ArticlePDF Available

Medicalization of female genital mutilation/cutting

Authors:
  • International Islamic center for population studies and Research AlAzhar Un

Abstract

Globally 100–140 million women and girls have been subjected to female genital mutilation/cutting (FGM/C) which is a harmful practice, associated with immediate and long term complications, has no benefit what so ever, is unethical and has no religious basis. Inspite of global efforts to eradicate FGM/C every year 3 million girls are subjected to this harmful practice mostly in Africa and Asia. In some countries FGM/C is increasingly performed by health-care providers, which is alarming. Medicalization of FGM/C is proposed by some health professionals to reduce the incidence of its complications. However medicalization of FGM/C will not reduce the long term complications of FGM, has no benefit what so ever, has no medical indication, and thus its performance violates the code of medical ethics. Furthermore its medicalization would result in a setback in the global efforts to eradicate this harmful practice, and will give the green light to its performance by non health-care providers with subsequent increased incidence of complications. In some Muslim countries where FGM/C is prevalent it is often wrongly quoted that the basis for performing FGM/C is religious instruction. FGM/C has no religious basis what so ever and has been condemned by Al-Azhar based on several verses in the Holy Quraan that relates explicitly or implicitly to female circumcision. The use of the gender term “Sunna circumcision” is nothing but a form of deceit used to misguide people and give the impression that this act is one of the Islamic practices. As for the traditions attributed to Prophet Mohamed (PBUH), scholars of the past and present have agreed that none of these traditions are authentic and therefore should not be attributed to the Prophet (PBUH).
African
Journal
of
Urology
(2013)
19,
145–149
Pan
African
Urological
Surgeons’
Association
African
Journal
of
Urology
www.ees.elsevier.com/afju
www.sciencedirect.com
Review
Medicalization
of
female
genital
mutilation/cutting
G.I.
Serour
a,b,1,
a
International
Islamic
Center
for
Population
Studies
and
Research,
Al-Azhar
University,
Egypt
b
Clinical
director,
the
Egyptian
IVF&ET
center,
Maadi,
Egypt
Received
1st
November
2012;
received
in
revised
form
28
January
2013;
accepted
28
January
2013
KEYWORDS
Genital
Mutilation;
Medicalization;
Female
Abstract
Globally
100–140
million
women
and
girls
have
been
subjected
to
female
genital
mutilation/cutting
(FGM/C)
which
is
a
harmful
practice,
associated
with
immediate
and
long
term
complications,
has
no
benefit
what
so
ever,
is
unethical
and
has
no
religious
basis.
Inspite
of
global
efforts
to
eradicate
FGM/C
every
year
3
million
girls
are
subjected
to
this
harmful
practice
mostly
in
Africa
and
Asia.
In
some
countries
FGM/C
is
increasingly
performed
by
health-care
providers,
which
is
alarming.
Medical-
ization
of
FGM/C
is
proposed
by
some
health
professionals
to
reduce
the
incidence
of
its
complications.
However
medicalization
of
FGM/C
will
not
reduce
the
long
term
complications
of
FGM,
has
no
benefit
what
so
ever,
has
no
medical
indication,
and
thus
its
performance
violates
the
code
of
medical
ethics.
Fur-
thermore
its
medicalization
would
result
in
a
setback
in
the
global
efforts
to
eradicate
this
harmful
practice,
and
will
give
the
green
light
to
its
performance
by
non
health-care
providers
with
subsequent
increased
incidence
of
complications.
In
some
Muslim
countries
where
FGM/C
is
prevalent
it
is
often
wrongly
quoted
that
the
basis
for
performing
FGM/C
is
religious
instruction.
FGM/C
has
no
religious
basis
what
so
ever
and
has
been
condemned
by
Al-
Azhar
based
on
several
verses
in
the
Holy
Quraan
that
relates
explicitly
or
implicitly
to
female
circumcision.
The
use
of
the
gender
term
“Sunna
circumcision”
is
nothing
but
a
form
of
deceit
used
to
misguide
people
Correspondence
address:
International
Islamic
Center
for
Population
Studies
and
Research,
Al-Azhar
University,
Egypt.
Tel.:
+20
225755869;
fax:
+20
225754271.
E-mail
address:
giserour1@link.net
1
FIGO
Past
President.
Peer
review
under
responsibility
of
Pan
African
Urological
Surgeons’
Association.
1110-5704
©
2013
Pan
African
Urological
Surgeons’
Association.
Production
and
hosting
by
Elsevier
B.V.
All
rights
reserved.
http://dx.doi.org/10.1016/j.afju.2013.02.004
146
G.I.
Serour
and
give
the
impression
that
this
act
is
one
of
the
Islamic
practices.
As
for
the
traditions
attributed
to
Prophet
Mohamed
(PBUH),
scholars
of
the
past
and
present
have
agreed
that
none
of
these
traditions
are
authentic
and
therefore
should
not
be
attributed
to
the
Prophet
(PBUH).
©
2013
Pan
African
Urological
Surgeons’
Association.
Production
and
hosting
by
Elsevier
B.V.
