet intensely moral, orientation of Islam. 54 Actions undertaken by human beings, while guided by the creative and supreme power of God, are not predeterrnined, which would allow the individual to elude aIl responsibility for wrongful actions. Each human being will be judged according to his or her own actions at the end of the world, as God is understood to be just and merci fuI. 55 God "allows man the

50 Esposito, Islam: The Straight Path, 22. 51 Quran 6:54,6:156, among countless others. 52 Rahman, Islam, 12. 53 Esposito, Islam: The Straight Path, 23. 54 Denny, An Introduction to Islam, 110. 55 Ibid., 64.

22 freedom of those actions upon which he will be judged,,,56 thus placing ethical

responsibility squarely on the shoulders of each Muslim. Human beings were created

with a capacity for moral reasoning and are expected to use this capacity in conjunction

with the message and teachings of the Qur' an. It is from this very notion that Islamic

ethics originate.57 Furthermore, it is this capacity for reason that creates a space in which

evil deeds can occur; they are not, however, understood as the works of God, as this

would be an imperfection in the ultimate being. Ethical responsibility, therefore,

maintains God's supremacy in the universe and the perfection ofhis creative abilities.

A second and related principle is that Muslims are obliged to do aIl that is

necessary to maintain human life. Humans are conceived of as God's representative on

earth, the highest of aIl creations: "It is He who has appointed you viceroys in the earth,

and has raised sorne of you in rank above others, that He may try you in what He has

given you. Surely thy Lord is swift in retribution; and surely He is AIl-forgiving, AIl-

compassionate" (Qur'an 6:165). Each human being is unique in character and occupies a

special place in the cosmic order; as such, each individual human life is seen as separate

and irreplaceable. 58 As demonstrated by the Qur'anic verse at the beginning of this

chapter, everything possible should be done to sustain each life. Human life should be

valued above aIl else because it is one of the greatest expressions of God' s creative

power. Endowed with reason and capable of moral judgment, human beings represent the

pinnacle of God' s creation. It is important to note the subtlety of this belief: human life is not valued in and of itself; instead, it is valued because it is of God. As Brockopp states,

th 56 Caesar E. Farah, Islam: Beliefs and Observances, 5 Ed., (Hauppauge, Barron's Educational Series, Inc., 1994), 117. 57 Esposito, Islam: The Straight Path, 25. 58 Fazlur Rahman Health and Medicine in the Islamic Tradition, (New York: Crossroads Publishing, 1989), 100.

23 "there is nothing essential to the human creature that always demands an overriding consideration for human life ... human life is to be preserved because of God's essential attribute as the author oflife and death.,,59

A further extension of the notion that human beings are God's viceroys is that life is viewed as a gift bestowed upon human beings by God; 60 such a special gift requires the utmost respect. The purpose of this life, however, is very specific: human beings are to carry out God's will on earth. The divine justice of God finds its expression in the finite world through the social and economic justice described in the Qur'an. Muslims are enjoined to create a just and equitable society in which the poor and destitute are cared for, where unnecessary exploitation does not occur and a true sense of community is fostered by all. Esposito expresses this view well: "as God's representatives, the measure of human actions, and indeed life, is the extent to which the Muslim contributes to the realization of God's will on earth.,,61

The third principle, one closely related to the first two, is the dignity of the human body. This stems from the underlying notion that the human body is given in Divine

Trust to human beings by GOd. 62 The human body does not "belong" to the individual who uses it. Rather, "the human body is the property of Allah,,,63 with the expectation that it will be retumed in the condition in which it was originally given.64 Related also to

59 My emphasis. Brockopp, Islamic Ethics ofLife: Abortion, War, and Euthanasia, 16. 60 A. F. Sabin, "Islamic Transplantation Ethics," Transplantation Proceedings 23, no. 3 (1990): 939. 61 Esposito, Islam: The Straight Path, 27. 62 Nazeem M.1. Goolam, "Human Organ Transplantation- Multicultural Ethical Perspectives," Medicine and Law 21 (2002): 548. 63 Y.I.M EI-Shahat, "Islamic Viewpoint of Organ Transplantation," Transplantation Proceedings 31 (1999): 3273. 64 Goolam, "Human Organ Transplantation- Multicultural Ethical Perspectives," 548.

24 the eschatology of Islam, it is understood that at the Last Judgment, a bodily resurrection

will occur for the dead. 65 The body should be whole, or as whole as it was originally.

This "limited and conditional ownership with responsibilities to God" and the

emphasis on the physical integrity of the human being precludes any unnecessary

mutilation of the body, such as tattooing, unnecessary piercing, and branding, but can

also be seen as supportive of a prohibition against postmortem examinations or organ transplantation. The historical basis ofthis prohibition can be found in the battle ofUhud,

in 625. In pre-Islamic Arab, a common battlefield practice was to mutilate the bodies of

fallen enemy soldiers in order to make an example of them. At this particular battle, the

heart of the Prophet's uncle was removed and chewed. Consequently, this type of violation of the corpse became proscribed in Islam and many scholars extend this proscription to include any type of dissection, regardless of intention.66 However, the prohibition on violating a corpse pertains to actions carried out "with malice and vengeance,,,67 as was the case in the battle of Uhud. Organ transplantation, on the other hand, is motivated by beneficence.

Just as everything should be done to maintain life, preserving the dignity and integrity of the human body is also of paramount importance. Just as God is unified, so too is his preeminent creation: "the essential Oneness or tawhid of God ... reflects itself in the unity of the creation, including the unity of the human being.,,68 This is further reflected in the five moral principles of Islamic law, two of which are of direct relevance to a discussion of organ transplantation and female genital cutting: the principle of

65 Denny, An Introduction to Islam, Ill. 66 Rahman Health and Medicine in the Islamic Tradition, 106. 67 EI-Shahat, "Islamic Viewpoint of Organ Transplantation," 3273. 68 Waardenburg, Islam: Historical, Social and Political Perspectives, 62.

25 respect for man's physical integrity and the principle of respect for man's mental

integrity.69 Each of these two are supported by numerous verses from the Qur'an, most

notably "We indeed created Man in the fairest stature," (95:4), "He shaped you, and

shaped you weIl" (64: 3, 5 and 40:64), and "There is no changing God's creation"

(30:30). These verses clearly demonstrate the high value placed on the physical integrity

of human beings in Islam. In the context of health and illness, this obliges Muslims to not

only seek treatment for any and aIl ailments,70 but to be dignified and pious even in

illness. Illness is not seen as a punishment or as a result ofwrong/evil behavior. Rather, it

is understood as a natural phenomenon and "a type oftribulation which expiates sin.,,71

This constitutes an overview of three basic principles upon which Islamic

bioethics are based. Although not exhaustive, when viewed in the context of social justice, this does provide solid grounding upon which an Islamic position on organ transplantation can be considered. These principles and the texts that form their basis are

central to the position on transplantation. Throughout the following discussion on this

position, the se connections will be highlighted and explored.

Organ Transplantation and Islam

The Islamic position on organ transplantation extends from the general ethical principles discussed above, but also draws on other important ideas found in the Qur'an, the Sunna and Islamic jurisprudence. Organ transplantation has been of concern to

Muslim physicians, scholars and lay people alike since the 1950s when transplantation

69 Ben Hamida, "Islam and Bioethics," 83-84. 70 Sahin, "Islamic Transplantation Ethics," 939. 71 Albar, Contemporary Topics in Islamic Medicine, 5.

26 first became a viable medical option. The initial skepticism towards the vanous

procedures eventually gave way, in the 1980s and 1990s, to a near-universally accepted

position advocating the use of organ transplantation.72 The following will explore sorne

of the most commonly cited reasons given in favor of transplantation. l will organize these reasons around three broad themes- (1) public interest, (2) necessity and the lesser

evil, and (3) the Islamic imperative to seek remedies- as a means of relating the earlier

discussions of sources, social justice and basic bioethical princip les in Islam to organ transplantation.

The principle of maslaha, public interest, introduced earlier, has a long history in

Islamic jurisprudence. Scholars have often claimed that "the purpose of the Law is to protect the interests of believers as a whole; the interests of the individual are protected

only in so far as they do not come into conflict with the general interest.,,73 Furthermore,

"the Law is the path to guide men to do the good and to avoid evil. .. the Law is designed to protect the public interest (maslaha).,,74 Clearly demonstrated in the Qur'anic verse that opened this chapter, this message runs throughout the Qur'an and the Sunna of the

Prophet. Reaffirmed by the great Islamic scholar Abu Hamid al-Ghazzali in the 12th

century and emphasized by Najm al-Din al-Tawfi and Ibn Taymiya in the 13th century,

appeals to public interest have often been the basis upon which modern legal reforms have been built. 75

72 There have been numerousjatwas issued since the late 1950s from different parts of the Muslim world, most notably Egypt's Al-Azhar University. Examining the progression of the content ofthesejatwas demonstrates how the different transplant possibilities became acceptable. See Albar, Contemporary Topics in Islamic Medicine, 7-10, EI-Shahat, "Islamic Viewpoint of Organ Transplantation," 3271-3272. 73 Majid Khadduri, The Islamic Conception of Justice, 138. 74 Ibid., 137. 75 Ibid., 144.

27 A further indication of public interest being at the heart of Islam is the legal requirement of zakat, discussed earlier, and the emphasis on charity, sadaqa. Organ donation would be an example of charity more than almsgiving, referred to as a

"perpetuaI charitable act" by Gatrad and Sheikh.76 Charitable acts are highly revered in

Islam, both in and of themselves, but also because they form part of the criteria upon which one's final judgment will be based. While the first, zakat, ensures that those less fortunate are supported and protected, reflecting God's work as ultimate Sustainer, the latter, sadaqa, creates strong bonds ofbrotherhood through selfless, altruistic acts.

Altruism, al-ithar, should be the motivating factor behind aIl donations, whether the decision is made by the family postmortem, prior to death by donors themselves or by the live donor. Altruism requires that Muslims consider the needs of others over and above their own. Altruism and beneficence are often paralleled in Islam, particular in the following hadith "the best ofyou is the one who is most beneficial to others.,,77

Anything done without self-interest in mind is very much encouraged in Islam.

Organ donation, in the absence of financial gain, represents perhaps one of the most selfless acts an individual can undertake.78 EI-Shahat states this position concisely,

"donations of organs represent the pinnacle of the nation's unity and a good example of

76 A.R. Gatrad and A. Sheikh, "Medical Ethics and Islam: Principles and Practice," Archives of Disease in Childhood 84 (2001): 75. 77 Sabin Aksoy and Abdurrahman Elmali, "The Core Concepts of the 'Four Principles' of Bioethics as Found in Islamic Tradition," Medicine and Law 21 (2002),220. 78 The Islamic position on organ transplantation firmly prohibits the sale of organs (Vardit Rispler Chaim, Islamic Medical Ethics in the Twentieth Century (Leiden: Brill, 1993), 38). Relating to the notion that human beings hold their bodies in trust from God, and are therefore not full owners oftheir parts, one can never be permitted to sell something which they do not fully own. In addition, if the sale of organs were to be permitted, this might lead to the exploitation of the poor and disadvantaged, something that Islam actively seeks to avoid. However, as is the case in sorne hospitals in the western world, organ recipients sometimes give small gifts as tokens of appreciation to their donor or the donors' family; this is often facilitated by the transplant coordinator. This, while by no means encouraged by Muslim scholars, is permitted by sorne (Rispler-Chaim, Islamic Medical Ethics in the Twentieth Century, 38).

28 cooperation amongst its members.,,79 Much of what is written in the Qur'an and the

Sunna instructs Muslims on the merits of community building and beneficence towards

others; organ transplantation clearly accomplishes both.

It is this emphasis on public interest that brings the doctrine of necessity into the

discussion of organ transplantation. Krawietz asserts that maslaha holds darura,

necessity, as one of its most essential components.80 Essentially, this doctrine states

"necessities render the prohibited permitted.,,81 Firmly rooted in the Qur'an, the doctrine

of necessity is constructed from two separate verses: "Allah says: 'He has explained to

you in detail what is forbidden to you, except under compulsion or necessity,'" (16: 89)82

and "but if one is compelled by necessity, neither craving nor transgressing- there is on

him no sin, for indeed God is Clement, Merciful" (5:5).83

In the context of medical ethics, otherwise prohibited actions are permitted to

save human life. According to a hadith, Muhammad stated "breaking the bone of the

dead is similar in sinfulness and aggression to breaking it while the person is alive.,,84

From this it was argued that any activity violating the integrity of a corpse, such as

postmortem examination, cadaver research, or organ transplantation, was a violation the

Sunna of the Prophet. However, as discussed above, this prohibition is based on actions

carried out maliciously, with the intention of cause harm, suffering and disrespect. Organ

79 EI-Shabat, "Islamic Viewpoint of Organ Transplantation," 3273. 80 Birgit Kraweitz, "Darura in Modem Islamic Law: the Case of Organ Transplantation," in Islamic Law: Theory and Practice eds. Robert Gleave and Eugenia Kermeli (London: LB. Taurus, 1997), 186. 81 Rispler-Chaim, Islamic Medical Ethics in the Twentieth Century, 29. 82 Found in Arberry's translation as "And We have sent down on thee the Book making clear everything, and as a guidance and a mercy, and as good tidings to those who surrender." 83 Found in Arberry's translation as "But whosoever is constrained in emptiness and not inclining purposely to sin- God is All-forgiving, AII-Compassionate." 84 Goolam, "Human Organ Transplantation- Multicultural Ethical Perspectives," 547 and Albar, Contemporary Topics in Islamic Medicine, 5.

29 transplantation is perforrned in order to aIleviate illness and suffering and with good intentions. Given the life saving capabilities of organ transplantation, and the beneficent motivations behind the practice, the prohibition on violating the integrity of a corpse can be circumvented in the name of maintaining human life.85 This principle of savinglmaintaining human life is given priority over and above aIl other arguments on the subject.86 As Albar states "the harrn done, if any, by removing any organ from a corpse should be weighted against the benefit obtained,,87 from the operation. Rispler-Chaim states that this extends to include the use of blood. Although considered a defiling and impure substance when separated from the body, blood can be used when infused from a healthy person to a sick person with the intention of saving life.

Despite the seeming straightforwardness of this doctrine, it raises these questions: when, and under what circumstances, should a need be considered a necessity? What criteria should be used to evaluate a "necessity"? Krawietz identifies medical necessity as a particular type of necessity and cautions that not aIl medical needs can be considered examples of "a valid necessity (darura).,,88 However, EI-Shahat provides one possible criteria: "when the need persists and represents a danger, it will be dealt with as a necessity.,,89 In the case of a person in need of an organ transplant as a matter of life or death, this need will not subside and does pose an imminent threat to life. As such, this

85 Goolam, "Human Organ Transplantation- Multicultural Ethical Perspectives," 547. This logic is extended to permit anatomical and physiological research on human corpses. In order to teach the human body, it must be fully understood; cadaver research is therefore necessary (Albar 144). 86 Albar, Contemporary Topics in Islamic Medicine 7. 87 Ibid., 6. 88 Krawietz, "Darura in Modem Islamic Law: the Case of Organ Transplantation," 188. Krawietz cites the commonly discussed examples of drinking wine and eating pork ifthey are the only resources available to a dying Muslim. These concessions are found in the Qur'an itself, while permitting the violation of a corpse is not as clearly discussed. 89 EI-Shahat, "Islamic Viewpoint of Organ Transplantation," 3273.

