Female Circumcision Research Paper Example

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Abstract

Female circumcision (otherwise called as female genital mutilation or female genital cutting) refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for nonmedical reasons. More than 125 million girls and women alive today have been cut in the 29 countries in Africa and Middle East where the practice is concentrated. The procedure varies from an insigniﬁcant cut to a major mutilation. However, it has been shown to have no health beneﬁts, can harm girls and women, and therefore raises ethical concerns about the right of the child and dignity of the woman. In its cultural context, ensuring that a daughter undergoes genital cutting as a child or teenager is a parental loving act meant to make certain of her marriageability. This is particularly important in societies where there is little economic viability for women outside marriage.

The health profession faces ethical issues and challenges about medicalization of the procedure, medical alternative rituals, obstetric care for women who have had the procedure, and responding to requests for resuturing after delivery. The elimination of this harmful traditional practice may be promoted less effectively by insensitive enforcement of criminal laws than by the counseling and education of patients and communities.

Introduction

Female circumcision (otherwise known as female genital mutilation (FGM) or female genital cutting (FGC)) refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for nonmedical reasons. The practice is most common in the western, eastern, and northeastern regions of Africa, in some countries in Asia and the Middle East, and among certain immigrant communities in North America and Europe. The World Health Organization estimated that more than 125 million girls and women alive today have been cut in the 29 countries in Africa and Middle East where FGC is concentrated (WHO 2014a). In Africa, more than three million girls have been estimated to be at risk for FGC annually. The percentage of women ages 15–49 who have undergone genital cutting in the countries of northeast Africa (Egypt, Eritrea, Ethiopia, and Sudan) ranges from 80 % to 97 %, while in East Africa (Kenya and Tanzania), it is markedly lower and ranges from 18 % to 32 % (UNICEF 2013). Overall, the chance that a girl will be cut today is lower than it was around three decades ago, but the pace of change is uneven, both within and among countries.

FGC is commonly carried out on young girls sometime between infancy and age 15. The practice is mostly carried out by traditional circumcisers, who often play other central roles in communities such as attending childbirths. However, WHO estimates that more than 18 % of all FGC are being performed by health-care providers, and the trend toward medicalization is increasing (WHO 2014a).

Conceptual Clarification/Definition

The terminology used to describe this practice varies. The term “female circumcision” has been used historically. However, as the harm that such procedures caused to girls and women became increasingly recognized and because this procedure, in whatever form it is practiced, is not at all analogous to male circumcision, the term “female circumcision” gave way to the term “female genital mutilation.” The term “female genital mutilation” (FGM) has been adopted by many women’s health organizations and by intergovernmental organizations, such as the World Health Organization and UNICEF. However, the use of the term female genital mutilation may offend women who have undergone the procedure and do not consider themselves mutilated or their families as mutilators. Consequently, the term “female genital cutting” is used in an attempt to ﬁnd language that is value neutral, but which adequately describes the nature of the procedure.

It is important to note that FGC bears little or no relationship with male circumcision. In male circumcision, the part removed is the prepuce, and this has possible health beneﬁts such as protection against HIV infection and carries little risk of harm (Tobian et al. 2014). The degree of cutting in the female procedure is anatomically much more extensive than male circumcision. The anatomical male equivalent of the female procedure in which all or part of the clitoris is usually removed would be the cutting off of most of the penis. In addition, the procedure carries no health beneﬁt and can be associated with physical and psychological harm. Unlike male circumcision, FGC is neither supported by any religion nor bears any relationship to the geographical distribution of any religion. A religious justiﬁcation has commonly been offered in some Muslim communities, in order to bestow some sort of sanctity on the practice. An authoritative review published by the World Health Organization lends no support to such justiﬁcation (Al-Sabbagh 1996).

History And Background

The origin of the practice of cutting parts of the external genitalia of girls or young women, including the clitoris, is lost in antiquity. The clitoris is, to the outward appearance, a tiny organ which even the woman to whom it belongs may ﬁnd difﬁculty in seeing. When erotically stimulated, the clitoris becomes engorged and erectile. Perceptions of, and attitudes toward, the clitoris reﬂect wider societal attitudes to female sexuality. The clitoris has been a “victim” of assault in African and non-African societies. It was the subject of assault in Western countries in the past (Fathalla 2000). Excision of the clitoris was performed by Western gynecological surgeons in the second half of the nineteenth century and the early twentieth century on allegedly medical grounds. It was considered necessary not only to cure such sexual deviations as nymphomania but also to prevent masturbation and to cure a number of disorders, some of which were alleged to be caused by masturbation, such as hysteria, epilepsy, melancholia, and insanity. Also, it was unthinkable at the time that any decent woman should derive pleasure from sex, and it was clear that conception did not require female sexual satisfaction.