All
rights
reserved.
Female
genital
mutilation/cutting
(FGM/C)
comprises
all
proce-
dures
that
involve
partial
or
total
removal
of
female
external
genitalia
and/or
injury
to
the
female
genital
organs
for
cultural
or
any
other
nontherapeutic
reasons
[1].
While
the
term
“muti-
lation”
reinforces
the
idea
that
this
practice
is
a
violation
of
the
human
rights
of
girls
and
women,
at
the
community
and
indi-
vidual
levels
the
term
can
be
problematic
and
offensive,
and
the
term
“cutting”
may
be
more
acceptable.
FGM/C
is
practiced
in
28
African
countries
and
in
some
nations
in
Asia
and
the
Mid-
dle
East.
As
a
result
of
international
migration,
FGM/C
is
a
global
problem
and
is
not
limited
to
any
cultural
or
religious
groups
[2].
The
World
Health
Organization
classifies
FGM/C
into
4
types,
varying
in
severity
from
partial
or
total
removal
of
the
clitoris
to
extensive
mutilation
of
the
external
genitalia
[3].
The
type
of
FGM/C
practiced
varies
within
and
between
countries
[1–4].
According
to
WHO
modified
typology,
type
III
FGM/C
known
as
infibulation
is
narrowing
of
the
vaginal
orifice
through
the
creation
of
a
covering
seal
formed
by
cutting
and
apposition
of
the
labia
minora
and/or
the
labia
majora,
with
or
without
exci-
sion
of
the
clitoris
[3].
The
term
infibulation
is
derived
from
the
Latin
“fibula”
meaning
tightening
of
the
vaginal
introitus
to
leave
only
a
very
small
opening
for
the
flow
of
urine
and
menstrual
blood.
Defibulation
is
an
anterior
midline
vulval
incision
of
the
scar,
commonly
performed
before
gynecological
operations,
such
as
cervical
biopsy,
evacuation
colposcopy
or,
polypectomy,
and
before
urological
operation
such
as
cystescopy,
to
allow
access
to
the
female
genital
organs
or
the
lower
urinary
tract
through
the
vagina.
It
is
also
performed
at
the
time
of
delivery
or
prenatally
to
avoid
acute
problems
at
the
time
of
delivery,
such
as
obstructed
labour,
vesicovaginal
and
rectovaginal
fistulas,
and
laceration
of
the
scar
tissue
which
results
in
various
obstetric
complications
such
as
laceration
of
the
perineum,
maternal
haemorrhage
or
perinatal
asphyxia.
Resuturing
of
the
vulva
after
delivery,
gynecologicalor
urological
procedures
of
the
incised
scar
tissue
is
knwon
as
reinfibulation.
Sometimes
what
is
locally
interpreted
as
reinfibulation
is
also
per-
formed
on
women
who
have
not
been
infibulated
in
the
first
place
[5,6].
An
estimated
91.5
million
girls
and
women
aged
10
years
and
older
have
been
subjected
to
FGM/C
in
African
countries
where
preva-
lence
data
is
available
[7].
The
number
of
women
who
are
likely
to
have
undergone
reinfibulationis
estimated
to
be
around
6.5–10.4
million
women
[6].
The
prevalence
of
reinfibulation
differs
markedly
in
different
countries.
Reinfibulation
is
most
prevalent
in
countries
where
type
III
FGM/C
is
prevailing,
such
as
Somalia
(98–100%),
Sudan
(82%),
Djibouti
(50%),
and
Eritrea
(34%).
Reinfibulation
is
less
prevalent
in
other
countries
where
infibulation
is
rarely
performed,
such
as
Egypt
(9%),
Chad,
Ethiopia,
Kenya,
and
Nigeria,
where
infibulation
is
only
performed
in
certain
regions.
It
is
less
prevalent
in
Burkina
Faso,
Central
African
Republic,
Ivory
Coast,
Guinea,
Liberia,
Senegal,
Sierra
Leone,
Cameron,
Democratic
Republic
of
Congo,
Guinea-
Bissau,
Mauritania,
and
Uganda
where
type
I
and
type
II
FGM
is
performed
[2–8]
.
Reinfibulation
is
occasionally
performed
among
immigrants
in
Europe
and
North
America
even
though
FGMC
is
prohibited
in
these
countries
[9].
Despite
efforts
to
abandon
FGM/C,
it
is
estimated
that
each
year
approximately
3
million
girls
in
Africa
alone
are
at
risk
of
being
subjected
to
FGM
[10].
Despite
global
strategy
to
stop
health
care
providers
from
perform-
ing
FGM
it
is
still
being
performed
by
health
care
providers
in
many
parts
of
the
world
[5].
Risks
of
FGM/C
on
medical
grounds
FGM/C
is
physically
invasive,
emotionally
damaging,
and
is
asso-
ciated
with
complications
that
may
seriously
affect
the
reproductive
health
of
women
and
increase
the
risks
for
the
unborn
child.
FGM/C
violates
human
right
to
the
highest
attainable
standard
of
health
and
to
bodily
integrity
[11].