30 doctrine is applicable in the case of organ donation.90 While this clearly encourages organ donation, this notion of necessity and need does not solve the aIl too common problem that organ supply more often than not faIls far short ofthe demand for transplantation.91

Closely related to the above doctrine is the notion of darar akhafJ, lesser injury, and darar ashadd, greater injury.92 When confronted with a difficult situation, one where two seemingly bad choices are the only options, one must select the one that will have the fewest negative consequences. A commonly cited medical example is abortion. Sorne legal schools in Islam permit abortion in order to save the life of the mother, should the pregnancy or birth pose a serious threat to her health.93 In the case of organ donation, corporeal integrity and life are the two desired positive outcomes. However, the actual decision facing medical personnel is the alteration or violation of the body or the death of a living patient. The high value placed on life, and the requirement to do aIl reasonably possible to preserve it, means choosing to remove the needed organ. This should be done while taking aIl the necessary and possible precautions to cause the least amount of damage to the body and maintaining the life of the recipient.94

This principle works alongside the doctrine of necessity to ensure that abuses are kept to a minimum and ideaIly avoided altogether. Organ donation should be done in the

90 While Krawietz supports this notion, she raises the more problematic case ofwhen an organ transplantation will only pro long or "improve" the quality of life, but the recipient remains ill. Furthermore, she also draws attention to those cases when there is not a reasonable expectation of recovery after the procedure. Both ofthese examples of organ transplantation require further reflection and perhaps faH outside the position outlined in this chapter (Krawietz, "Darura in Modem Islamic Law: the Case of Organ Transplantation," 189). 91 Interestingly, Rispler-Chaim equates organ donation with that of social obligation. The community is therefore obliged to frnd the right organs for those who require them; when this is not accomplished and the sick person dies, the death is the responsibility of the whole community (Rispler Chaim, Islamic Medical Ethics in the Twentieth Century, 30). This argument is based on the Islamic Code of Medical Ethics. 92 Rispler-Chaim, Islamic Medical Ethics in the Twentieth Century, 29. 93 Sahin, "Islamic Transplantation Ethics," 939 and Bowen, ,56-58. 94 EI-Shahat, "Islamics Viewpoint of Organ Transplantation," 3273.

31 absence of coercion, financial gain and without harm to the donor. This last point is of particular importance in the case of blood, bone marrow and kidney donations when the donor can be, and often is, a living donor. One life should never be sacrificed to save another, thus prohibiting the donation of any organ, for any reason, that will result in the death of the donor.95

Continuing with this belief, organ transplantation is allowable if, and only if, there is little or no harm to the donor and the procedure and recipient carry a high expectation of succesS. 96 One should never violate a corpse, cause discomfort to a living donor, or take resources in the forrn of medical personnel, operating equipment and space, unless there is a reasonable expectation of succesS.97

The final theme under which arguments for organ transplantation can be grouped is the imperative to seek remedies. Found in the Qur'an and further elaborated on in the

Sunna, where Muhammad said "0 servants of Allah! Seek remedies! He who causes ailments also brought cures and redemption. There is a cure for every illness. ,,98 Islam actively advocates medical and scientific research. The Qur'anic verse, "who created me, and Himself guides me, and Himself gives me to eat and drink, and, whenever l am sick, heals me" (26:78-80) and the above hadith give evidence of several of the ideas that have been presented throughout this chapter. First, they reinforce the supremacy of God; just as God has created the ailments from which humans suffer, so too does God create the space for cures. The human capacity of reason will allow for these cures to be discovered.

Second, they reinforce the notion that the Islamic conception of illness is not one of

95 Donating an organ that will result in the death ofthe donor is tantamount to suicide, which is veliemently prohibited in Islam. 96 Sabin, "Islamic Transplantation Ethics," 939. 97 Krawietz, "Darura in Modem Islamic Law: the Case of Organ Transplantation," 189. 98 EI-Shabat, "Islamic Viewpoint of Organ Transplantation," 3273.

32 punishment for evil deeds, but rather illness is understood as a trial to be endured in good faith. Finally, they allow for the doctrine of necessity to be applicable to the case of illnesses that can be cure through organ transplantation.

The above discussion of organ transplantation highlights several of the most commonly cited reasons given in support of organ transplantation. Taken in the broader context of Islamic bioethics and alongside notions of social justice, this position will be used to argue against female genital cutting. The following chapter will consider female genital cutting in the context of Islam, with particular reference to Egypt and Sudan.

Once the various Islamic justifications are explored, l will present an argument against

FGC, using the above bioethical principles.

33 Chapter 2: Female Genital Cutting in Egypt and Sudan

"People are more likely to observe normative propositions if they believe them to be sanctioned by their own cultural traditions. ,,]

Female genital cutting (FGC) has gained much attention since the early 1980s.

Referred to as female genital mutilation (FGM) by most Western feminists, international organizations and the Western media, this practice is believed to affect up to 2 million girls every year.2 Commonly associated with Islam and seen as a barbaric ritual intended to maintain the patriarchal social systems present in communities and societies where it takes place, most feminists call for the immediate and total eradication of the practice.

The United Nations, World Health Organization, International Monetary Fund, United

Nations International Children's Emergency Fund, Amnesty International and the World

Bank, along with countless other aid and activist organizations, also advocate a position of total, immediate eradication.3 Couched in the language of public health strategies,

1 Zebra F. Arat, "Women's Rights in Islam: Revisiting Quranic Rights," in Human Rights: New Perspectives, New Realities, eds. Adamantia Pollis and Peter Schwab (London: Lynne Rienner Publishers, 2000): 88. 2 World Health Organization, Female Genital Mutilation: The Prevention and Management of the Health Complications: Policy Guidelines for Nurses and Midwives, (Geneva: World Health Organization, 2001),6. 3 At the beginning ofthe push towards eradication, most campaigns were very much top down. United Nations action is characterized by use of official declarations, conventions, charters and treatises, such as the Universal Declaration of Human Rights (1948), the Convention on the Elimination of AlI Forms of Discrimination against Women (1979), the Convention on the Rights of the Child (1989), and most recently, the Declaration and Platform for Action of the Fourth World Conference on Women (1995). The International Monetary Fund and the World Bank have taken these one step further, on the behest of the United States govemment. Loans to countries where FGC is known to be prevalent are often contingent on govemment action, in the form of legislation, public health programs or other eradication efforts, against FGC (see Elizabeth Heger Boyle, Fortunata Songora and Gail Foss, "International Discourse and Local Politics: Anti-FGC Laws in Egypt, Tanzania and the United States," Social Problems 48, no. 4 (2001): 524- 44 and Melissa Parker, "Rethinking Female Circumcision," Africa 65, no. 4 (1995): 506-523). Again, however, FGC often ranks fliirly low on the list ofpriorities for many ofthese governments, many ofwhich govern poor, developing nations. Hicks states that this should come as little surprise, "given the many life tbreatening health issues that prevail in countries where this practice is indigenous, most of which are impossible to address unless coupled to extensive socioeconomic reform" (Esther K. Hicks Infibulation: Female Mutilation in Islamic Northeastern Africa, (New Brunswick: Transaction Publishers, 1996),212).

34 most eradication programs attempt to enforce Western notions of universal human rights,

sexual equality and the rights of children on communities with radically different

worldviews.

However, many areas that have been the targets of such programs for years still

have high rates of FGC. Further, "even in countries where nearly all families engage in

FGC, states uniformly oppose it.,,4 Given this situation, many advocate for a more

culturally sensitive approach to this issue, one that reconciles the position of the above-

mentioned organizations with the beHef systems and worldviews of those who practice

FGC. In this chapter, 1 will consider the various types of genital cutting, where it is most

prevalent, the main reasons for its occurrence and several of the eradication strategies in place in various parts of the world. Specifically, 1 will examine how Islam has been

implicated in the perpetuation of FGC.

Language is often a point of contention between those who study FGC, those who

advocate against it and those who engage in it. 5 Female circumcision is the name

traditionally used by both members of the communities who practice it and those who

study them. When it emerged as a topic of scholarship, anthropologists, ethnographers

and sociologists followed this convention and used "female circumcision" in their work.6

However, the late 1970s and early 1980s saw increased feminist scholarship and the issue

of female circumcision was taken up along side female specifie traditional practices such

as Chinese foot binding and Indian safi. Once this practice was placed in the context of

Moreover, in the case of the Sudan, years of civil war and political instability make top down eradication activities difficult and often of little use. 4 Boyle, Elizabeth Heger. Female Genital Cutting: Cultural Conflict in the Global Communitv. (Baltimore and London: The John Hopkins University Press, 2002), l. 5 Ibid., 24. 6 Ellen Gruenbaum and Melissa Parker, among others.

35 what were perceived to be examples of the patriarchal oppression and exploitation of and

violence against women, a shift in language occurred. Female genital mutilation (FGM)

came to dominate Western rhetoric on the matter, a term introduced by Fran Hosken in her 1979 book The Hosken Report: Genital and Sexual Mutilation of Females. This book

is widely considered the most influential book on the matter, having initially brought the

issue of FGC into the mainstream.7 Feminist literature produced by both scholars and activists, as weIl as documents from United Nations affiliate organizations, claim that

FGM is the most appropriate and accurate term. This is based on the outcome of the practice, the mutilation of healthy and functioning tissue of girls too young to consent: "it is a mutilation from the human rights and legal points of view because it is carried out with the intention of limiting and controlling women's sexuality and in perpetuating the subordination of women, denying them the full citizenship they deserve."g FGM represents a practice unthinkable to western sensibilities, one believed to be very much at odds with Western attitudes towards sexuality, autonomy and human rights.9

7 Stanlie M. James and Claire C. Robertson, eds., Genital Cutting and Transnational Sisterhood: Disputing U.S. Polemies (Urbana: University of Illinois Press, 2002), 60. 8 Amal Abd El Hadi, "Female Genital Mutilation in Egypt." in Afriean Women's Health, ed. Meredith Turshen (Trenton: Afriea World Press, Inc., 2000), 146. 9The history of Western genital surgeries, partieularly those performed on intersexed children, is often contrasted to FGC in Africa (Cheryl Chase" 'Cultural Practiee' or 'Reconstructive Surgery'? U.S. Genital Cutting, the Intersex Movement, and Medical Double Standards," in Genital Cutting and Transnational Sisterhood: Disputing U.S. Polemics, eds. Stanlie M. James and Claire C. Robertson (Urbana and Chicago, University of Illinois: 2002), 126-151 and Alice Domurat Dreger, Hermaphrodites and the Medieal Invention ofSex, (Cambridge: Harvard UP, 1998),258 n. 59). In addition to the psychiatrie use of genital surgeries to cure such female "conditions" as nymphomania, hysteria and fridgity in Western world as late as the 1950s, surgi cal advances in the latter half of the 20th century combined with psychological theories of gender identity development thrust intersex children into the surgical realm. These children undergo countless surgeries throughout their life course, aH of which aim at normalizing their bodies. The Western definition of normal, one premised on the duality ofmale and female, guides the medical management of intersexed children. This comparison is deemed inappropriate by many, mainly because FGC is seen as a ritual practice that serves no medical purpose, while genitoplasty is responding to a medical problem. However, it should be remembered that most surgeries are performed for cosmetic purposes and that the medical management ofintersexuality is responding to a social emergency, not a medical one.

36 However, in recent years, a second shift has occurred. Many Western scholars and

African activists have rnoved away frorn FOM in favor of a more politically neutral and

less pejorative term, namely, fernale genital cutting (FOC). FOC conveys the result of the

traditional practice without passing judgrnent on those who practice it. 10 Mutilation has a

negative tone, irnplying an intention to harm. Harrn, pain or suffering are never the goals

of those who practice FOC. Often, quite the opposite is the case. Oirls who do not

undergo FOC can, and often do, face dire social consequences as a result. Il In light of

this, FOC is becorning increasingly cornrnon. l will use FOC in what follows.

Finally, a very recent developrnent in the debate on FOC has been the use of such

terms as ritual fernale genital surgeries 12 or traditional fernale genital surgeries. These

terms present a cornrnon set of problerns, rnost notably the problern of rnedicalizing a

practice that damages otherwise healthy organs and tissue. The issue of rnedicalization

will be addressed below.

Prevalence

Although the practice is associated with Africa in general, it occurs rnainly in the

equatorial region and in the horn of Africa. F ourteen countries have prevalence rates of at

least 60%, with sorne, such as Sornalia and Djibouti, having an alrnost 100% rate of FOC.

The other twelve in this group are Egypt, Mali, Sierra Leone, Ethiopia, Eritrea, Sudan,

10 Boyle, Female Genital Cutting, 25. 11 Sandra D. Lane and Robert A. Rubinstein. "Judging the Other: Responding to Traditional Female Genital Surgeries," Hastings Center Report 26, no. 3 (1996): 38. 12 Aldo Morrone, Jana Hereogova and Torello Lotti, "Stop FGM: Appeal to the International Dermatologie Community," International Journal of Dermatology 41 (2002): 254.

37 Guinea, Burkina Faso, Chad, Cote d'Ivoire, Gambia and Liberia. 13 An additional thirteen have substantial prevalence rates, ranging from just over 5% to about 50%. These are

Benin, Central African Republic, Guinea Bissau, Kenya, Nigeria, Mauritania, Ghana,

Niger, Senegal, Togo, Tanzania, Uganda and Zaire. 14 Boyle points out that aIl of these countries have internaI groups agitating for the cessation of the practice15 and that in these countries, where an official govemment is in place, there is an official position against FGC. 16 In terms of actual numbers, most agree that at least 130 million women and girls have undergone sorne form of FGC 17 and about 2 million girls are at risk of undergoing the procedure each year. 18 It is also believed that although Nigeria has a prevalence rate of about 50%, it has the highest number of circumcised women, due to its large population.

Egypt and Sudan: studying FGC

My focus will be on FGC in Egypt and the Sudan. The reason for this selection lies in several demographic, political and economic factors of the two countries, coupled with their close geographic proximity. Egypt is the most developed nation with a high level of FGC. 19 With a relatively stable economy and govemment, the FGC situation

13 Ellen Gruenbaum, The Female Circumcision Controversy: An Anthropological Perspective, (Philadelphia: University of Pennsylvania Press, 2001), 8. 14 Ibid., 8. 15 Ibid., 160. 16 Ibid., 84. 17 World Health Organization, UNICEF, UNFPA, Female Genital Cutting, (Geneva: World Health Organization,1997),5. 18 WHO, The Prevention and Management ofthe Health Complications: Policy Guidelines for Nurses and Midwives, 6. 19 Elizabeth Heger Boyle, Barbara J. McMorris and Mayra Gomez. "Local Conformity to International Norms: the Case ofFGC," International Sociology 17 (2002), Il.