FGC varies from an insigniﬁcant cut to a major mutilation. It is commonly performed by nonprofessionals who may not adequately know the anatomy of the female genitalia. Based on observation of women who have undergone a version of these procedures, an attempt has been made to classify different forms or degrees of female genital cutting (WHO 2014a). Most procedures involve partial or total removal of the clitoris. They may also involve excision of the labia minora. In extreme forms, known as inﬁbulations, the clitoris, labia minora, and sometimes labia majora are removed, and the raw surfaces are either stitched together or kept closely in contact to adhere by tying the legs together. This seals the vagina, leaving only a small opening for the ﬂow of urine and menstrual blood.

Health Concerns

Apart from the effect on sexual life of the woman and the psychological trauma to the child, there are health hazards, largely related to the fact that the procedure is performed outside health-care facilities by nonprofessionals and varying according to the extent of the excision in the procedure. WHO afﬁrms that FGC has no health beneﬁts, and it harms girls and women in many ways (WHO 2000). FGC interferes with the natural functions of girls’ and women’s bodies. Immediate complications can include severe pain, shock, hemorrhage, tetanus or sepsis, urine retention, open sores in the genital region, and injury to nearby genital tissue. Long-term consequences can include recurrent bladder and urinary tract infections, cysts, infertility, an increased risk of childbirth complications and newborn deaths, and the need for later surgeries. Procedures that seal or narrow the vaginal opening need to be cut open later to allow for sexual intercourse and childbirth. They may be stitched again after each childbirth, with repeated exposure to immediate and long-term risks.

Ethical Issues And The Cultural Context

It is important to understand why parents want genital cutting for their daughters. Within their communities, young girls may not be eligible for marriage if “uncircumcised.” Ensuring that a daughter undergoes genital cutting as a child or teenager is a loving act to make certain of her marriageability, particularly in societies where there is little economic viability for women outside marriage. This distinguishes FGC from most other forms of child abuse. The practice is also common where premarital virginity is required, often as an indication of a family’s honor. FGC is associated in these cultures with personal and familial purity. Removal of the folds of skin of the labia may also maintain a childlike, innocent cosmetic appearance. The need to maintain virginity may explain inﬁbulations. For FGC procedures involving excision of the clitoris, there is a supposed role of FGC in attenuating the sexual desire in women. Removal of women’s drive for sexual satisfaction is thus supposed to reduce the likelihood of a woman’s voluntary surrender of virginity before marriage and may also ease her demands for sexual attention that her husband may be unwilling or unable to provide.

A wider societal role for FGC may be seen as a quest of control of women’s sexuality in male dominated communities, which is a feature of many traditional societies of various religious faiths. Women’s sexuality is seen to endanger social order and virtue, and morality requires that women’s sexual and other empowerment must be suppressed.

Other normative issues associated with FGC include those related to autonomy and cultural paternalism, how education can shape these issues in societies where FGC is practiced, and whether female children at risk for being subject to FGC can be categorized as vulnerable.

Voices Of Women

In the rhetoric about FGC, the voices of women who have been subjected to the practice are often not heard. It should be understood that deep-rooted traditions die hard. Although the procedure is painful and may result in adverse health consequences, for women in some communities, not having the procedure may be psychologically more disturbing than having it, and women in certain cultures may not be unhappy that they were “circumcised.”

Legal Aspects

A growing number of countries are enacting laws to prohibit FGC (Cook et al. 2002). Signiﬁcantly, many are African countries in which the practice has been widely prevalent. Other countries with relatively high prevalence consider existing laws against aggravated assault to govern FGC that lacks subjects’ legally competent consent. Countries may also apply their laws against child abuse. Practice among immigrant communities in Europe, North America, and Australia has resulted in the enactment of prohibition of female circumcision acts. In the absence of speciﬁc ways of reporting, there are legal constraints to the enforcement of these laws.