FGM/C
is
associated
with
the
potentials
of
localized
infection
or
abscess
formation,
septicemia,
tetanus,
hemorrhage,
shock,
death,
acute
retention
of
urine,
and
contraction
of
hepatitis
and/or
HIV
particularly
when
it
is
performed
in
non
sterile
settings
[1–3].
Although
the
medicalization
of
FGM/C
may
reduce
the
incidence
of
these
acute
complications,
it
has
no
effect
on
the
incidence
of
late
gynecological
and
obstetric
complications.
The
gynecological
complications
of
FGM/C
include
sexual
dysfunction,
apareunia,
superficial
dyspareunia,
chronic
pain,
scar
formation,
dysmenor-
rhea,
vaginal
laceration
during
sexual
intercourse,
difficulty
passing
urine,
and
difficulty
during
gynecological
or
urological
examination
and
procedures
[2].
A
multicenteric
study
by
WHO
had
shown
that
there
are
increased
relative
risks
for
cesarean
delivery
(RR
1.31),
postpartum
hemor-
rhage
(RR
1.69),
extended
maternal
hospital
stay
(RR
1.98),
infant
resuscitation
(RR
1.66),
and
stillbirth
or
early
neonatal
death
(RR
1.55)
[12]
.
Justification
for
performing
FGC/M
appears
to
be
a
deeply
rooted
and
ancient
custom.
The
practice
of
this
custom
in
ancient
Egypt
was
reported
by
Herodotus
(500
B.C.)
and
Strabo,
the
Greek
geographer.
Herodotus
reported
500
years
BC
that
female
circumcision
was
practiced
by
Phoenicians,
Hittites,
Ethiopians
as
well
as
the
Egyptians.
FGM
is
mostly
performed
to
emphasize
a
cultural
identity.
Cus-
tom
and
tradition
are
by
far
the
most
frequently
cited
reasons
for
undergoing
FGM
and
often
perpetuated
by
older
women
who
were
subjected
to
FGM.
Medicalization
of
female
genital
cutting
147
In
a
FGM
practicing
society
a
girl
cannot
be
considered
as
an
adult,
unless
she
has
undergone
FGM.
It
is
done
because
it
always
has
been
done.
It
is
also
performed
to
identify
a
gender
identity.
For
a
girl
to
be
considered
a
complete
woman
FGM
is
often
deemed
necessary.
FGM
marks
the
divergence
of
the
sexes
concerning
their
roles
in
life
and
marriage.
FGM
is
supported
by
the
widespread
belief
that
the
human
body
is
androgynous
at
birth.
To
ensure
adulthood,
girls
must
be
relieved
of
their
male
part,
the
clitoris
and
or/labia
[13].
Excision
of
such
parts
of
a
woman’s
body
is
thought
to
enhance
the
girl’s
feminity.
FGC/M
is
also
performed
with
the
wrong
assumption
that
it
controls
women’s
sexuality
and
reproductive
functions
and
reduces
women’s
desire
for
sex.
One
of
the
reasons
given
to
support
FGM
in
some
cultures
is
enhancement
of
the
man’s
sexual
pleasure
[14–17].
Cleanliness
and
hygiene
are
frequently
quoted
as
justifications
for
FGM.
Terms
for
mutilation
are
synonymous
with
purification
(Tahara
(Egypt),
Tuhara
(Sudan),
Sili-ji
(Bambarra
in
Mali).
Circumcision
is
also
quoted
to
promote
virginity
and
chastity
and
guards
young
girls
from
sexual
frustration
by
deadening
their
sexual
desire.
FGC/M
and
informed
consent
FGM/C
is
a
surgical
procedure
and
the
code
of
medical
ethics
necessitates
obtaining
free
informed
consent
from
the
patient
before
performing
the
procedure.
The
majority
FMC/M
procedures
are
performed
on
girls
between
ages
of
4
and
14
years
or
sometimes
young
infants.
All
these
victims
are
non
capable
of
autonomy
and
consequently
cannot
give
their
free
informed
consent.
Even
when
FGM/C
is
performed
on
adult
women
they
are
not
included
in
the
decision
making
process
and
the
midwife
and
female
relatives
are
usually
behind
the
decision
to
perform
reinfibulation.
This
may
pro-
tect
them
from
being
deserted
or
divorced
by
their
husbands.
Lack
of
women’s
rights
and
economic
dependence
on
men
influences
a
woman’s
acceptance
of
reinfibulation.
Who
performs
FGC/M,
when,
where,
and
why?
While
FGC/M
is
usually
performed
by
traditional
healers,
barbers
or
dayas
on
young
girls
or
infants
reinfibulation
is
usually
performed
by
doctors
or
midwives
between
2
h
and
40
days
after
delivery.
It
may
also
be
performed
following
gynaecological
or
urological
oper-
ations
on
the
vagina,
cervix,
uterus
urethra
and
bladder.
A
worrying
trend
is
that,
FGM/C
is
increasingly
performed
by
health
profes-
sionals
[6].