38 calls into question theories of development and education as factors that influence a decrease in FGC.20 For example, the 1997 Egyptian Demographic and Health Survey found that 98% of women between the ages of 20 and 24 had undergone FGC?l In addition, although it is considered a secular state, Egypt is predominantly Muslim, with approximately 94% ofthe population ascribing to Sunni Islam. The presence of Al-Azhar

University contributes to Egypt's prestige across the Muslim world. Finally, Egypt's long history with Western colonialism, due partially to its prime geographic location, has left a strong skepticism towards aIl things Western in the minds of its citizens. Although partial independence from Britain was given in 1922, it was not until after World War II that

Egypt became an independent nation. Despite official political independence, Egypt has been subject to British and American political influence throughout the latter half of the

20th century. Economically, Egypt depends heavily on the United States and world organization such as the International Monetary Fund and the W orld Bank. The govemment must adhere, consequently, to a certain extent, to international ideals such as universal human rights?2 Thus foreign attempts to change Egyptian society have continuously met with strong internaI resistance.

Egypt has undergone an Islamic revival in recent years, moving towards a more traditional/fundamentalist form of Islam. The Islamist movement, begun by the Muslim

20 Much of the literature on FGC characterizes the practice as primitive and a clear sign of a lack of development. Many assert that levels ofFGC decrease when women are given even the most minimal education. Furthermore, urbanization is also believed to be a factor in reducing FGC. Both of the se are generally believed to increase the overall status ofwomen in a society. However, the se ideas are very much called into question when a noticeable trend in the opposite direction is discernable, as is the case with Egypt. In fact, the Demographie and Health Surveys Program found that at least 91% ofEgyptian girls with secondary school education have undergone sorne form of genital cutting (Dara Carr, Female Genital Cutting: Findings fromthe Demographie and Health Surveys Pro gram, (Calverton, MD: Macro International, 1997), 5). The same study revealed that educated women in Sudan are more likely to undergo FGC than less educated women (Ibid., 18). 21 Ibid., 45. 22 Nadje Al-Ali, Secularism, Gender and the State in the Middle East: The Egyptian Women's Movement, (Cambridge: Cambridge UP, 2000), 75.

39 Brotherhood in the 1920s, has significantly changed the social view of women. After its

founding in 1928 by Hasan al_Banna,23 the Muslim Brotherhood gained much support

from the lower middle class during the 1930s as a result of the economic depression.

However, the "disenchantment with the existing social and political structure,,24 and the

continued presence of the British in Egypt following World War II brought the

movement into the mainstream of Egyptian society. It represented a socially conservative

Islamic movement that atlracted both men and women.25

The main goal of the Brotherhood was to establish an Islamic society that is true

to the ways of the Prophet, as described in the Qur'an and the Sunna, independent of

external influence.26 They do not call for a total revolution, in a Marxian sense, but rather

see this goal as the end of a three-stage process.27 All the problematic aspects of modem

society, such as poverty and political instability, will be appropriately addressed through this transformation?8 Despite what might appear to be an egalitarian movement with a

religious background, the Brotherhood firmly advocated the ideals of "the patriarchal

family, male authority over women, and a clear-cut differentiation of gender roles.,,29 The

rise of the Islamist movement corresponds to increased levels of FGC,30 further

separation of the gender, and stricter dress codes for women. The Islamist movement has

23 Saad Eddin Ibrahim, Egypt, Islam and Democracy: 12 Critical Essays, (Cairo: American University in Cairo Press, 1996), 121. 24 Ibid., 121. 25 Margot Badran, Feminists, Islam and Nation: Gender and the Making of Modem Egypt, (Princeton: Princeton UP, 1995), 163. 26 Margot Badran, "Competing Agenda: Feminists, Islam, and the State in Nineteenth- and Twentieth-century Egypt," in Global Feminisms Since 1945: Rewriting Histories, ed. Bonnie G. Smith. (London: Routledge, 2000), 22. 27 Nissim Rejwan, The Many Faces ofIslam: Perspectives on a Resurgent Civilization, (Gainesville: University Press of Florida, 2000),189. 28 Ibid., 190. 29 Badran, "Competing Agenda: Feminists, Islam, and the State in Nineteenth- and Twentieth century E§ypt," 22. 3 Amal Abd El Hadi, "Female Genital Mutilation in Egypt," in Women and Health in Africa, ed. Meredith Turshen. (Trenton: Africa World Press, 1991), 147.

40 also increased the anti-Western nationalism of the Egyptian population,31 widening the

gap between the govemment and the people.32 Many laws and policies adopted from or

as a result of Western ideals mean little to the population at large. IMF and World Bank

lending policies are examples of policies that have raised anti-Western sentiment in the

country.33

The second country, Sudan, presents a radically different situation than its

Egyptian neighbor. Roughly 70% of Sudanese are Sunni Muslims, concentrated mainly

in the northern regions of the country. The inhabitants of the South follow either an

indigenous African religion or Christianity. Since receiving independence from Britain in

1956, Islamic-oriented govemments have dominated the country. The military regime that took power in 1989 by military coup began enforcing National Islamic Front (NIF) policies that moved the country towards a more conservative, fundamentalist position.34

Divided and ravaged by years of civil war, Sudan has anything but a stable economic or political system. The political, economic and social domination of the Northern Muslims

over those in the south has made progress difficult. However, in recent years, several of the IMF's macroeconomic policies have been implemented with sorne success.

Nonetheless, the continuous civil war, limited arable land, frequent dust storms and persistent drought have hampered economic development. Furthermore, the Islamist slant

of the govemment, which mirrors the ideals of the Muslim Brotherhood in Egypt, has made changes to social customs and norms difficult. This problem is particularly

31 Gruenbaum, The Female Circumcision Controversy, 3I. 32 Aida SeifEI Dawla, "The Political and Legal Struggle over Female Genital Mutilation in Egypt: Five Years Since the ICPD," Reproductive Health Matters 7, no. 13 (1999): 13I. 33 Ibid., 134 34 Gruenbaum, The Female Circumcision Controversy, 187.

41 pronounced in the area of women's issues.35 The presence of the Public Order Police is

indicative of this; "commissioned to enforce proper social behavior, including restrictions

on 'immodest dress' by women,,,36 this type of surveillance distinguishes Sudan from

Egypt, where gender equality, while perhaps not completely socially visible, is legally

upheld.

Finally, Egypt and Sudan have an interesting history with respect to FGC, partly

due to their similar experience with British colonialism. Both countries have laws that

ban the practice, but statistics show that the FGC is still very widespread. Sorne privately

conducted surveys demonstrate a slight increase in FGC in recent years. Traditional or

customary elements of popular forms of Islam are sometimes more influential on the practices of a community than the more dogmatic position put forth or supported by

Islamic scholars and clerics. This is very much the case with FGC. y ount, in her studies

in Egypt, characterizes customary Islam as a combination of regional and shared practices.37 FGC is one such regional practice that has been very successfully adopted in the name of Islam. Given this, despite education and an urban setting, levels of genital

cutting are not always reduced. This is one of the reasons why both Egypt and Sudan will be considered, as the former is considered the most developed of all the nations that practice FGC, while the latter is more representative of nations with high levels of FGC.

35 Boyle and others, "Local Conformity to International Norms: the Case ofFGC," 12. 36 Boyle, Female Genital Cutting, 122. 37 Kathryn M. Y ount, "Symbolic Gender Politics, Religious Group Identity, and the Decline in Female Genital Cutting in Minya, Egypt," Social Forces 82, no. 3 (2004): 1085.

42 Female genital cutting is an umbrella term that encompasses a large variety of

practices. Although United Nations organizations use female genital mutilation, the four

categories defined by the UN are the most universally used and will be used here. Until

recently, three types of genital cutting were commonly discussed; a fourth category has

been added to account for diversity. While each ofthese categories has a neat definition,

it is rare that any woman would match the technical definitions of each category. The

exception to this might be those who have undergone the third type of FGC, for reasons

that will be apparent when it is discussed in detail. The categorization that follows is

found in a joint statement published by the WHO, UNICEF and the United Nations

Population Fund (UNPF A) in April 1997.38

Type l is often referred to as sunna circumcision?9 It involves the excision of the prepuce of the clitoris, "with or without excision of part or the entire clitoris." When performed on young girls, it is not always easy to detect later in life. 4o This is most

common among Ethiopians, Eritreans and Nigerians.41

Type II involves the excision of the clitoris with "partial or total excision of the

labia minora." This practice most closely mirrors the clitoridectomies performed in

North America and parts of Europe as late as the 1950s as a cure for female hysteria and

nymphomania. In Africa, several different methods may be used to stop or limit the initial

bleeding, from stitching using catgut to the application of mud poultices.42 This type is

38 World Health Organization, UNICEF, UNFPA. Female Genital Cutting. Geneva: World Health Organization, 1997. 39 Boyle and others, "International Diseourse and Local Politics: Anti-FGC Laws in Egypt, Tanzania and the United States," 526. 40 American Aeademy ofPediatrics, Committee on Bioethies. "FGM," Pediatries 102 (1998): 153. 41 Nawal M. Nour, "FGC: Clinieal and Cultural Guidelines," Obstetries and Gyneeology Survey 59, no. 4 (2004): 275. 42 Committee on Bioethies, "FGM," 154.

43 commonly found in Sierra Leone, Gambia and Guinea.43 These first two types are the most common, accounting for almost 80% of genital cuttings,44 although the distinction between the two is not as clear in practice as it is in theory. They are both classified as reduction operations, as they involve sorne type of reduction of the female genitalia.45

The third and most severe of the four types is classified as a covering operation46 and accounts for approximately 15% of aIl genital cutting.47 It is alternately referred to as infibulation or Pharonic circumcision and is found mainly in Somalia, Northern Sudan and Djibouti.48 It also occurs with lower prevalence in several other countries, most notably southern Egypt, northern Nigeria, and parts of Ethiopia and Eritrea.49 It involves the complete excision of the external genitalia, followed by a significant narrowing of the vaginal opening. This is accomplished by stitching the excised sides of the labia minora/majora together and maintaining a miniscule opening by inserting a small cylindrical object, such as a piece of straw or a thorn, where the vaginal opening was. 50

This small opening allows for urine flow, menstruation, and eventually intercourse. Scar tissue forms, leaving a "perfectly smooth vulva of skin al1d scar tissue" and a small opening that usually needs to be cut prior to first intercourse and childbirth.51 This practice clearly carries the most risk for infection and hemorrhage; Gruenbaum observed

43 Nour, "FGC: Clinical and Cultural Guidelines," 275. 44 WHO, The Prevention and Management of the Health Complications: Policy Guidelines for Nurses and Midwives, 6. 45 Lane and Rubinstein, "Judging the Other: Responding to Traditional Female Genital Surgeries," 32. 46 Ibid., 32. 47 WHO, The Prevention and Management ofthe Health Complications: Policy Guidelines for Nurses and Midwives, 6. 48 Nour, "FGC: Clinical and Cultural Guidelines," 275 and Gruenbaum, The Female Circumcision Controversy, 8. 49 Morrone and others, "Stop Female Genital Mutilation: Appeal to the International Dermatologie Community," 41 and Gruenbaum, The Female Circumcision Controversy, 8. 50 Lane and Rubenstein, "Judging the Other: Responding to Traditional Female Genital Surgeries," 32. 51 Gruenbaum, The Female Circumcision Controversy, 3.

44 that many midwives and circurncisers have begun to leave the clitoris intact underneath the infibulation as a means of minimizing bleeding.52 While this is a positive step, infibulated women are still at greater risk for severe long-term complications.

The final category is a miscellaneous one encompassing a variety of practices that do not fall into one of the other categories. The remaining 5% of women undergo this type of genital cutting, although cutting is slightly inaccurate for this category. What each practice entails is self evident from its name; examples included, but are not limited to, pricking, piercing or burning the clitoris or introducing a corrosive substance into the vagina.53

Although the age at which cutting occurs vanes greatly across Africa, from newborn to late puberty,54 it appears that it is most commonly done when the girl is between 5-11. The cutting is performed using a knife, a razor, scissors or a piece of glass/broken bottle.55 TraditionaIly, a midwife or traditional healer performs this practice,56 although in recent years, many women in urban areas are seeking the services of Western-style medical professionals and the safety of a hospital/clinic environment.57

In many cases, the woman performing the practice has no training that would, by Western standards, prepare her for the type of procedure she is performing. Many leam through

52 Ellen Gruenbaum, "The Islamic Movement, Development, and Health Education: Recent Changes in the Health of Rural Women in Central Sudan," Social Studies of Medicine 33, nO.6 (1991), 642. 53 WHO, "Female Genital Mutilation," 3. Many ofthese forms of genital alteration have only recently been recorded. As such, the reasons for why they occur are less clear. However, the nature ofthese practices places them more in the context of sexuality rather than religious/cultural identity. As such, it is more likely that these practices would be carried out as a means of controlling female sexuality. nd 54 Fran P. Hosken, The Hosken Report: Genital and Sexual Mutilation ofFemales, 2 ed. (Lexington: Women's International Network News, 1979),3 55 Asma El Dareer, Woman, Why Do Vou Weep? Circumcision and Its Consequences (London: Zed Press, 1982), 6. 56 Ibid., 14 57 Dorkenoo, Cutting the Rose: Female Genital Mutilation: The Practice and Its Prevention, 9.

45 apprenticeship or actual practice, another factor that accounts for the variation in end result.

Health Consequences

The health consequences of FGC are as varied as the practices themselves. While it is the case that "long term complications are more likely to be associated with type III than with type 1 and II,,,s8 in much of the literature on the subject little distinction is made between the side effects most common to each type of cutting. From the descriptions provided of the different types of FGC, it is evident that infibulation carries not only a greater risk for side effects, but also lengthens the list of possible health risks. There is also debate as to just how common many of these side effects are. Greater attention will be paid to this in chapter 3.

The immediate side effects include "hemorrhage, severe pain and shock from blood 10ss."s9 Urine retention, dehydration, fever and infection, including tetanus and gangrene,60 are common and can have other long term consequences in and of themselves. Fractures to such major bones as the clavicle, femur and humerus or the dislocation of the hip joint can occur due to the force required to restrain a child who is circumcised without anesthesia.61 Damage to other tissue and organs can also occur as a result of movement during cutting. 62

58 U. Larsen, and F.E. Okonofua, "Female Circumcision and Obstetric Complications," International Journal Gynecology & Obstetrics 77 (2002): 256. 59 Ibid., 256. 60 Nour, "FGC: Clinical and Cultural Guidelines," 274. 61 Morrone and others, "Stop Female Genital Mutilation: Appeal to the International Dermatologie Community," 260 and Nour, "FGC: Clinical and Cultural Guidelines," 274. 62 Toubia, Female Genital Mutilation: A CalI for Global Action, 60.