While the religious justiﬁcation of FGC is contestable, there have been no medical beneﬁts demonstrated for the practice. Indeed, parental consent no longer holds sufﬁcient grounds to render it lawful. In addition, it is increasingly considered to constitute unlawful child abuse and a violation of the right of the child. The UN Convention on the Rights of the Child Article 19(1), for instance, requires “measures to protect the child from all forms of physical or mental violence, injury or abuse,” and Article 24(1) protects “the right of the child to the enjoyment of the highest attainable standard of health” (UN Convention on the Rights of the Child 1989). The African Charter on the Rights and Welfare of the Child calls on states parties to take speciﬁc measures to protect the child from all forms of torture, inhumane, or degrading treatment (African charter on the rights and welfare of the child 1990).

Parents’ power to impose their preference on young daughters denies the girls their right to autonomy in their future adult lives and denies them immediate defense as children against parental insistence on the performance of a nontherapeutic, irreversible, and risk-laden procedure.

It should, however, be realized that elimination of FGC may be promoted less effectively by insensitive enforcement of criminal laws than by the counseling and education of patients and communities. It was agreed by the world government community at the International Conference on Population and Development, Cairo, 1994, that “Governments are urged to prohibit female genital mutilation wherever it exists and to give vigorous support to efforts among non-governmental and community organizations and religious institutions to eliminate such practices” (United Nations 1994).

Ethics And Medicalization Of FGC

Medical complications of FGC are partly the result of its being performed by unqualiﬁed people in unsafe settings. One proposed approach to address these complications could be to ensure that FGC is done by qualiﬁed people in safe settings. The argument in favor of medical involvement is utilitarian, namely, that injuries and risks of heavy bleeding and other complications would be reduced through skilled medical management of FGC when the alternative is that procedures would be undertaken by unskilled traditional practitioners, who use primitive means. The argument against is one of principle, pitched at the societal or macro-ethical level. While this approach might reduce the medical harm to a particular individual, it still causes a profound social injury to women more generally. Performing any type of FGC is considered an approval of the practice of societal control of women’s sexuality and an affront to women’s bodily integrity and dignity of the person. Even if FGC did not present risks of physical and psychological harm, it would still constitute a violation of women’s human rights. The claim that physicians should participate in order to limit injury, since if physicians refuse to perform such procedures, they may be performed more harmfully by unqualiﬁed persons, is rejected, in much the same way that medical professional organizations prohibit medical participation in such inhumane practices as capital and corporal punishment, judicially ordered amputation, or physically invasive means of police or prison interrogation torture and execution of judicial sentences of ﬂogging, amputation, and death.

The Stand Of The Medical Profession

The ethical approach taken by the medical profession, as indicated in resolutions of the International Federation of Gynecology and Obstetrics (FIGO) and the World Health Organization (WHO), is that FGC is individually and socially harmful to women’s and girls’ health and dignity and of no compensating medical advantage.

In 1994, the FIGO General Assembly, meeting in Montreal, passed a resolution on FGC:

Recognizing that female genital mutilation is a violation of human rights, as a harmful procedure performed on a child who cannot give informed consent, FIGO recommends that obstetricians and gynecologists OPPOSE any attempt to medicalize the procedure or to allow its performance, under any circumstances, in health establishments or by health professionals. (FIGO 1994)

In a more recent statement, on the occasion of “The International Day of Zero Tolerance to Female Genital Mutilation (FGM)” held each 6 February, FIGO reiterated its position that “medicalization of FGM – encouraged by some health-care professionals – is not an acceptable practice, and all efforts should be made to prevent this by the presence of ethical guidelines and regulatory rules” (FIGO 2014). The World Health Organization has consistently and unequivocally advised that female genital cutting in any form should not be practiced by health professionals in any setting – including hospitals or other health establishments. The WHO’s position rests on the basic ethics of health care, whereby unnecessary body mutilation cannot be condoned by health providers. Medicalization is also considered inappropriate as it reinforces the continuation of the practice by seeming to legitimize it (WHO 2008).

Medical licensing authorities and professional associations in many countries, particularly Western countries, have condemned action that would present FGC as an authentic medical procedure and considered that it constitutes professional misconduct. The European Academy of Pediatrics (EAP) in a recent statement indicated that “The whole community of pediatricians in Europe, as represented by the EAP, strongly condemns female genital mutilation and councils its members not to perform such procedures” (European Academy of Pediatrics 2014).