They
claim
that
they
are
fulfilling
the
cultural
demands
of
the
community,
enhancement
of
women’s
value
in
the
society,
and
respecting
patients’
cultural
rights
since
some
of
those
making
the
decisions
are
of
mature
age
and
capable
of
autonomy
[17–19].
However,
the
real
reason
is
that
it
is
a
source
of
income
for
those
who
perform
it;
the
fees
are
high,
especially
in
countries
where
it
is
illegal.
It
is
also
argued
that
when
the
procedure
is
performed
by
health
care
providers
the
incidence
of
complications
is
significantly
reduced
but
not
eliminated.
It
is
often
quoted
that
women
who
undergo
reinfibulation
are
adult
consenting
women
who
are
fully
capable
of
autonomy.
The
analogy
of
consenting
women
undergoing
body
piercing
procedures
and
cosmetic
surgery
is
often
used.
However,
in
body
piercing
and
cosmetic
surgery
the
woman
is
counseled
and
gives
her
informed
consent,
which
she
can
withdraw
at
any
time
before
the
procedure.
In
contrast,
women
who
undergo
reinfibu-
lation
are
not
usually
included
in
the
decision-making
process
or
provided
with
the
information
that
enables
them
to
make
a
freely-
informed
consenting
decision
[6].
A
woman
may
perceive
that
cosmetic
procedures
have
some
benefits,
and
the
procedures
are
typically
performed
only
after
careful
consideration
of
their
impli-
cations
[1–12].
A
health
professional
performing
FGC/M
or
reinfibulation
has
a
conflict
of
interest.
While
he/she
should
advise
the
guardian
of
the
female
child
or
women
against
FGM/C
and
reinfibulation,
based
on
its
risks,
best
medical
practice
evidence
and
medical
ethics,
it
is
in
his/her
best
interest
to
perform
FGM/C
or
reinfibulation
for
personal
financial
gain.
Medicalization
of
FGM/C
A
joint
technical
consultation
on
the
medicalization
of
FGM/C
held
by
WHO,
UNICEF,
and
UNFPA
in
Nairobi,
Kenya,
from
20
to
22
July,
2009,
condemned
the
practice
of
female
genital
cutting
by
medical
professionals
in
any
setting,
including
hospitals
and
other
health
establishments.
Demographic
and
Health
Surveys
data
show
that
the
medicalization
of
FGM/C
has
increased
substantially
in
recent
years,
particularly
in
Egypt,
Guinea,
Kenya,
Nigeria,
North-
ern
Sudan,
Mali,
and
Yemen
and
recently
in
Indonesia.
In
many
of
these
countries
one-third
or
more
of
women
had
their
daugh-
ters
cut
by
a
trained
health
professional.
An
increased
number
of
younger
compared
with
older
women
are
undergoing
FGM/C
by
medical
personnel,
demonstrating
a
trend
toward
the
practice
[10].
There
are
various
arguments
made
by
medical
doctors
who
excise
women
and
girls.
Some
believe
that
FGM/C
including
reinfibula-
tion
is
a
medical
necessity;
others
argue
that
performing
FGM/C
under
sanitary
conditions
reduces
its
risks;
while
others
consider
their
personal
economic
benefits.
Sadly
medicalization
of
various
forms
of
FGM/C
including
reinfibulation
has
been
supported
by
some
international
humanitarian
organizations,
professional
orga-
nizations
and
governments.
In
1994,
the
Egyptian
minister
of
health
stated
that
doctors
could
perform
FGM/C
on
girls
in
designated
facilities
at
fixed
times
and
prices,
claiming
that
medicalization
of
the
practice
would
reduce
complications
and
eventually
end
the
practice
[20].
Subsequent
pressure
from
international
agencies,
as
well
as
the
reported
deaths
of
girls
who
were
cut
in
hospitals,
insti-
gated
a
renewed
ban
on
the
practice
in
public
hospitals
in
Egypt
[10].
In
1999,
the
international
medical
aid
agency,
Medicines
Sans
Frontiers
(MSF),
said
its
workers
provided
surgical
equipment
for
FGM/C,
but
claimed
it
did
not
support
the
procedure.
MSF
argued
that
providing
clean
instruments
was
a
“first
aid
response,”
since
female
genital
mutilation
can
result
in
infections
and
cause
“horrific
complications”
in
childbirth
and
during
intercourse
[21].
Following
public
condemnation
by
advocacy
groups,
MSF
issued
a
policy
paper
in
the
same
year
opposing
female
genital
cutting.
The
organization
stated
that
the
procedure
would
not
be
undertaken
in
any
of
its
facilities
and
that
instruments
it
supplied
would
not
be
used
for
the
procedure
[21].
In
2010,
The
American
Academy
of
Pediatrics
organization
in
the
USA
recommended
to
its
members
148
G.I.
Serour
performing
minor
forms
of
FGM/C
for
girls
to
maintain
the
traditions
and
customs
for
some
communities
in
the
USA.
The
International
Federation
of
Obstetrics
and
Gynecology
(FIGO)
immediately
responded
by
the
following
statement:
Professor
GamalSerour
FIGO
President
is
deeply
concerned
and
alarmed
at
the
terrible
news
that
has
recently
surfaced
supporting
medicalisation
of
some
forms
of
Female
Genital
Mutilation/Cutting
(FGM/C).