46 The immediate consequences often lead to numerous long-term consequences.

While death can sometimes be the result of the practice itself, particularly as the result of uncontrollable hemorrhage, it is also the possible end result of many of the long-term complications as weIl. Nour divides the most common long-term consequences into four main groups: urinary, scarring, pain and infertility/sexual dysfunction. This is a helpful way of organizing the fairly extensive list of complications that can occur.

Urinary complications include urinary tract infections, prolonged urine retention

and difficult or slow urination. Related to these, Toubia also cites chronic pelvic

infections and incontinence.63

The scarring, or dermatological, complications are extensive, and tend to be more pronounced and acute the older the girl is when the circumcision takes place. Sorne of the most common are: fibrosis, keloids, dermoid cysts, abscesses and fistulae. 64 The last of these is particularly troublesome in rural areas and among the more economically

disadvantaged. It can lead to constant leakage, an embarrassing problem made worse when absorbent pads are not available; this can be grounds for divorce and the cause of

social o straci sm. 65

Nour's third category, pain, can be associated with the side effects described in

each of the other three. However, she further identifies pain associated with recurrent yeast infections and menstrual problems such as severe dysmenorrhea66 and menorrhagia. 67 Perhaps one of the most dangerous consequences associated with

63 Ibid., 60. 64 Nour, "FGC: Clinical and Cultural Guidelines," 275. 65 Gruenbaum, The Female Circumcision Controversy, 6. 66 Severe menstrual cramps. 67 Vaginal bleeding and/or uterine growths, found in Nour, "FGC: Clinical and Cultural Guidelines," 275.

47 menstruation in infibulated women is hematocolpos, a condition that presents as a pregnancy. This can have dire social consequences for a young unmarried girl.

In sorne cases infertility can result from FGC. Nour states that infertility rates can

be as high as 25 to 30% for infibulated women.68 However, sometimes infertility is the

result of an inability to achieve proper penetration. Persistent failed efforts at penetration

can cause a multitude of other side effects, most notably frustration, stress and marital

strife.69 Further, while the pain from attempted intercourse can be both physical and psychological in nature for the woman, sorne studies point to psychological trauma for

men who realize they are continuously hurting their wives. 70

Finally, a variety of problems are associated with pregnancy itself, aIl of which

are life threatening. 71 Related to obstructed labor, these include hemorrhage during

delivery as a result of tearing, maternaI exhaustion and stress on the infant. Ultimately, when adequate medical care is not available, infant mortality and maternaI mortality can

occur. 72 While these do not occur in the majority of women who have undergone type III

73 FGC, they occur frequently enough to be considered of epidemiological significance .

Boyle asserts an important cautionary note on this matter. Early marri age is common in

most of the communities that practice FGC; distinguishing between the complications

from early pregnancy and those from FGC is difficult and often exaggerates mortality

68 Ibid., 275. 69 Morrone and others, "Stop Female Genital Mutilation: Appeal to the International Dermatologie Community," 260. 70 Nour, "FGC: Clinical and Cultural Guidelines," 276. 71 Gruenbaum, The Female Circumcision Controversy, 5. 72 Ibid., 6 73 Fran Hosken's report on female genital mutilation, frrst published in the late 1970s, tended to exaggerate the frequency of the more severe complications, particularly death. The impact ofher work should not be underestimated, as it appears frequently in most of the literature on the topie. As such, her estimates and statisties became viewed as "facts," prompting advocacy, awareness campaigns and activism. Interestingly, it did not cause increased statistica/ study of the issue. This was taken up by Carla Obermeyer in 1999 and 2003; the latter was in response to Gerry Mackie's 2003 critique of Ohermeyer's original study. This will he taken up in greater depth further in this study.

48 figures related to FGC. 74 This serves to further sensationalize the topic, increasing the divide between the women who practice FGC and the women and men who criticize and attack it. In recent years, HIV / AIDS has become a concern, mainly in regions where FGC is performed on several girls at once or where questionable implements are used. 75

However, additional research on this subject is required.

While there are undoubtedly serious sexual and psychological effects of FGC, the se are less well researched and documented. Sorne of the reasons for this relate to conventions concerning modesty, sexuality and sexual relations, cultural differences vis-

à-vis sexual satisfaction, orgasm and appropriate female sexual behavior. The consequences for sexuality are often discussed in the feminist literature, but contradictory evidence exists. Many assert that no matter which form ofFGC is performed, a woman's ability to enjoy sexual relations is seriously compromised.

Shweder points out that this view might be more firmly based on the Western emphasis on the clitoris than the actuallived experience of circurncised women.76 Several ethnographic/anthropological accounts of the sexual experience of circurncised women found that many do experience orgasm. 77 In addition, women often claim that other erogenous zones experience heightened sensitivity.78 Despite an overall lack of information on the psychological impact of FGC, sorne scholars have explored and published on the subject. 79 Gruenbaum notes that the "psychological consequences clearly can be expected to vary considerably, depending on cultural meanings that are

74 Boyle, Female Genital Cutting, 34. 75 WHO, "Female Genital Mutilation," 7. 76 Richard Shweder, Why Do Men Barbecue? Recipes for Cultural Psychology, (Cambridge: Harvard UP, 2003), 194. 77 See Gruenbaum, The Female Circumcision Controversy and Lightfoot-Klein. 78 Boyle, Female Genital Cutting, 35. 79 See Raqiya Haji Dualeh Abdalia, Sisters in Afflication: Circumcision and Infibulation of Women in Africa (London: Zed Press, 1982).

49 taught and whether girls are prepared for the operations.,,80 The most commonly discussed psychological consequences are depression, fear of intimacy and anxiety.81

From this list of health consequences, one cannot help but ask the question "why does this practice still take place?" 1 explore the various reasons for FGC in what follows.82

Justification and Rationale for FGC

Evidence of FGC has been found as far back as the 2nd century BCE in what is now Egypt. 83 It appears that the region where infibulation is now most common, namely the Nile Valley region, is where the practiced originated. As the practice spread, lesser forms of genital cutting became more common, moving from infibulation towards clitoridectomy.84 Several scholars link this spread with slave trading and the advent of

Islam. Infibulation provided a physical barrier to sexual intercourse; as such, female slaves who had undergone infibulation were more valuable.85 With the spread of Islam in the i h century CE, an Islamic prohibition on enslaving fellow Muslims forced Muslim

80 Gruenbaum, The Female Circumcision Controversy, 7. 81 Ibid., 7. 82 While it is extremely important to consider the many health consequences, the consequences of no! performinglundergoing FGC are less often discussed. This is particularly true of much of the feminist literature, which tends to sensationalize FGC. In many communities where FGC is prevalent, both Muslim and non-Muslim, marriage is the only means of social security for women. Furthermore, marriage is intimately linked with procreation, as marriage provides the only acceptable relationship in which procreation can occur. Quality oflife is intimately linked to having many children. It is therefore extremely important for a woman to be able to have children. Securing a good marriage is therefore crucial to family prosperity. This is especially true ofrural, less educated communities, where children are a necessary labor force and a support system in old age. When FGC is near universal, men will often refuse a non circumcised wife and in sorne cases, the circumcision performed in early childhood will be deemed insufficient, often by the grandmothers. Not getting married can result in destitution for a young girl, whose own family might not be able to continuing supporting her once she is of marriageable age. 83 Gerry Mackie, "Ending Footbinding and Infibulation: A Convention Account," American Sociological Review 61, no. 6 (1996), 1003. 84 Ibid., 1003. 85 Boyle, Female Genital Cutting, 28.

50 slave traders from the Nile Valley into the continent to find slaves. The slave routes expanded further into Africa and conversion to Islam followed the same path, thus introducing the custom into other areas as one supported by Islam. 86 This partially explains how the custom became associated with Islam, why it is only practiced in sorne areas of Africa and why other, non-Muslim groups also practice female circumcision.

Ethnographic and anthropological studies give the most common reasons, in very generic terms, for why communities practice FGC. Among the most common are tradition, religious requirement, purity, and other notions related in sorne way to locally understood notions of appropriate female sexuality.87 What each of these means from community to community cannot be expected to be the same; however, it does give a solid indication of the dominant motivation behind the continuation of the practice. l will consider each of these reasons in sorne detail, followed by an explication of the place of

FGC in Islam.

Although most often associated with Islam by activists and feminist scholars, perhaps for the above-mentioned historical reason, FGC is practiced by different

Christian groups, most notably Coptic Christians, Ethiopian Jews (the Falashas), and believers of various African tribal religions. In aIl cases, "the practice is deeply embedded in local traditional belief systems.,,88 In sorne regions, FGC is so much a part of what is normal that many do not know anyone who is not circumcised; many ethnographers and anthropologists recount stories of the shocked reaction they received

86 Ibid., 28. 87 Noor J. Kassamali, "When Tradition Confronts Traditional Praetiees: Female Genital Cutting in Northeast Afriea," in Women in Muslim Soeieties: Diversity Within Unity, eds. Herbert L. Bodman and Nayereh Tohidi, (Boulder: Lynne Rienner Publishers, 1998),42. 88 Morrone and others, "Stop Female Genital Mutilation: Appeal to the International Dermatologie Community," 259.

51 when the women in the community being studied realized that the researcher had not herself been circumcised. 89

Among believers of non-monotheistic religions, the "Pharonic belief in the bisexuality of the gods,,90 is one of the most commonly cited reasons for FGC. It is believed that humans mirror the gods in their dual sexuality. Every hurnan possesses both a male and a female soul. The clitoris of a woman represents the male soul and the prepuce of the penis is the female side of the male. Both of these need to be removed to ensure proper gender identity development and hence circurncision is often performed on both boys and girls in these communities.91 This view justifies the less severe forms of

FGC, but does not account for infibulation. Interestingly, even when this notion of bisexuality is not discussed, men and women will characterize a non-circumcised girl as more masculine,92 and view uncircurncised genitals as ugly, animalistic, or unnatural.93

Similarly, both men and women believe that FGC serves to enhance the beauty and cleanliness of the female genitalia. The smooth surface that results for almost aIl forms of FGC, more so with infibulation than the less severe forms, is thought to be more feminine and is further believed to carry less risk of disease. W omen are often cited as saying that uncircurncised genitals are unattractive.94 Vissandjee and coIleagues claim

89 See Lane and Rubenstein "Judging the Other: Responding to Traditional Female Genital Surgeries," and Melissa Parker, "Rethinking Female Circumsicion" 510. 90 Boyle and others, "International Discourse and Local Politics: Anti-FGC Laws in Egypt, Tanzania and the United States," 526. 91 Boyle, Female Genital Cutting, 27. 92 Ibid., 28. 93 Lois S. Bibbings, "Female Circumcision: Mutilation or Modification?" in Law and Body Politics: Regulating the Female Body, eds. Jo Bridgeman and Susan MilIns, (Aldershot: Dartmouth Publishing Company Ud., 1995), 155. 94 Gruenbaum, The Female Circumcision Controversy, 68.

52 that FGC is viewed as a corrective procedure aimed at fixing a girl's imperfections.95 It is also believed that if the clitoris is not cut, it will grow to be the size of a penis.96 Others claim that the clitoris can harm an infant during childbirth, should it touch the child during delivery.97

These beliefs support the various reasons related to appropriate female sexuality.

In many of the communities that practice FGC, marriage provides security for women; in many cases, women are valued almost exclusively as wife and mother. In this type of system, female virginity before marri age is essentia1.98 Preservation of virginity is therefore a very common reason for FGC, particularly where inflibulation is the norm.

The narrowing of the vaginal opening coupled with the scar tissue that forms are believed to create a physical barrier to premarital sex. Penetration can be difficult and painful, often requiring graduaI progression before intercourse can occur. This difficulty functions to curb extra-marital sexual relations, pre-marital as well as adulterous relations, but also causes great anxiety for newly married women who fear the pain ofpenetration.99

Many also believe that women have an insatiable sexual appetite, one that is understood to be well beyond the control of the individual female. 100 Measures are thus put in place to control this sexuality, as a means of protecting not only the honor and

95 Bilkis Vissandjee, Mireille Kantiébo, Alissa Levine and Radegonde N'Dejuru, "The Cultural Context of Gender Identity: Female Genital Excision and Infibulation," Health Care for Women Intemationa124, no.2 (2003): 118. 96Gruenbaum, The Female Circumcision Controversy, 68. 97 Bibbings, "Female Circumcision: Mutilation or Modification?" 155. 98 Ibid., 155. 99 Boyle, Female Genital Cutting, 27. It is often the case that women, particularly infibulated women, must be cut open on their wedding night in order to allow for consummation of the marriage. Furthermore, these same women are often cut prior to childbirth and are then stitched closed again after delivery. 100 Bibbings, "Female Circumcision: Mutilation or Modification?" 155.

53 integrity of the individual woman, but of her entire family as weIl. 101 Removing the clitoris is thought to decrease the female sexual drive. FGC therefore not only makes a woman less likely to engage in non-marital sexual relations, but allows men to maintain control over female sexuality, reinforcing the social view that a woman is the property of her husband. 102 By controlling and decreasing her desire, FGC can also allow a woman to be satisfied by her husband. This latter reason is common among communities where polygamy is practiced, where a woman will have to share her husband. Furthermore, speculation about lesbianism in such contexts is also a motivation, although secondary, for many. In the context of non-penetrative sexual relations, removing the clitoris removes the threat of lesbianism, a social problem that is seen as not only undermining the heterosexual family model, but patriarchal social structures as a whole. FinaIly, both men and women believe that FGC, particularly infibulation, makes intercourse more pleasurable for men. 103

Although not a direct reason for why FGC occurs, one of the reasons it continues in sorne are as is because it is an income-generating activity for the women who perform genital cutting. 104 Economic opportunities are extremely limited for many women in communities that practice FGC. Eradicating FGC would eliminate this opportunity for these women, who are either traditional healers or midwives, many of whom support themselves with this money. In regions where infibulation is the most common type of genital cutting, the midwife or healer who performs the original cutting is also needed before and after childbirth and often prior to the tirst sexual relations, clearly

101 Hieks, Infibulation: Female Mutilation in Islamic Northeastem Africa, 8I. 102 Boyle, Female Genital Cutting, 27. 103 Ibid., 29. 104 Carr, Female Genital Cutting: Findings from the Demographie and Health Surveys Pro gram, 20

54 demonstrating how financially important this practice is for sorne women. 105 While they might represent the first target in a plan for eradication, they are often the most resistant.