The health profession thus remains not persuaded by the fact that in some cultures, the procedure is considered beneﬁcial and described as “puriﬁcation,” with the inference that women and girls not subjected to it are in some way impure. Accordingly, the ethical opinion of organized medicine is that physicians and health facilities should not participate in this procedure, since it implicates health-care providers in a procedure of unrelieved harm (WHO 2010). However, there are no speciﬁc sanctions in place for those who violate extant anti-FGC Codes and resolutions.

Ethics Of A Medical Alternative Ritual To FGC

Some physicians, who work closely with immigrant populations in which FGC is the norm, have voiced concern about the adverse effects of criminalization of the practice (American Academy of Pediatrics 2010). They proposed an alternative ceremonial ritual involving only pricking or incising the clitoral skin as sufﬁcient to satisfy cultural requirements. This alternative is proposed as a last resort option for the women who did not accept to abandon the practice. A concern was that parents who are denied the cooperation of a physician will send their girls back to their home country for a much more severe and dangerous procedure or use the services of a nonmedically trained persons.

In contrast, it has been argued that such a practice would mean legitimizing the cultural belief system behind it, making it more difﬁcult to eradicate. Many anti-FGC activists in the West, including women from African countries, strongly oppose any compromise that would legitimize even the most minimal procedure. The European Academy of Pediatrics took a ﬁrm stand that “The practice of offering a ‘clitoral nick,’ a minimal pinprick, must also be condemned as an unnecessary and extremely painful procedure” (Sauer and Neubauer 2014). The option of offering a “ritual nick” is currently precluded by US federal law, which makes any nonmedical procedure performed on the genitals of a female minor a criminal act (American Academy of Pediatrics 2010).

Ethical Issues In Obstetric Care For Women Who Had FGC

Obstetric care for women who had FGC can be a new challenge to health-care workers in Western countries with large immigrant communities. With globalization and the increased movement of the people across countries, health professionals have to equip themselves to deal with health situations prevalent in other countries. Women who have been subjected to FGC may seek health care for pregnancy and childbirth in countries where this practice is little known. Caring for women with FGC requires sensitivity and cultural awareness. Birthing process may not be detrimentally affected directly by FGC. What women may miss and need more is psychosocially sensitive support. Innocent little girls who did no harm, but were obedient to their parents and elders, deserve tender loving culturally sensitive care from their health-care providers and not just technically sound clinical care. A recent WHO statement highlighted that many women, in general, experience disrespectful and abusive treatment during childbirth in facilities worldwide (WHO 2014b).

Ethics Of Re-Infibulation

A difﬁcult challenge may arise when an inﬁbulated adult patient, having been de-inﬁbulated in order to give birth, asks to be re-inﬁbulated (Abdulcadira et al. 2011). On the one hand, this is a request by a person, who enjoys competence and free will, for what she considers a cosmetic reinstatement of her predelivery condition. In communities where FGC is virtually universal, even if resuturing is refused after delivery, it is likely that the woman will be resutured at some later date, often as a result of direct or indirect pressure from her husband or from immediate family. On the other hand, the same professional objection applies as to initial FGC, namely, that it is a medically unnecessary, socially contrived procedure which should not be given respectability by medicalization. Accordingly, demands for resuturing to recreate a small vaginal opening (“re-inﬁbulation”) should be resisted, and the potential future health problems of such a procedure should be explained.

The recent practice of female genital cosmetic surgery in the West raises issues on what relationship it may have with FGC and genital re-inﬁbulation and whether a double morality is being applied (Essén and Johnsdotter 2004). Cosmetic surgery, although its beneﬁt and ethics may be questionable, is performed on a requesting competent person, for the purpose of enhancing (not suppressing) sexuality by qualiﬁed surgeons.

Conclusion

The ritual practice of FGC raises ethical concerns and challenges to society generally and to the health professions in particular. It must be realized that the so-called female circumcision is deeply enmeshed in local traditions and beliefs. Mothers who bring their daughters for the procedure believe they are doing the right thing for their welfare. Any change that requires a readjustment of long-established social mores makes people highly uncomfortable. While health professionals should be culturally sensitive, they should also be aware of the ethical implications of their actions. Counseling and education, of patients and communities, of which caring health-care professionals are capable, are needed for the elimination of this harmful traditional practice.

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