FIGO–an
international
Federation
embracing
124
mem-
ber
societies
of
obstetricians
and
gynecologists
in
the
developed
and
developing
world–strongly
condemns
all
forms
of
FGM/C,
per-
formed
by
traditional
or
medical
personnel
in
all
countries
and
all
communities
around
the
globe,
as
they
are
harmful,
unethical,
with
no
benefits
whatsoever,
and
are
against
the
code
of
medical
practice.
FIGO
strongly
condemns
all
past,
present
or
future
calls
to
medi-
calise
any
form
of
FGM/C.
FIGO
affirms
its
firm
stance
on
this
issue
as
outlined
in
its
previous
resolution,
guidelines,
publications
and
conjoint
statements.
FIGO
welcomes
the
withdrawal
of
the
deci-
sion
of
the
few
organisations
who
issued
or
considered
the
issue
of
statements
implying
the
support
of
any
form
of
FGM/C.
The
professional
organization
in
USA
responded
to
the
Plea
of
FIGO
and
the
pressure
of
many
Humanitarian
groups
by
withdrawing
its
recommendation.
In
2011,
the
MOH
of
one
government
in
Asia
issued
its
clinical
guideline
on
FGC/M
to
be
performed
by
health
professionals
in
hospitals.
The
rationale
behind
these
regulations
that
when
conducted
by
a
qualified
healthcare
professional,
under
sterile
conditions,
the
procedure
is
a
safer
option
than
if
it
were
to
be
carried
out
by
a
traditional
healer.
The
MOH
argument
was
that
this
first
contact
presents
doctors,
midwives
and
nurses
with
the
opportunity
to
counsel
mothers
about
the
futility
of
the
pro-
cedure,
thereby
discouraging
future
practice.
On
December
14th,
2011,
FIGO
responded
by
a
communicé
to
the
MOH
stating
that
the
fundamental
issue
that
FIGO
President
has
with
the
guidelines
is
that
it
legitimises
a
procedure
which
has
no
known
medical
or
health
benefit.
This
places
pressure
on
healthcare
workers
to
be
involved
in
a
ritual
practice
which
they
may
be
professionally
and/or
morally
opposed
to.
Urging
MOH
to
visit
FIGO
Ethical
Guidelines
on
FGM
at
www.figo.org.
FIGO’s
President
highlighted
that
the
recent
MOH
guidelines
call
for
the
medicalization
of
FGM
con-
travenes
the
principles
in
the
previous
UN
and
WHO
resolutions
and
statement
signed
by
member
countries.
They
are
a
retrograde
step.
Egypt
has
gone
before
through
the
same
path
and
legalized
medicalization
of
FGM.
However
after
a
short
period
of
practice,
little
mortality
occurred
from
FGM
performed
by
doctors
in
hospi-
tals.
Consequently,
the
government
of
Egypt
banned
the
procedure
totally.
Implementation
of
the
national
guidelines
is
a
clear
signal
to
other
countries
that
female
circumcision
is
an
acceptable
form
of
FGM.
The
good
work
that
has
been
done
to
eradicate
the
practice
over
the
past
two
decades
will
be
in
jeopardy.
The
author
as
the
Director
of
the
International
Islamic
Center
for
Population
Studies
and
Research
(IICPSR),
Al-Azhar
University
has
pointed
out
to
the
MOH
that
(IICPSR)
dealt
with
the
issue
in
its
book
titled
“Chil-
dren
in
Islam:
their
care,
upbringing
and
protection”,
published
by
the
Al
Azhar
University
in
cooperation
with
UNICEF
2005,
and
condemned
medicalization
of
FGM/C
www.unicef.org,
p:
61–62
[22].
FGM/C
is
an
extreme
example
of
discrimination
based
on
sex
as
a
way
to
control
women’s
sexuality.
FGM/C
denies
girls
and
women
full
enjoyment
of
their
personal,
physical,
and
psycho-
logical
integrity,
rights,
and
liberties.
FGM/C
is
an
irreparable,
irreversible
abuse
of
the
female
child.
It
violates
girls’
“right
to
the
enjoyment
of
the
highest
attainable
standard
of
health
and
to
protec-
tion,”
contrary
to
the
ethical
principles
of
beneficence,
justice,
and
non-maleficence.
Health
professionals
who
support
the
practice
are
contravening
the
medical
code
of
ethics
to
“do
no
harm.”
Educating
the
public,
members
of
the
health
profession
and
practitioners
of
tra-
ditional
health
care,
community
leaders,
educators,
social
scientists,
human
rights
activists,
and
others
who
implement
policies
is
neces-
sary
to
trigger
awareness
of
the
extent
of
the
problem
and
the
dangers
of
medicalization
of
all
types
of
FGM/C,
including
reinfibulation.
The
medicalization
of
all
types
of
FGM/C
should
be
condemned
at
national
and
international
levels.