Research shows that within any given cornmunity, individuals will cite a different reason as the main reason for FGC; however, it is often the case that several reasons form part of an overall justification for the practice. 106 Many of these reasons involve "curing or, perhaps more precisely, controlling what are perceived to be 'problems' associated with females and female sexuality.,,107 This is very much the case with Islam. Although there is a general consensus among Muslim scholars and clerics that no authoritative text exists requiring any form of FGC, evidence shows that Islam is a strong predictor of the practice, particularly in Egypt and the Sudan. 108 Islam has also been shown to mediate other variables, such as education and exposure to Western ideals of human rights, which often decrease levels ofFGC.109

Islam and FGC

Scholars claim that one of the mam reasons why Islam continues to be a motivating factor behind FGC, and for the original association between the two, lies in the ease with which FGC was syncretized into the religion. liO This is particularly evident in Sudan, where several non-Islamic practices have been incorporated into Sudanese

105 Carr, Female Genital Cutting: Findings from the Demographie and Health Surveys Pro gram, 20. Carr also notes that "midwives ean eam more for genital cutting than for assisting at delivers" (20). 106 Bibbings, "Female Cireumeision: Mutilation or Modification?" 155. 107 Ibid., 155. 108 Carr, Female Genital Cutting: Findings from the Demographie and Health Surveys Program, 7. 109 Boyle, Female Genital Cutting, 19. 110 Gruenbaum, The Female Cireumeision Controversy, 44.

55 Islam. Of these, spirit posseSSIOn and FGC are the most evident. 111 Emphasis on patriarchal understandings of purity, virginity, fidelity and a later desire to control women left a perfect opening for FGC in the context of culture-specifie manifestations of Islam.

"By attaching itself to, and constructing a justification on, sorne ethical concem" of

Islam, FGC was seamlessly incorporated into Islam, despite its clearly pre-Islamic origins. 112

In Islam, the Qur' an is the supreme source of belief and practice, followed by the

Sunna. It should be remembered, however, that despite major commonalities across geographic and historical space, "Islam is not a unified, monolithic religion... the cultures created and experienced by Muslims have varied both spatially and historically.,,113 It is nonethe1ess interesting that there is no mention of female circumcision in the Qur'anY4 There is no specifie mention of male circumcision either, although this is also practiced in Islam as one of the five required deeds with respect to purity.115 This is based on the story of Abraham, found in the Book of Genesis in the

Hebrew Bible. As Kassmali notes, while this story in and of itse1f is not mentioned in the

Qur'an, the practice of male circumcision is still universally practiced by Muslims. 116 The sacred scriptures of Judaism and Christianity form part of the Muslim religion, with the

Qur'an and Muhammad being the culmination ofrevelation and the prophetie line.

III Gruenbaum, "The Islamic Movement, Development, and health Education: Recent Changes in the Health of Rural Women in Central Sudan," 643. 112 James and Robertson, "Genital Cutting and Transnational Sisterhood," 102. lI3 Zebra F. Arat, "Women's Rights in Islam: Revisiting Quranic Rights," 72-3. 114 El Dareer, Woman, Why Do You Weep? Circumcision and Its Consequences, 72. 115 Vardit Rispler-Chaim, Islamic Medical Ethics in the Twentieth Century, (Leiden: Brill, 1993), 84. 116 Noor J. Kassmali, "When Modemity Confronts Traditional Practices: Female Genital Cutting in Northeast Africa," 44. Reference to the practice ofmale circumcision is found in Sura 3, verse 95: "Follow, then, the community of Abraham, a man of pure faith who was not a polytheist."

56 Nonetheless, FGC is justified usmg a variety of sources within Islam, most predominantly the Sunna. The most commonly cited hadith is "lower, but do not completely uproot,,117 or "reduce but do not destroy; this is enjoyable to the woman and is preferable to the man.,,118 This hadith, or one of the few derivatives ofit,119 is perhaps the most powerful Islamic support for FGC. The hadith is based on a conversation

Muhammad had with a woman who circurncised female slaves. 120 It is alleged that

Muhammad asked her if she intended to continue this practice after her conversion. She replied that she would not if he disapproved. Rather than disapprove, Muhammad "not only told her it was allowed, he also demonstrated the correct way to do the operation.,,121

Interestingly, it is contested whether Muhammed had any of his daughters circurncised; 122 this would have been an excellent indication that the practice was something supported by Muhammed. Another hadith that is believed to accompany this is "circumcision is an ordinance in men and an embellishment in women,,,123 meaning that it is not required of women, but is viewed as an honorable deed. What is most striking about these two hadith is that neither can be said to support infibulation or any severe form of FGC. In addition, it must be kept in mind that the Islamic term for circurncision is khifad, meaning reduction, not removal.

117 Qtd. in Rispler-Chaim, Islamic Medical Ethics in the Twnetieth Century, 88. liS Qtd. in Kassmali, "When Modemity Confronts Traditional Practices: Female Genital Cutting in Northeast Africa," 44. 1I9 Other versions ofthis hadith are the following: "do not go deep. That is enjoyable to the woman and is preferable to the husband," "do not go deep. It is more illuminating to the face and more enjoyable to the husband," and "circumcise but do not go deep, this is more illuminating to the face and more enjoyable to the husband." These are aIl found in Gruenbaum, The Female Circumcision Controversy,64. 120 David L. GoIlaher, Circumcision: A History of the World's Most Controversial Surgery. (New York: Basic Books, 2000), 192. 121 Ibid., 192. 122 Kassamali, "When Modemity Confronts Traditional Practices: Female Genital Cutting in Northeast Africa," 43. 123 Qtd. in El Dareer, Woman. Why Do You Weep? Circumcision and Its Consequences, 72.

57 The above ahadith are considered debatable on several counts. First and foremost, these ahadith are not consistent with the Qur' an. 124 While there is a common belief in

Islam that sexuality should be controlled, it is never mentioned that this should be at the expense of enjoyment on the part of the woman. If anything, the opposite is true.

Compatibility and enjoyment on the part of both partners is one of the foundational elements of a solid marital bond; in effect, this satisfaction will prevent extra-marital sexual relations. In addition, the two ahadith given in support are not accepted as authentic by the majority of Muslim clerics and scholars. They have multiple forms and a broken chain, are not consistent with other ahadith and do not appear in Muhammad al-

Bukhari' s collection of ahadith, the more extensive and most authoritative collection. 125

However, when one considers FGC in the context of the development of Islam and the spread of FGC with the slave trade, a viable argument is discernable.

The notion of purity in Islam and what the Prophet said about this matter is also appealed to when justifying FGC. Here, a combination of ahadith are used. It is believed that Muhammed said "Islam is a religion of purity" and "purity is accompli shed by five deeds: circurncision, removal of pubic hair, trimming of moustache, paring of nails and removal of hairs from under the arm pit.,,126 While purity, chastity and modesty are aIl aspects of Islam that apply to women, it is difficult to state with a great degree of certainty that the above five deeds do apply to women. In the case of Sudan, it is

124 Boyle, Female Genital Cutting. 32 and Kassmali, 44. 125 Kassmali, "When Modemity Confronts Traditional Practices: Female Genital Cutting in Northeast Africa," 44. 126 Qtd. in El Dareer, Woman, Why Do You Weep? Circumcision and Its Consequences, 72.

58 interesting to note that the Sudanese Arabic tenn tuhur, meaning purity, is the tenn used to described FGC in that country; 127 this tenn is also linguistically related to chastity.

Since there is no mention of the practice in the Qur'an, most scholars believe that the practice is pre-Islamic; evidence shows that the practice probably pre-dated Islam by at least 2500 years, as noted above. This notion gives credence to the idea that the above hadith said to a midwife was uttered by Muhammed as a way ofmitigating a pre-Islamic practice prior to its incorporation into Islam in a different fonn. 128 Accepting that infibulation was common in the Nile Valley, both among slaves and freewomen, it is plausible that the Prophet sought to lessen this practice, favoring perhaps sorne lesser fonn of clitoral excision.129 This view is the one generally adopted by those who appeal to official sources for justification of FGC.

As with non-Muslim groups, notions of appropriate female sexuality play a large role in the Islamic justification for FGC. 130 Sexuality in Islam, particularly female sexuality, is believed to be a strong force that needs to be controlled and regulated. In his

1985 study of genital cutting, Lawrence Cutner claims that "there seems to be an implicit cultural belief in Islamic countries that a woman's sexuality is irresponsible and wanton and therefore must be controlled by men."l3l This is accomplished through marriage, as it

127 Gruenbaum, The Female Circumcision Controversy, 79. 128 Gruenbaum, The Female Circumcision Controversy. 65. 129 Kassamali, "When Modemity Confronts Traditional Practices: Female Genital Cutting in Northeast Africa," 45. 130 Lane and Rubenstein, "Judging the Other: Responding to Traditional Female Genital Surgeries," 34 and EI-Hadi, "Female Genital Mutilation in Egypt," 149. Sexuality as a reason for FGC will be revisited briefly here in order to illustrate similarities between Muslim and non-Muslim beliefs about sexuality. These similarities further reinforce the notion that FGC is a pre-Islamic practice that was easily syncretized into the religion in sorne areas. 131 Lawrence Cutner, "Female Genital Mutilation," Obstetrical and Gynecological Survey, 40 (1985),438. While many Muslims, both clerics and laypeople alike, support this view it is not a universally held belief. Furthermore, many claim that it is at odds with Muslim notions of sexuality, whereby sexual relations are seen as a positive aspect of society, if carried out in the confines of a proper marriage

59 prevents "women from having sex with abandon.,,132 Marriage permits the fulfillment of sexual des ire and the organization of procreation in an acceptable manner; it "ensures that this procreative function will be both sanctified and orderly, not vulgar and chaotic.,,133

Conversely, it is widely believed that "men are aggressive in their interaction with women, and women are passive.,,134 Herein lies the contradiction present in many

Muslim societies: while mechanisms are put into place to control women and their

"destructive, all-absorbing power" that, if left unchecked willlead a society into peril, women are also thought, or perhaps more accurately desired to be, the passive sexual agent. 135 FGC satisfies both understandings of sexuality: through FGC, women's sexuality is controlled and they become the passive partner in sexual relations.

In addition, there is a great emphasis on chastity in Islam and sexual relations outside marriage are strictly prohibited. 136 Circumcision is believed to curb a woman's sexual desire by those who practice the lesser forms,137 while Pharonic circumcision, given the nature of the procedure, ensures that no pre-marital sexual relations occur. 138

By removing or altering the clitoris, it is believed that a woman' s sexual desire is significantly reduced; this is desirable as a means of ensuring that she will be satisfied only by her husband, therefore eliminating the possibility that her sexual desire will cause

(Kassamali, "When Modemity Confronts Traditional Practices: Female Genital Cutting in Northeast Africa," 43-44). 132 Kate Conway-Tumer and Suzanne Cherrin. Women, Families and Feminist Politics: A Global Exploration. (New York: Haworth Press, 1998), 83. 133 Haifaa A. Jawad, The Rights ofWomen in Islam: An Authentic Approach, (London: Macmillan Press, Ltd., 1998), 31. 134 Fatima Memissi Beyond the Veil: Male-Female Dynamics in Modem Muslim Society (Bloomington and Indianapolis: Indiana UP, 1987),4. 135 Ibid., 4. 136 Gruenbaum, The Female Circumcision Controversy, 77. 137 Ibid., 66. 138 Ibid., 78.

60 her to seek relations outside of marriage. 139 Infibulation, on the other hand, forms a physical barrier to penetration as a result of scar tissue formation. While this is an

extremely effective means of controlling female sexuality, it also means that it can take

several days, weeks or even months for a couple to consummate their marriage. 140

Consequently, FGC can, and often is, placed in the same category as purdah, veiling, and early marriage, as means taken by communities to prevent social chaos resulting from female sexuality. An of these practices focus on the same idea, namely that a family's honor is very much tied to the behavior of its female members and, as

such, measures need to be put in place to protect women from being in dishonorable circumstances. 141

There have been several fatwas by influential Muslim religious authorities issued in recent years. A general consensus exists that infibulation is clearly not supported by

Islam, but the position on lesser forms of FGC is less unified. 142 The stance taken by the various schools of law can partly account for this. The four main Sunni schools of law each take a different position on the matter, hence affecting the orientation of any particular fatwa and how Muslims in general view the matter. The Shafi 'i school holds that circumcision is equally required for women and men. The Maliki school maintains that although it will add to a woman's dignity, it is not a sin to forego circumcision. The

Hanbali and Shar 'i schools both take more neutral positions, with the former finding the practice sunna, a good practice or tradition and hence favoring it, while the latter finds it

139 Ibid., 78. 140 Ibid., 78. 141 Ibid." 78 and EI-Hadi, "Female Genital Mutilation in Egypt," 150. 142 Ibid., 63.

61 to be permissible, but not obligatory.143 These are the more mainstream, traditional ways that FOC is justified in Islam. Use of the term sunna in relation to FOC has greatly problematized its eradication, as aIl things named sunna are viewed as required of aIl pious Muslims.

FinaIly, two folk stories exist concerning prophets, their wives and FOC. The first

story is of Abraham's wife Sarah and his concubine Hagar. As one of the preeminent prophets in the line to which Muhammad is the seal, the actions of Abraham are thought to be of great importance. In the story, Sarah is said to have circumcised Hagar out of jealousy that she had a son144 and was then ordered by Abraham, and presumably by

Ood, to "pierce her ears and have herself circumcised.,,145 This story is significant since

Abraham was told by Ood to be circumcised, setting a precedent for male circumcision in

Islam. However, this story is problematic. If there were sorne degree of validity to this

story, it would most likely be the case that aIl Muslims would practice sorne form of

FOC, as is the case with male circumcision. In particular, sorne form of the practice would be found in Saudi Arabia, the cradle of Islam; historicaIly, this has not been the

case, nor is FOC practiced there today.

The second story is similar to the story of Hagar and Sarah, however it involves the Prophet and his wives. It is alleged that Muhammad took a wife who was very old

and could not have a child. He decided to take a younger wife, in the hopes that she could

have a child. At the time, Muhammad often had to leave on trade trips. On one such

143 Rispler-Chaim, Islamic Medical Ethics in the 20th Century, 86. 144 Michelle Johnson, "Becoming a Muslim, Becoming a Person: Female 'Circumcision,' Religious Identity, and Personhood in Guinea-Bissau," in Female :Circumcision in Africa: Culture, Controversy, and Change, eds. Bettina Shell-Duncan and Ylva Hemlund, (Boulder: Lynne Rienner Publishers, 2000), 221. 145 Barbara Stowasser, qtd. in Kassamali, "When Modemity Confronts Traditional Practices: Female Genital Cutting in Northeast Africa," 45 and Gruenbaum, The Female Circumcision Controversy, 43.

62 occasion, the older wife, in a fit of jealousy, pierced the earlobes of the younger wife.

This was customary for slaves at the time and the first wife hoped this would make the

second wife less appealing to Muhammad. However, Muhammad received a message

from God, saying that he should not be angry, but rather should encourage all women to

do the same.

On a second occasion, Muhammad again left the two women alone when he

departed on a trip. This time, the first wife cut off the clitoris of the second wife; when

Muhammad returned, the second wife refused to lie with him as she was in pain.

Muhammad again received a message from God, this time saying that with the clitoris

removed, the second wife was even more "beautiful and pure.,,146 In light of this, all

women should be circumcised. This story, like the previous one, is more of a folk tale than anything else. However, in regions where literacy rates are low and many do not

know the actual contents of the Qur' an or all the exact tenets of their religion, tradition,

custom and folk tales serve to fill the gaps and can eventually become authoritative. 147

AH these different elements form the basis for why Muslims in Africa practice

FGC. However, the official stance taken by most clerics and scholars of Islam is that this practice is not, and never was, part of Islam. Although upheld by the Grand Mufti of

Egypt, Shayhk Muhammad Sayyid Tantawi in 1994, this position is not as firm as many

would like. 148 Throughout history, there have been instances when the practice was

upheld as a Muslim requirement, or at the very least a practice that was considered sunna.

In 1950, an important Islamic scholar, Fadilat Allam Bey Nassar, issued afatwa declaring

146 Johnson, "Becoming a Muslim, Becoming a Person: Female 'Circumcision,' Religious Identity, and Personhood in Guinea-Bissau," 221. 147 James and Robertson, Genital Cutting and Transnational Sisterhood, 27. 148 Kassamali, "When Modemity Confronts Traditional Practices: Female Genital Cutting in Northeast Africa," 43.

63 "(f)emale circumcision is an Islamic practice mentioned in the tradition of the Prophet,

and sanctioned by Imams and Jurists, in spite of differences on whether it is a duty or a sunna [tradition]. We support the practice as sunna and sanction it in view ofits effect on

attenuating the sexual desire in women and directing to the desirable moderation.,,149 In

1985, another mufti issues a fatwa claiming that FGC to be part of Islam; of the many reasons cite d, Rispler-Chaim draws attention to the anti-Iesbian stance. The mufti

claimed that FGC prevents the "physical pleasure which one woman can draw from

another, 'something which is common in countries where no female circurncision takes place. ",ISO Most recently, Sheikh Gad al-Haqq, the rector of Al-Azhar University in

Egypt, issued afatwa stating "female circurncision is a part ofthe legal body ofIslam and

is a laudable practice that does honor to the women."lSI Furthermore, al-Haqq stressed that FGC is "even more necessary today because the temptations before girls are many, 1 especially in Egypt's state of overpopulation." 52 This statement carried much weight, as

it originated from the highest authority at the most respected university in the Muslim world. Issued in response to the position adopted by the Egyptian government against

FGC based on the 1994 fatwa by Tantawi, this statement caused, and continues to cause, problems for eradication efforts among Egyptian Muslims. Given this examination of

FGC and Islam, it is evident that the practice, while perhaps not a Muslim practice, does

carry religious significance for many. As such, appealing only to the "official" position of the ulema might not be enough to eradicate a popular religious tradition.

149 Qtd. in Boyle, Female Genital Cutting, 32-3. th 150 Vardit Rispler-Chaim, "Islamic Medical Ethics in the 20 Century" Journal of Medical Ethics 15, no.4 (1989), 206. Taking this idea one step further, this "anonymous mufti" believed that "lesbian relationships result from a lack of female circumcision and consequently he accuses governments that prohibit female circumcision of encouraging lesbianism" (206). 151 Kassamali, "When Modemity Confronts Traditional Practices: Female Genital Cutting in Northeast Africa," 43. th 152 Rispler-Chaim, "Islamic Medical Ethics in the 20 Century," 206.

64 This overview clearly situates FGC in the context of Egyptian and Sudanese

Islam .. l will now turn to the crux of the proj ect: demonstrating how the Islamic principles discussed in connection with organ transplantation can be used to argue against FGC.

Rather than demonstrating how FGC is incompatible with Western notions of sexuality, human rights and "appropriate" medical actions, it will be illustrated that FGC is irreconcilable with Islamic princip les of morality and ethics.

65 Chapter 3: Arguing Against Female Genital Cutting- A Case from Within Islam

"The believers, in their love and sympathy for one another, are like one body; when one part of it is affected with pain the whole body endures it and responds accor dmgy.· 1 ,,1

The prevalence of FGC in certain parts of the world and the dire consequences it has for the millions of women and girls who are affected by it demands attention.

However, the type of attention it has received from the international community thus far has proven somewhat ineffective in many communities. While human rights activity and feminist intervention have brought an end to the practice in sorne areas, there are still millions who suffer because ofFGC. Interventions and arguments must be developed that take into serious consideration the worldview and values of the societies that continue to practice sorne form of genital cutting.2 In light of the above discussion of Islamic bioethics and the specific position on organ transplantation, 1 will develop such an argument for communities where Islam is the dominant reason for FGC. By considering both the motivation and justification behind FGC, the end result of the practice and the many health consequences, the ideas discussed in connection with organ transplantation will be used to illustrate how Islam cannot be said to support any form of genital cutting.3

1 Hadith found in Nazeem M. 1. Goolam, "Human Organ Transplantation- Multicultural Ethical Perspectives," Medicine and Law 21 (2002): 548. 2 Among other scholars who assert this, Kassamli summarizes the point well: "this has been the recurrent plea from African women to Western agencies: do not dictate to us, but help us eradicate this practice in a manner that is effective in Africa" (Noor J. Kassamali, "When Modernity Confronts Traditional Practices: Female Genital Cutting in Northeast Africa," in Women in Muslim Societies: Diversity Within Unity, eds. Herbert L. Bodman and Nayereh Tohidi, (Boulder: Lynne Rienner Publishers, 1998),50). Attempting to impose foreign notions ofuniversal human rights, rights of the child, or gender equality is often met with great resistance,. It is therefore imperative to develop strategies that reflect the values understood and lived by women in Egypt and Sudan. 3 It could be argued that this approach be taken from the opposite direction: using the reasons for FGC to discuss organ transplantation. However, the position adopted by this paper, to be illustrated in the following chapter, that organ transplantation be used to argue against FGC is a more firmly grounded in Islam. The majority of Muslims, clerics, scholars and lay people alike, accept organ transplantation as a

66 This argument will follow the same organization as the section on organ transplantation, while linking each of the three themes in organ transplantation to the general principles of

Islamic bioethics.

Medicalization of a TraditionallReligious Practice

In both the African nations where it is widely practiced and those non-African

countries that are currently being affected by it, there has been a noticeable trend towards medicalizing FGC. Medicalization as a sociological concept was first discussed in the early 1950s. However, it was not until the 1970s and 1980s that it became a central aspect of the sociological study of medicine and health care. Peter Conrad, one of the most notable theorists on this matter, contributed to the discourse on medicalization, which he characterized as "defining a problem in medical terms, using medical language to describe the problern, adopting a rnedical framework to understand a problern, or using rnedical intervention to 'treat' it.,,4 Whereas Irving Zola originally attributed rnuch agency and responsibility for this process to the rnedical institution itself,5 Conrad points out that in sorne cases, the rnedical institution is not responsible for the rnedicalization of a particular condition. Rather, those who suffer or are afflicted with a particular condition

seek its rnedicalization.

viable and even required medical procedure. The same cannot be said ofFGC, as it is practiced by a small minority of Muslims in a geographically confined area. 4Peter Conrad, "Medicalization and Social Control," Annual Review of Sociology 18 (1992): 211. 5Irving Kenneth Zola, Socio-medica1 Inquires: Recollections. Reflections, and Reconsiderations, (Philadelphia: Temple University Press, 1983).

67 Conrad asserts that "medicalization occurs when a medical frame or definition has been applied to understand or manage a problem.,,6 This understanding allows any problem defined and discussed using medical language and rubric to fall under the heading of medicalization.7 Medicalization, therefore, aptly illustrates that "what gets defined as a disease ... is an aspect ofwider social expectations about what is appropriate

social behavior."s

Medicalization can thus be seen as a double-edged sword. On the one hand, it reinforces social norms and values, acting as another powerful institution of social control. Medicalization serves to downplay the underlying social factors that might be contributing to the condition in question, as it removes the issue from its social context.9

On the other hand, medicalization does allow those who are suffering to receive treatment and support. JO Treatment, support services, funding, research- aIl become available when

something is placed withinldefined by medicine. Citing J. Comwell, Conrad daims that different groups are more willing to accept or seek the label of medicalization for this reason. 11 Mark Nichter further states that this self-initiated medicalization might be undertaken without the support of the medical community, and might even occur

6 Conrad, "Medicalization and Social Control," 211. 7 Conrad, "Medicalization and Social Control," 211. 8 Kevin White, An Introduction to the Sociology of Health and Illness, (London: SAGE Publications Ltd., 2002): 41. 9 Peter Conrad and Valerie Leiter, Health and Health Care as Social Problems, eds (Lanham, MD; Oxford: Rowman & Littlefield, 2003),189. The medicalization ofa1coholism in the West is one pertinent example; although it is recognized as a disease, the social factors, such as poverty, that increase the risk of alcoholism are often minimized. In the African context, understanding the spread of HIV/ AIDS solely as a health issue ignores the various socio-economic factors that underlie the current pandemic. Prolonged absenteeism, one of the by-products of a migrant work force, contributes to extra-marital sexual relations, increasing the number of men and women at risk of contracting the disease. This has just as much to do with the socio-economic reality of southem Africa as with the disease itself. \0 White, An Introduction to the Sociology of Health and Illness, 50. 11 Conrad, "Medicalization and Social Control," 212.

68 "contrary to the opinion of doctors.,,12 It is this latter form of medicalization that is now taking place in parts of Egypt and Sudan.

FGC is recognized by sorne who practice it and many who study it as a dangerous traditional practice that has irnrnediate and long-term consequences on the health and well-being of women and girls, particularly the more extreme forms when it is performed in a septic environrnent. While health care workers in many of the countries where it occurs have long recognized this, it is only recently that this knowledge is spreading to lay people as weIl. However, it is also recognized as a deep-rooted practice in both of these countries, one that is very much embedded in the cornrnunities that continue to practice it today. It is therefore crucial that an argument against the continuation of the practice recognize the importance and significance of the practice, while simultaneously highlighting the limiting effects it has on women.

Since FGC first carne to the attention to the Western world, the numerous health consequences have been emphasized and discussed. Be it an article by an anthropologist, a feminist scholar, a medical professional or the UN, the health consequences are listed.

This list is consistent across this vast array of literature and has been one of the key elements in mobilization efforts towards eradication. 13 However, this list has also motivated a move towards medicalization in many communities.

12 Mark Nichter, "The Mission within the Madness: Self-Initiated Medicalization as Expression of Agency," Pragmatic Women and Body Politics, eds. Margaret Lock and Patricia A. Kaufert (Cambridge: Cambridlfe UP, 1998),327. 3 However, in an article published in 1999, Carla Obermeyer made the highly controversial point that these mobilization efforts cannot be supported by the few, methodologically tlawed studies that have attempted to ascertain the actual occurrence of the many health effects (Carla Obermeyer, "Female Genital Surgeries: the Known, the Unknown, and the Unknowable," Medical Anthropology Quarterly 13 (1999)). She reviewed the vast literature on FGC in order to ascertain whether the claims being made about the harmfulness ofFGC were adequately supported by the literature. Studies or surveys werè evaluated using what Shweder referred to as "standard epidemiological quality control criteria for evaluating evidence" (Richard A. Shweder, Why Do Men Barbecue? Recipes for Cultural Psychology, (Cambridge: Harvard UP,

69 In areas of Egypt and the Sudan that continue to practice infibulation, this medicalization has often moved FGC towards the lesser forms, with the ultimate goal of eliminating the practice altogether. FGC has often been brought into the medical realm, first by governments and health organizations and then by the women who undergo the practice themselves. The former type of governmental activity is similar to harm reduction strategies employed in many Westem nations for behaviors such as smoking and injection drug use. 14 By bringing FGC into the realm of medicine and primary health

2003), 173. Reasons for exclusion included: "(1) sampling and/or methods were not described. (2) the sample was too small to make inferences (3) the study reported on a single case without information about the population from which it came," among others. Using this criteria, Obermeyer was left with only 8 studies that met these standards. (See Obermeryer 1999,92 and n.24). Rather than confmning this, Obermeyer instead found that ''the ill-health and death that these practices are thought to cause are difficult to reconcile with the reality oftheir persistence in so many societies, and raises the question of a possible discrepancy between our 'knowledge' oftheir harmful effects and the behavior of the millions ofwomen and their families" (Obermeyer, "Female Genital Surgeries: the Known, the Unknown, and the Unknowable," 91). Obermeyer concluded that "the widely publicized medical complications of African genital operations are the exception, not the rule; that female genital alterations are not incompatible with sexual enjoyment; and that the claim that untold numbers of girls and women have been killed as a result of this 'traditional practice' is not well supported by the evidence" (Shweder, Why Do Men Barbecue? Recipes for Cultural Psychology, 173). Four years later, Gerry Mackie published a response to Obermeyer's original article (Gerry Mackie, "Female Genital Cutting: A Harmless Practice?" Medical Anthropology Ouarterly 17, no. 2 (2003): 139-140). Mackie methodically scrutinized Obermeyer' s article, highlighting many aspects that were problematic. Mackie came to the very pointed conclusion that ''the international consensus and mobilization to which the article objects is based primarily on something like the understanding that FGC is an irreversible limitation of a human capacity ... [and] that by appropriate standards of evaluation, FGC entails nontrivial complications" (my emphasis, Mackie, "Female Genital Cutting: A Harmless Practice?" 154). While Obermeyer highlights several key issues surrounding the dangers ofattacking and condemning a practice that is at odds with our own worldview, Mackie's conclusion is compelling nonetheless. Even if one were to accept Obermeyer's claim that estimates of health effects are exaggerated as a means of inciting eradication efforts, the fact of the matter remains that most girls and women do suffer as a consequence ofFGC, particularly those who undergo infibulation. 14Shell-Duncan discusses the concept ofharm reduction in the realm of public health as a paradigm "that seeks to minimize the health hazards arising from a variety ofbehaviors by encouraging safer alternatives, including, but not limited to, abstinence" ("The Medicalization of Female 'Circumcision': Harm Reduction or Promotion of a Dangerous Practice?" Social Science and Medicine 52 (2001): 1014). The ultimate goal ofsuch schemes is ''to reduce the health consequences ofvarious behaviors for both the individual and the community in which they live by offering a pragmatic and culturally acceptable set of alternatives (Marlatt 1996, cited in Shell-Duncan 1014). Bringing FGC under the auspices of medicine aims to do exactly that: reduce the health consequences while ultimately aiming to abolish the practice altogether. Kassamali also points to the potential benefit of a harm reduction strategy, based on medicalizing FGC (51). Referring to lesser forms of genital cutting, such as pricking or nicking the clitoris, as an "interim strategy," Kassamali maintains that these actions would be a transitional phase.

70 care, many of the consequences of aIl forms of the practice can be significantly minimized. Medicalization as harm reduction is often understood as a step towards eradication, one that takes into account the extreme difficulty of moving from extraordinarily high rates of practice to total eradication. Not wanting to give up the practice itself but aware of the risks associated with septic conditions and the benefits of anesthesia and antibiotics, women are initiating a medicalization of FGC by frequenting clinics, midwives and even hospitals to have some form of FGC performed on their daughters.