It
is
the
duty
of
professional
bodies
and
organizations
to
advise
members
and
all
health
workers
not
to
undertake
FGM/C,
including
reinfibulation,
and
to
hold
them
accountable
for
this
unethical
practice.
We
need
a
concerted
effort
and
collaboration
of
UN
agencies,
world
professional
organizations,
and
their
member
societies
including
obstetricians,
midwives,
and
pediatricians.
These
agencies
and
bodies
must
be
supported
by
the
commitments
of
governments,
politicians,
parliamentarians,
legis-
lators,
mass
media,
religious
leaders,
and
NGOs.
Women
who
have
been
infibulated
should
be
counseled
with
their
spouses
about
the
harmful
effects
of
reinfibulation
during
prenatal
care
whenever
possible
to
encourage
them
not
to
undergo
reinfibu-
lation
after
childbirth.
Women
of
all
ages
who
have
been
subjected
to
infibulation
should
be
treated
at
all
stages,
including
pregnancy
and
childbirth,
with
sympathy,
respect,
and
medically
evidence-
based
care.
Depending
on
local
laws,
properly
informed
women
who
have
been
infibulated
and
who,
following
childbirth,
independently
request
resuturing,
should
be
treated
carefully.
The
practitioner
should
explain
the
benefits
of
unsuturing
and
advise
the
patient
on
the
immediate
and
long-term
complications
of
reinfibulation.
The
practitioner
should
also
emphasize
that
all
FGM/C
procedures
are
professionally
condemned
[11].
In
conclusion,
the
medicalization
of
FGM/C,
including
reinfibu-
lation,
although
it
may
reduce
the
immediate
health
hazards
of
the
procedure,
underestimates
its
overall
physical
and
psychologi-
cal
complications.
Medicalization
of
all
forms
of
FGM/C
violates
human
rights,
ethical
principles
of
justice,
beneficence
and
non
mal-
eficience
and
the
medical
code
of
ethics.
It
creates
tacit
approval
that
only
propels
this
harmful
cultural
behavior,
rather
than
tacit
disapproval
and
encouragement
to
change
the
behavior.
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... [17][18][19][20] The findings may suggest that medicalisation of FGM (FGM performed by a doctor, nurse, midwife or other health professional) is not prevalent in SSA, although reports indicate that some health professionals engage in the practice in Nigeria, Sudan, Mali and other sub-Saharan African countries. [51][52][53] In 2010, the WHO developed a strategy to stop healthcare professionals from performing FGM by engaging them to support abandonment of the practice. 54 The WHO, United Nations Population Fund and ministries of health of the included countries may have to persist in dissuading healthcare professionals from performing FGM. ...
Article
Full-text available
Background This study examines the association between maternal healthcare service utilisation and circumcision of daughters in sub-Saharan Africa (SSA). Methods This study is based on a cross-sectional study design that draws on analysis of pooled data from current demographic and health surveys conducted between 2010 and 2019 in 12 countries in SSA. Both bivariate and multivariable binary logistic regression models were employed. Results Mothers who had four or more antenatal care visits were less likely to circumcise their daughters compared with those who had zero to three visits. Mothers who delivered at a health facility were less likely to circumcise their daughters than those who delivered at home. With the covariates, circumcision of daughters increased with increasing maternal age but decreased with increasing wealth quintile and level of education. Girls born to married women and women who had been circumcised were more likely to be circumcised. Conclusions This study established an association between maternal healthcare service utilisation and circumcision of girls from birth to age 14 y in SSA. The findings highlight the need to strengthen policies that promote maternal healthcare service utilisation (antenatal care and health facility delivery) by integrating female genital mutilation (FGM) information and education in countries studied.
... activist organisations), the national (e.g. national legislation) and the international (e.g. by the who) levels are based mainly on the ethical argument that preventing the medicalisation of fgc is an essential component of a holistic, human-rights-based approach to the elimination of the practice, and that no forms of fgc should be tolerated (Serour, 2013). Moreover, they strongly oppose medicalisation based on the argument that the involvement of health professionals in the performance of fgc will counteract efforts to eliminate it and impede progress towards its abandonment (Shell-Duncan, 2001;who, 2010). ...
Article
Today, female genital cutting (fgc) is more often performed by health professionals. In this dissertation we aim to answer the question of why mothers opt to medicalise their daughters’ cut, and how this decision relates to their social position within their community. We focus on Egypt and Kenya. The first important conclusion of our research is that increasing medicalisation and decreasing fgc prevalence can coexist. Moreover, we identify three major drivers behind mothers’ choice to medicalise their daughters’ cut. Firstly, mothers argue that they opt for a medicalised cut to reduce the health risks related to the cut. They seek a less harmful but still culturally acceptable alternative. Secondly, the medicalisation of fgc is socially stratified. Thirdly, medicalisation may act as a social norm in itself. In conclusion, we state that the debate about medicalisation should be more nuanced and that the general discourse on medicalisation should be challenged and empirically grounded.