Nonetheless, the United Nations and World Health Organization vehemently oppose such action. The UN and the WHO strongly condemn any type of pro gram that places FGC in the medical sphere. It is assumed that such action would appear to condone the practice and might actually lead to its spread and perpetuation, rather than its elimination. While there is a great degree of validity in this argument, the unfortunate reality of the CUITent situation is that of the 2 million girls who are subjected to FGC, countless women and girls live with and die from the consequences of the practice each year. Total and immediate eradication has been accomplished in very few communities, despite over 20 years of intervention in some places. Furthermore, as the case of Egypt and Sudan has demonstrated, some areas are actually experiencing an overall increase.

Given that in an increasing number of women, poor health is associated with FGC, eradication efforts must work with this understanding; in the long term, medicalization

Since it is widely acknowledged that FGC, even with a worldwide ban, will not disappear immediately, steps such as this will reduce the harm done, without moving away from the practice completely. This movement towards less severe forms ofFGC is aIready present in Sudan (Noor J. Kassamali, "When Modemity Confronts Traditional Practices: Female Genital Cutting in Northeast Africa," 51).

71 might be the best way towards completely eliminating FGC in the future, while protecting the greatest number of girls from "unnecessary" harm in the present day.

It is of particular importance that more and more women are recognizing or are being made conscious of the fact that FGC carries these health risks. In sorne communities where FGC is universally practiced, many of the health consequences of

FGC were believed to be a normal part of womanhood. In others, only the more extreme, and as such less common effects, were understood to be deviant. However, knowledge of the health risks is gradually becoming more widespread; the following argument, which to sorne extent medicalizes FGC, is particularly pertinent at this time. By appealing to an understanding of the health risks associated with FGC and the ethical framework of

Islam, it is hoped that this thesis will provide another argument in favor of eradication.

God's Unity, Notions of Community and Public Interest

The connection between the Islamic conception of God's unit y and sovereignty on the one hand, and the emphasis on brotherhood and community solidarity on the other was alluded to briefly above. These will be further elaborated now, as one part of the argument against FGC. In addition, the use of public interest, maslaha, will be considered in the context of community.

The unity and sovereignty of God is to be reflected in the actions of the Muslim community. Muslims are encouraged to carry out just actions that will lead to a strong community. The imperative to do good and forbid evil extends equally to men and

72 women, an inclusion that is based in the Qur'an. 1S Furthermore, taking Islam to be a religion of social justice, one that seeks as much as possible to move away from the jarring social divisions that result from socio-economic differences, it becomes clear that any action that perpetuates disharmony in the community is at odds with the ideas of unity and justice. When one considers the consequences of FGC, it becomes plainly obvious that anything but unity results from this practice.

The known psychological consequences of FGC are perhaps the best illustration of disharmony and lack of unity that can result from FGC. On a private basis, the marital relationship can be the source of much anxiety and stress for women; as stated earlier, penetration often requires repeated attempts that can be quite painful and psychologically straining for both the man and the woman. The marital relationship, understood as the basis of a strong Muslim society, is then not built on a solid foundation. The family unit is not a cohesive unit, but rather can be characterized as one of anxious interaction.

Building a strong social unit on such a foundation is extremely difficult.

Furthermore, the physiological effects can also lead to disharmony, in this case on a more macro level. Infertility, most common among infibulated women,16 can have devastating consequences for women when they are valued primarily for their procreative abilities. In many cases, perhaps even in most cases, this can lead to divorce. While divorce does not carry the same negative connotations it does in sorne other traditions, for example Christianity, and it is recognized as necessary in sorne cases to prevent extra marital affairs, women still suffer greatly in the event of a divorce. In communities that value them as mothers and wives, divorced women are left with little means of social and

15 Qur'an 9:71. 16 Nour placed infertility rates as high as 25-30% for infibulated women. Nawal Nour, "FGC: Clinical and Cultural Guidelines," Obstetrics and Gynecology Survey 59, no.4 (2004): 275.

73 financial survival. This stands in stark contrast to the reforms introduced by the Qur'an to improve the status of women, orphans and other disadvantaged groups discussed in

Chapter 1.

Despite the emphasis on community that might appear to value the absence of promiscuity above individual female health, the fact that FGC is so widespread means that many women are not fully functional, productive members of their society, hence reducing the benefit these women can bring to the community. Even if "benefit" is defined as the ability to bear and raise male children to be socially, politically and financially productive members of society, this ability can be significantly hampered by aIl forms ofFGC. Damage to surrounding organs can lead to infertility, fistulae formation can lead to social ostracism, maternaI AIDS can be transmitted vertically to the child, and obstructed labor can lead to maternaI and infant mortality. Women are then rendered unable to contribute to society in the ways permitted and upheld for them. 17 When women are valued as mothers, those who are "unable to conceive are often considered deviant", as "childbearing and motherhood are the primary functions afforded to women in these patriarchal cultures.,,18 In her study of procreation in Islam, focusing on Egypt,

Hania M. Sholkamy quotes a 37 year old mother of 9 on how important childbearing is and the lengths women go to in order to have children: "many a time women have almost lost their lives, lost their minds, even almost lost their religion just to see the fingernail of

17 Consideration ofthis point from a different perspective presents an interesting challenge to the position 1 put forward above. The only legitimate means ofhaving children is within the confines of marriage. In parts of Egypt and Sudan, marriage is contingent upon a proper circumcision; this makes it difficult to separate childbearing and FGC. However, highlighting the negative aspects ofthis association is but one of several arguments against FGC. When taken together with the other points elaborated on, it becomes evident how the health consequences ofFGC on childbirth far outweigh the necessity ofFGC for marriage. 18 Kassamali, "When Modemity Confronts Traditional Practices: Female Genital Cutting in Northeast Africa," 55.

74 a child.,,19 Given the priority of childbearing, practices and problems that impede this should be eliminated; FGC is one such practice.

It is at this point that one can consider the legal notion of public interest. Although applied historically to legal matters, the general principle behind this judicial theory can contribute to the debate on FGC. If the purpose of Shari'a20 is taken to be the benefit and welfare of the community, and law is of paramount importance in Islam, concern for public interest should be the motivation behind all actions, legally mandated or not. This idea of acting beneficently is found throughout the Qur'an; many of the passages have been mentioned in previous chapters. The pillar of zakat was introduced in Chapter 1 as a concrete example of how this concern for others is found at the very core of Islam; actions undertaken should therefore be done with beneficent motivations. While this might appear straightforward, the case of FGC is highly problematic.

From a medical perspective, there is no physiological reason for any form of

FGC; in fact, all medical indications demonstrate why the practice should be ended.

However, the social repercussions of not undergoing FGC can be disastrous for the individual woman. Scholars often emphasize this aspect of FGC; the intention behind

FGC is never to cause bodily harm or invite a host of medical complications over the life course. Melissa Parker articulates this well throughout her brief work on FGC in Sudan, summarized in this reflection on a conversation with a woman in the village where she conducted her research:

19 Hania M. Sholkamy, "Procreation in Islam: a reading from Egypt of People and Texts," Conceiving Persons: Ethnographies of Procreation, Fertilitv and Growth eds. Peter Loizos and Patrick Heady (London: Athlone Press, 1999), 141. 20 While Shari'a is often translated simply as 'law', it should be understood as a more encompassing term. Literally translated as "the path or the road leading to the water," Shari'a provides guidance for the realization of the Divine Will (Rahman, Islam, 101).

75 While she did not deny the pain or any of the problems which are frequently associated with circumcision, there was no question of it being anything other than kwaiys (good), tahir (pure), nazif (clean) and smooth (na'im). And l felt humbled. My questions were so useless, so utterly irrelevant to that which was seen as being important. Of course women do not circumcise their daughters to create problems for them later on. They do so to protect them. An uncircumcised girl is unmarriageable and would bring undying shame to her and her family. People would calI her kaaba (bad), waskham (dirty) and nigsa (unclean). Her life would be intolerable, as she would be taunted by friends and relatives wherever she went. 21

While it is evident that malicious motivations are rarely at the heart of FGC, causing physical harm does little to contribute to harmonious social relations. 22 A practice that limits the abilities of half the community cannot be reconciled with the greater Islamic orientation towards social justice and community concem, nor can it be said to mirror the unit y of GOd?3

Dignity of the Body and the Doctrine ofNecessity

As discussed above, the human body commands the utmost respect in Islam.

Understood to be the pinnacle of God's creative work in this finite world, the human body should be preserved and protected throughout the life cycle. This obligation is further enhanced by the eschatological belief in bodily resurrection. Based on the

21 Melissa Parker, "Rethinking Female Circumcision." Africa 65, noA (1995): 510. 22 Parker presents a compelling explanation for why FGC occurs, revealing its community importance. It should be remember that while there are serious social repercussions of not undergoing FGC, both health consequences and social consequences can occur when FGC is performed. Social consequences include infertility and divorce, as outlined above. Taken together, the social and health consequences of FGC outweigh the social consequences discussed by Parker. It is essential, however, to remain aware of the ideas put forward by Parker when constructing a position or program against FGC. 23 In this context, it is interesting to explore the role men play in perpetuating FGC. Men must play a role in ending FGC if this goal is to be accomplished. This will be achieved through socializing men to accept women as wives who have not undergone FGC. This would eliminate the social necessity of performing FGC, allowing the health consequences to be seriously contemplated.

76 following two Qur'anic verses dealing with the Day of Judgment (Q41-39-40, 49-50), it has been argued that the body should always remain who le, regardless of the reason given to justify its violation. Unlike Christianity, where the body and soul are dichotomized, particularly in the afterlife, Islam envisions the world beyond earthly existence as experienced both spiritually and physically.24 The body must therefore be whole, able to experience the pleasures ofParadise to the fullest.2s

This argument against FGC is further advanced by Goolam's discussion of the trust relationship between God and human beings. The Islamic belief that the body is held in Divine Trust, amanah, illustrates the hierarchical nature of God's relationship with human beings. God, as the owner of the trust, dictates how the trust should be used; human beings, as trustees, "must act in accordance with the wishes of the Owner of the

Trust.,,26 Keeping with the eschatological orientation of Islam, it is understood that this trust will be returned to God at the time of Judgment. Altering the status or composition of the trust without the express wishes of the owner of this trust would violate this agreement. This represents one of the stronger arguments against organ transplantation, one that is overcome by appealing to the doctrine of necessity. As stated earlier, the dignity of the human body can be justifiably violated in the event of extreme necessity or to bring about certain benefit to another person. However, neither ofthese reasons can be applied to FGC. Unlike organ transplant, FGC does not prevent the imminent death of the individual undergoing the procedure, considered the extreme need when violating a

rd 24 John Esposito, Islam: The Straight Path. 3 Ed. (Oxford: Oxford UP, 1998),30. 25 This belief is cited by sorne who find comea transplantation particularly difficult as it removes one of the senses from the believer. Interestingly, this view on the wholeness of the body would seem to make male circumcision problematic, yet this type of discussion was not found in the literature. 26 Nazeem M. 1. Goolam, "Human Organ Transplantation- Multicultural Ethical Perspectives." Medicine and Law 21, no. 3 (2001): 548.

77 corpse, nor does anyone benefit from the removed tissue. Therefore, the trust relationship and its implication for human actions on the body can be utilized to construct a position against FOC.

At this juncture, it is necessary to revisit notions of sexuality that are commonly used to justify FOC in Islam. The need to control sexuality can be seen as essential to the proper and smooth functioning of society.27 Furthermore, as discussed above, sexuality in

Islam, particularly women's sexuality, is conceived of as an active, sometimes uncontrollable force. Several social mechanisms are put in place to help control and direct this force in an appropriate manner, and are often justified as contributing to the overall strength of the community. By controlling sexuality, men and women will be better able to engage in just conduct, following the way of Ood by commanding right and forbidding wrong. Limiting women's access to public space, or the manner in which they access and participate in public activity, and mode st dress are two other examples of how sexuality is regulated in both Sudan and Egypt, to different degrees. However, this raises the question of how far a society should go to control sexuality. Is sexuality or, more specifically, the female sexual urge so strong that it necessitates such an extreme intervention like FOC?

Oiven that this conception of sexuality is one held by Muslims in various parts of the world, while FOC only occurs in sorne places, the answer to this question appears to be no. Different forms of veiling and varying amounts of seclusion are practiced under

27 As alluded to previously, good sexual relations are viewed positively in Islam; both partners should derive pleasure from intercourse. Furthermore, Islam recognizes women as sexual beings, allowing them to initiate sexual relations with their husbands (Qur'an 4: 1). The Sunna upholds this view, describing a situation where Muhammad granted a divorce to woman because ofher husband's sexual impotency (Fazlur Rahman, Health and Medicine in the Islamic Tradition, (New York: Crossroad Publishing, 1989), 121).

78 the assumption that they will limit, or perhaps more accurately eliminate, immorality from society. While both of these practices have garnered much resistance and criticism from within these countries and from Western activists and scholars, they are both considerably less invasive than any form of FGC. Interestingly, Kassamli points to a study conducted in Sierra Leone of women who were sexually active prior to their circumcision. Unable to achieve the same amount of sexual pleasure after FGC, many of these women sought other sexual partners; in this case, FGC led to increased promiscuity.28

If sexuality can be controlled through other means, FGC does not constitute a necessity the way organ transplantation does. By contrast, many transplant surgeries are the final treatment option, or oftentimes the only one, and without them, life would be lost. Sexuality will not go unregulated in the absence of FGC.29 Moreover, the completion of FGC is not a matter of physical life or death as is a transplant operation.

While there is often a risk that the potential recipient will die should a suitable donor not be found or that complications can place the live donor at risk for morbidity or mortality, death will not result from foregoing FGC.

Based on medical evidence, FGC presents what is arguably the opposite situation.

The number of severe side effects that are common and the very fact that death is always a potential outcome show that FGC presents Muslims with a situation where the principle of necessity actually dictates that this practice be stopped. This is particularly true in the

28 Kassamali "When Modemity Confronts Traditional Practices: Female Genital Cutting in Northeast Africa," 46. 29 While 1 do not personally advocate either of the practices discussed (purdah and extreme modest dress), particularly when they are imposed on women, they do not infringe on a woman's physical health the way FGC does. However, prolonged seclusion and extreme veiling can have mental health consequences for women.

79 case of infibulation, where sorne type of complication almost always occurs. However, even the less severe forms of FGC can, and do, lead to death, especially when performed by unskilled midwives without anesthesia.

FinaIly, removal of healthy organs for transplant purposes is also justified since the organ is used in a beneficial way to maintain life in another person. The body is not altered from its original state for aesthetic or social reasons, but rather for purposes of maintaining human life. Tattooing and piercing are prohibited as they modify creation from its original, God-given form to one that conforms to or suits human needs and desires "better." These actions, therefore, attempt to perfect what is already understood to be the pinnacle of creation, the epitome of God's creative abilities. Consequently, these actions defy the supremacy of God, allowing human beings a role in creation; essentiaIly, this can be se en as "playing God." This is completely unacceptable in Islam. FGC presents a similar case: any amount of cutting alters the female genitalia from its original form and this alteration is done according to human standards that, as described above, vary greatly from region to region. This variation, in the type of cutting, in the age when it is performed, in the variety of meanings and justifications given, even among Muslims, supports the idea that this practice is more cuiturally defined than religiously required.