... On the other hand, some non-essential religious or cultural practices that are incompatible with code of medical ethics might be medicalized, such as virginity testing (Crosby et al., 2020) and female circumcision (Serour, 2013). In addition, unlike religion, which is well-defined, there is no widespread agreement on the definition of spirituality (Koenig, 2018), which might have different connotations in Asian countries than in the West, were most studies on spirituality are conducted. ...
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Social distancing is crucial in breaking the cycle of transmission of COVID-19. However, many religions require the faithful to congregate. In Malaysia, the number of COVID-19 cases spiked up from below 30 in February 2020 to more than a thousand a month later. The sudden increase was mostly linked to a large Islamic gathering attended by 16,000 near the capital, Kuala Lumpur. Another large COVID-19 cluster was from a church gathering in Kuching, Sarawak. Within a few weeks, Malaysia became the worst hit country by COVID-19 in Southeast Asia. While religious leaders have advised social distancing among their congregants, the belief that "God is our shield" is often cited for gathering. There is a need to promote sound decision-making among religious adherents so that they will not prioritize their loyalty to the subjective interpretation of religion over evidence-based medicine. Malaysia, a multi-cultural and multi-faith country, is an example of how religious beliefs could strongly influence health behaviours at individual and community levels. In this article, we detail the religious aspects of COVID-19 prevention and control in Malaysia and discuss the possible role of religious organizations in encouraging sound decision-making among religious adherents in mitigating this crisis. We make recommendations on how to promote a partnership between the healthcare system and religious organizations, and how religion and faith could be integrated into health promotion channels and resources in the response of COVID-19 and future communicable diseases.
... It also deprives the right to life when the adverse consequences results in death. 1 FGC is a universal practice that result in many health-related and life girls who have had it performed on them. 2 Medicalization of FGC as defined by the World Health Organization refers to situations in which it is practiced by any category of health care provider, whether in a public or a private clinic, at home or elsewhere. 3 Some health practitioners argue that medicalization of FGC helps to prevent the complications associated with the practice. ...
Article
Background: Female genital cutting (FGC) affects over 200 million girls and women globally. It is inimical to health and increasingly being performed by healthcare providers. Medicalization of FGC is proposed by its proponents to reduce and prevent the incidence of its complications and though perceived to be safer, it is unethical and unjustifiable. This study assessed medicalization of FGC in Sapele Local Government Area, Delta State and made recommendations geared towards ending its practice.Methods: A descriptive cross-sectional study was conducted among reproductive age women (15 – 44 years) selected using multi-stage sampling. Pre-tested structured questionnaire was used to obtain quantitative data from 502 women while a focus group discussion guide was used to obtain qualitative data. Data was analyzed using SPSS version 20.0 and by themes. Results were presented as tables and narratives.Results: Prevalence of FGC was 277 (55.2%), of which 223 (80.5%) were medicalized. The mean age of cutting was 16.8 ± 5.46 years and nurses performed majority 220 (79.4%) of them. Few 44 (8.8%) of the respondents were aware of possible complications of FGC. Qualitative findings indicated that FGC is still being practiced with nurses being reported as major practitioners.Conclusion: Despite concerted efforts to eliminate FGC, its practice is still propagated with increasing heath workers as practitioners. Advocacy and health education for women and girls as well as training and retraining of health care providers is imperative to check this trend.
... The performance of FGM by health professionals violates the code of medical ethics. It can also result in a setback in the FGM eradication efforts [8]. ...
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Background Female genital mutilation (FGM) is commonly practiced in Iraqi Kurdistan Region, where there are extensive efforts to combat the practice over the last decade. This study aimed to determine the trends and changes in the FGM prevalence in Iraq between 2011 and 2018 and assess their associated factors. Methods Secondary data analysis of the Iraq Multiple Indicator Cluster Survey 2011 and 2018 was carried out to calculate the prevalence and the relative changes in the prevalence of FGM for 2011 and 2018 by governorate. The change in the prevalence was compared with the changes in other exposure variables such as age, education level, wealth, and area of residence over the same period. Results The prevalence of FGM in 2018 was high in Erbil and Suleimaniya governorates (50.1% and 45.1%). The prevalence of FGM decreased remarkably from 2011 to 2018 in all governorates of the Iraqi Kurdistan Region. The decrease in the prevalence was statistically significant in Erbil and Suleimaniya. FGM prevalence declined remarkably in all age, education level, residence area groups, and most economic level groups. Such decline was associated with a significant increase in the education level, wealth, and urban residence. The decline was highest in the younger age groups, with a relative change of − 43.0% among 20–24 years and − 39.2% among 15–19 years. The decline was also highest in those with secondary and higher education (relative change = −32%). The decline was higher in rural areas than in urban areas (relative change = −35.3% and − 27.4%, respectively). The decline was higher among the poorest and second wealth quintile (relative change = −38.8% and − 27.2%, respectively). Conclusion The trend of FGM in Iraqi Kurdistan Region declined remarkably and significantly from 2011 to 2018. Further decline is predicted because of having lower rates and a higher decline in the younger age groups. However, the rates remained high in Erbil and Suleimaniya governorates that need further intensifying the preventive measures. The education level of women plays a primary role in decreasing the prevalence and should be considered in future efforts to ban the practice.