Furthermore, the very fact that a part of the human body in good working order is discarded like trash is the most problematic aspect of FGC from the perspective presented here, as it clearly devalues the integrity and wholeness of the human body. Regardless of how little or how much is removed from the girl, aIl the "excess" flesh is discarded. No benefit is gleaned from the tissue and the child suffers considerably. It is also interesting, and even more troubling, that the clitoris and surrounding tissues are often acknowledged

80 as essential parts of the female sexual system, if not the essential element; often, it is for this very reason that this area of the body is eut. Removing a fully functioning part that is known and understood to contribute/control the female sexual response cannot possibly be in accordance with Islam. In the case of organ transplantation, the organ or tissue that is discarded is damaged beyond repair or completely non-functional, contributing to overall poor health. Although this itself is difficult from an Islamic perspective, it is justified as necessary to preserve human life.

Perhaps one of the most important aspects of a discussion about FGC is the questions the practice raises about God's role in the creation ofhuman beings, especially women. Why would God require functional aspects of a woman's body removed? If this was in fact the case, why is this not specifically outlined in the Qur'an? The Qur'an is understood to be the most perfect revelation, one that contains everything necessary for the formation of a proper and just society. Not only does it pre scribe broad social policies and expectations, such as a prohibition on usury, but it also describes conventions surrounding such personal matters as proper intercourse, menstruation and breastfeeding.3o Given the spectrum of issues addressed in the Qur' an, its preeminence in

Islam, and the nature of FGC, it is not unreasonable to expect sorne mention of it in the

Qur' an. Since this is not the case, it appears that humans have taken the design and formation of the body into their own hands, something that stands in stark contrast to

Islam.

This leads to a further question: is FGC correcting an error on the human body?

This question is especially pertinent in areas where infibulation is practiced, given how

30 Kassamali "When Modemity Confronts Traditional Practices: Female Genital Cutting in Northeast Africa," 44. Qur'anic verses on intercourse 2:187, 23:10, on menstruation 2:228,65:4, on breastfeeding 2:233, 31: 14.

81 significant the body modification can be; the area is so drastically altered that it in no way resembles the vulva before the operation. Would the female body not have been made this way had this been the form God wanted it to take? Would so much outside intervention be required in what are otherwise considered natural events, such as intercourse and childbirth? None of these questions can be definitely answered as they pertain to God's divine will and plan. However, given that tattooing and other permanent body modifications are prohibited in Islam and the dignity of the human body is to be respected, FGC represents an illogical deviation from otherwise universally held Islamic beliefs.

Maintenance of Human Life and the Imperative to Seek Remedies

The value of human life is understood in radically different terms than those articulated in much of Western thought. The individualistic orientation present in the

West tends to value human life in and of itself. In Islam, human life is valued as the epitome of God's creative abilities, as evidence of God's supremacy, and should be maintained and preserved because it belongs ultimately to this higher being. Muslims are obliged to seek remedies for the conditions that affect them. This imperative can be seen as perhaps stronger than the Western orientation towards "heroic measures" in health care, as Muslims are thus required to maintain human life. In addition, they may only interfere with God's creation, the human body, under certain, specifie conditions. Taken together, maintaining human life and seeking remedies are two of the strongest reasons used to justify organ transplantation. FGC, on the other hand, exposes women to

82 numerous health risks, increasing the need for medical attention, making these two reasons two of strongest in favor of eradicating FGC. MaternaI mortality, commonly associated with FGC in many parts of the developing world, will be considered and compared with the Islamic view of suicide in this section as a me ans of further illustrating this point.

In the Tenth Revision of the International Classification of Diseases (ICD-lO), the

W orld Health Organization defines maternaI mortality as

the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidentaI or incidental causes?1

MaternaI deaths are further divided into two categories: direct obstetric deaths and indirect obstetric deaths. The most common direct causes are hemorrhage, sep sis and unsafe abortion, while indirect causes are most often pre-existing conditions, such as anemia or heart disease, that are aggravated by the pregnancy.32 FGC contributes to maternaI mortality as it complicates the birthing process;33 in particular, the scar tissue that forms over or near the vaginal opening can lead to hemorrhage, which itself is the leading cause of maternaI death.34

MaternaI mortality is one of the leading causes of women's deaths in the developing world, Sudan and Egypt included. Statistics paint this picture in concrete, black and white terms. The WHO classifies life time risk as high when it is 1 in 100 or

Iess, while higher than 1 in 3000 is c1assified as low risk. Life time risk of maternaI death

31 World Health Organization, Reduction ofMatemal Mortality (Geneva: World Health Organization,1999),40. 32 Ibid., 13. 33 Ibid., 28. 34 Ibid., Il.

83 in Egypt is 1 in 130 and in the Sudan it is a shocking 1 in 12. Canada, on the other hand, has a maternaI mortality risk of 1 in 8700, while the United States and the United

Kingdom have a 1 in 3500 and 1 in 4500 respectively. A practice such as FGC that is known to put women at risk of death cannot be seen as something supported by Islam, given the priority ofhuman life and the prohibition on suicide.

The female body, designed by God to allow for intercourse and birth, is significantly weakened through FGC as the result of human intervention. The vaginal opening is obstructed in the case of infibulation, while the scar tissue that forms in the lesser two types can, and often does, decrease the elasticity of the vaginal area. Both of these outcomes contribute to difficulty during intercourse and complications during pregnancy and childbirth. The primary concern for women who have undergone one of the reduction operations is the amount of scar tissue that has formed; in cases where cutting is minimal, while the body has indeed been violated, scar tissue is less of a problem. Nevertheless, these forms of FGC do contribute to obstructed labor, one of the leading causes of maternaI death in the developing world/5 as they can lead to possible hemorrhage during delivery from the lack of elasticity. Furthermore, obstructed labor can cause stress to the infant, leading to infant mortality as weIl.

Similarly, infibulation further exaggerates the above problems. The scar tissue surrounding the vaginal opening can prolong the second stage of labor as it can inhibit fetal descent. Furthermore, infibulated women "are at increased risk of complications during vaginal deliveries .. .increased incidence of perineal tears, wound infections, separation of the episiotomy, postpartum hemorrhage and sepsis.,,36 GeneraIly, however,

35 Ibid., 14. 36 Nour, "Female Genital Cutting: Clinical and Cultural Guidelines," 276.

84 hemorrhage is the major concern for infibulated women during delivery?7 Pre-natal care can also be extremely difficult, if not impossible, given the "covering" nature of infibulation. Pregnancy related problems that could be averted go undetected, increasing the risk associated with each pregnancy.38 Finally, infibulation increases the chances of fetal complications, infant mortality being the most severe.39 It becomes clear from this discussion that all forms of FGC increase a woman' s need for medical intervention by altering aspects of the female form that naturally accommodate the birthing pro cess.

These alterations interfere with the perfect design fashioned by God. It would seem to follow from the overall legalistic orientation of Islam and the requirement to procreate that if these alterations were required, necessary or even of great benefit, they would be clearly articulated in the Qur'an.

"Kill not one another. Lo! Allah is ever Merciful unto you" (Qur'an 4:29) and

"Be not cast by your own hands to ruin; and do good. Lo! Allah loveth the beneficent"

(2:195) are imperatives appealed to in discussions of suicide and euthanasia and can therefore be used to evaluate FGC. Prohibited from causing harm leading to death, FGC cannot be seen as an Islamic practice if it contributes in any way to maternaI mortality.

Although classified as an indirect cause, it is a cause nonetheless.

In light of the prohibition against harm leading to death, FGC can be se en as quite the opposite. While it might serve to elevate the social status of a woman, it contributes to

37 Parker, "Rethinking Female Circumcision," 513. 38 A distinction is drawn between maternaI mortality rate and maternai mortality ratio. The former describes the "risk associated with each pregnancy," and is calculated per year, per 100 000 live births in that same period (WHO, Reduction of Maternai Mortality, 9). The maternai mortality ratio, on the other hand, "measures both the obstetric risk and the frequency with which women are exposed to this risk" and is calculated from the number of maternai deaths in a given period per 100 000 women of reproductive age (WHO 1999, 10). 39 Parker, "Rethinking Female Circumcision," 513. Other fetal complications include brain damage and malformations.

85 poor health and can lead ultimately to an early death, directly contradicting the above two

Qur'anic verses. This is even more problematic in areas or communities that acknowledge and recognize the health risks associated with FGC. Although this knowledge has contributed to the discernable trend towards seeking medical assistance in performing FGC,40 particularly among urban dwellers, the practice itself undermines the

Islamic imperative to seek remedies.

Since there is a risk of death, either from immediate causes or long term complications, FGC cannot be justified in Islam in that it infringes on the sanctity of human life. A tradition that has such a positive view of external medicine cannot be said to also support a practice that inflicts poor health on a believer.

Drawing on the principles of Islamic bioethics, specifically those appealed to in connection to organ transplantation, this chapter has illustrated how aIl forms of FGC are incompatible with Islam. Drawing on the many health consequences associated with the different types of genital cutting and the ethical orientation of Islam illustrated by Islamic bioethics, the different justifications for FGC have been refuted, establishing a firm position against FGC. Although there are problems associated with medicalizing a traditional practice that harms women, this strategy works with the knowledge and worldview that is fairly widespread in Egypt and Sudan. By appealing to basic ethical notions found at the core of Islamic medical ethics, this form of medicalization is sensitive to the teachings and beliefs of Islam. Furthermore, this medicalization fits into

40 Bringing FOC under the auspices of me di cine aims to reduce the health consequences while ultimately aiming to abolish the practice altogether. While this is a positive step, it still contradicts the Sunna of the Prophet.

86 the greater project of eradicating the practice completely, while simultaneously reducing the severity of the health consequences.

87 Conclusion

Female genital cutting is not a practice that can be eradicated worldwide in one generation. As a socio-religious practice firmly embedded in the foundation of the

Egyptian and Sudanese communities that continue to engage in sorne form of FOC, strategies for eradication must be culturally sensitive, responsive to the religious, cultural, political and economic factors that affect the overall way of life found in these communities. Ignoring the meaning FOC carries in Egypt and Sudan and focusing on what it has come to symbolize in the West, namely, the oppression and subordination of women at the hands of a patriarchal system, will lead to an impasse. In order to move past this, a common ground must be found upon which eradication efforts can be built.

From this common ground, the worldview and belief systems that dictate the continuation of FOC must be taken into serious account.

1 have identified health and illness as a possible common ground. This choice is the result of several different factors, all of which have been explored in great depth throughout the above discussion. Most significantly, however, are the many health consequences of the various forms of FOC and the recognition of these consequences by the women who practice genital cutting. Working with these two ideas, the principles of

Islamic bioethics have been explored and examined as a means of creating an argument against FOC that is firmly based in the morality and jurisprudence of Islam. This approach has highlighted how each of the most commonly cited reason in favor of FOC can be refuted or called into question using Islamic bioethics.

88 The first principle considered was the belief in God's supremacy in worldly affairs. As one of the more fundamental beliefs in Islam, it is no surprise that it figures prominently in bioethical discussions. 1 have tied the unity of God to the unity of the community, a connection found in much of the literature on the nature of God in Islam.

This connection was relevant to a discussion of FGC due in large part to the psychological consequences of FGC. A community cannot be unified in the image of

God when anxiety, stress and depression are common among marrie d, circumcized women.

The second princip le, also a fundamental Islamic belief, is the requirement to maintain human life. As the pinnacle of God' s greatness, human life should be protected and preserved. God' s supremacy further dictates that humans should live according to

God's Divine Will, which prevents humans from taking their own lives. Given that the death of both the woman who undergoes FGC and any child she bears can result from

FGC, it appears that human actions are increasing the risk of death, rather than preserving and maintaining life.

Finally, the third general principle presented was the dignity of the human body.

Based on similar reasoning as the above requirement to maintain human life, the human body reflects God's creative superiority and therefore should not be violated unless sorne extraordinary need justifies it. As discussed, while it is possible to argue that the social need dictated by notions of chastity, purity and proper marri age customs justifies FGC, the health consequences were demonstrated to outweigh this need. These three general principles were also used to establish a foundation upon which to consider a particular bioethical issue.

89 l considered the" position in favor of organ transplantation, the more dominant position within Islam because of its direct relevance to FGC. By demonstrating the circumstances under which organ transplantation is necessary, l illustrated how Islam could not possibly support the perpetuation of FGC. l then described and paralleled an additional three themes, encompassing several distinct ideas, with the general principles already outlined. Each of these themes further refuted the idea that Islam supported or condoned FGC.

l first discussed social justice in Islam. As a religion, Islam emphasized not only doing good but forbidding evil as weIl. The legal requirement of zakat and the high regard for sadaqa were presented as two clear examples of this. These actions unify the community, reinforcing the interdependence of aIl the members and highlighting their dependence on God as the ultimate giver. Since organ donation is often understood as

"the gift of life," it fits perfectly into a worldview that supports, encourages and mandates various forms of giving. It permits believers the opportunity to give the ultimate human gift, leading to the preservation of life, thus unifying the community. FGC, on the other hand, was shown to create divisions between men and women, as the result of both the psychological and physical health consequences. As such, FGC does not correspond to one of the first themes used to justify, even require, organ transplantation.

l then explored the theme of necessity and the lesser evil. Organ transplantation can be taken as a necessary action as it allows medical practioners to maintain human life with all the resources available to them. It does not violate any other Islamic principles, save the prohibition on violating the body. This objection is circumvented using the notion of lesser evil; the body is only violated as a means of saving a life. However, in

90 the case of FGC, the body is violated for what can be considered aesthetic reasons, akin to body piercing and tattooing. There is no justifiable need that mandates any form of genital cutting.

Finally, l discussed the Islamic imperative to seek remedies for the afflictions from which human beings suffer was discussed. Organ transplantation is often the only remedy that will cure the illness or condition of a particular patient; as such, it is permissible in Islam. FGC presents the opposite situation. Rather than a remedy, FGC requires medical intervention or care where it would otherwise not be necessary. The many complications, particularly those that are long term and more serious, entail resources and care that might beyond the means of the woman. This places her in a situation where one practice has actually decreased her level of health and well-being, rather than maintained it.

When discussing FGC in the context of Islamic bioethics, which draw heavily from the basic principles of the tradition itself, it becomes c1ear that Islam cannot be said to officially support FGC. Using foundational notions from Islam that form the basis upon which its bioethics is built, l hope to have engaged in a culturally sensitive, religiously informed position against FGC that can be used as part of an eradication campaign. Rather than simply highlighting the numerous health consequences, these health consequences are placed in the context of Islam, bioethics specifically. l hope that such an approach will be met with less resistance from the predominantly Muslim population of Egypt and Sudan, leading to the eventual cessation of all forms of female genital cutting.

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