... Given the relative nature of both the concept of 'best' and '(significant) harm' as seen before the cost/benefit analysis seems not to give an unambiguously answer to the question if these practices are in the 'best interest' of the involved children. Furthermore a cost/benefit analysis, as already noted by some scholars, could even become a useful starting ground for those who have proposed the medicalization of those procedures, in particular of male circumcision, as a solution to render them safer and less harmful (Erlings 2016;Serour 2013). ...
Article
Many international and regional human rights’ measures were adopted to eliminate female genital modifications, as they are performed in lack of medical necessity and interfere with the growth of healthy genital tissue, which can lead to severe consequences for women’s physical and mental health. The aim of this paper is to contribute to the discussion on other practices that are carried out on children without their consent and without therapeutic reasons, such as male circumcision and intersex treatment. These practices will be discussed by examining three different arguments: the best interest standard, the do no harm principle and the right to bodily integrity combined with the children’s right to an open future. In doing so, the intent is to find out if by opening the discussion to other forms of early non-therapeutic genital interventions it could be a way to improve the protection of children against embodied practices that are grounded on cultural/social norms.
... There is a growing opposition and change of attitudes towards FGC after migration among migrants in Sweden (12,13). Additionally, fewer FGC procedures occur in unhygienic circumstances, although the "medicalization" of FGC is a problematic and unethical issue, as has been extensively discussed elsewhere (14,15). In some settings, such as in Mali and Chad, there is a slight movement towards less severe forms of FGC, replacing tissue removal with symbolic nicking/pricking (16). ...
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Rosling et al’s book Factfulness aims to inspire people to use strong supporting facts in their decision‐making, with 10 rules of thumb to fight dramatic instincts. In this paper, the Factfulness framework is applied to female genital cutting (FGC), in order to identify possible biases and promote evidence‐based thinking in studies on FGC, clinical guidelines on management of FGC, and interventions aimed at abolishing FGC. The Factfulness framework helps to acknowledge that FGC is not a uniform practice and helps address that variability. This framework also highlights the importance of multidisciplinarity to understand causalities of the FGC issue, which the authors argue is essential. This paper highlights the fact that FGC is a dynamic practice, with changes in the practice that are ongoing, and that those changes are different in different contexts. The “zero tolerance” discourses on FGC fails to acknowledge this. Factfulness encourages us to be more critical of methodologies used in the area of FGC, for example when estimating girls at risk of FGC in migration contexts. Factfulness provides the tools to calculate risks rather than judgments based on fear. This may help limit stigmatization of women with FGC and to allocate resources to health problems of migrant women based on real risks. The framework also calls for more research and production of less biased facts in the field of FGC, in order to improve interventions aimed at abolishing FGC, and clinical guidelines for the treatment of FGC. Factfulness is a useful and structured foundation for reflection over constructs, biases, and disputes surrounding FGC, and can help improve the quality of future evidence‐based interventions and education that address the actual needs women with FGC and girls at risk of FGC.
Article
Objectives: Female Genital Mutilation and Cutting (FGM/C) is an act of gender-based violence (GBV) and a global public health issue with well-documented adverse outcomes. With the rise in global migration, there is an increasing prevalence of FGM/C among Arab diaspora living in the West and Global South. What remains unclear is how to reduce the practice. This study was designed to identify interventions exerting an effect on reducing the practice of FGM/C. Methods: A systematic review of peer-reviewed articles was conducted on interventions targeting individuals and/or the broader community to prevent FGM/C within the Arab League and its diaspora, up to December 2021. Databases searched included PubMed, Medline, Web of Science, PsycINFO, EMBASE, CINAHL, BIOSIS, ASSIA, and Scopus. Quality assessment used the Mixed Methods Appraisal Tool (MMAT) 2018. Results: Twelve of 896 studies met the inclusion criteria. Eight interventions relied entirely on education with short-term gains but unchanged practices. Three interventions used social marketing and mixed media. Only one study took a multi-sectoral approach. Conclusions: At a macro level, opportunities to reduce or end the practice of FGM/C exist through legislation, policy, a public-health approach grounded in gender equality and human rights. Using multi-sectoral actions that consider the social context and challenge social norms at macro, meso and micro levels appears more effective than individual-level interventions. Promoting advocacy and developing supportive environments to reduce GBV, enhance gender equality and empower communities is crucial for interventions to succeed and achieve the Sustainable Development Goal target of FGM/C abandonment by 2030.
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Background Female Genital Mutilation/Cutting (FGM/C) is a non-medical procedure entailing the modification of the external female genitalia. A description of the prevalence and distribution of FGM/C allows the tracking of progress towards ending FGM/C by 2030 (Sustainable Development Goal (SDG) Target 5.3). This systematic review aimed to examine FGM/C prevalence and types, by World Health Organization (WHO) region and country. Methods A systematic search using Medical Subject Headings (MeSH) and keywords from 2009 to March 24, 2022 was undertaken in MEDLINE, PubMED, PsycINFO, Web of Science, and Embase to identify studies presenting FGM/C prevalence. Abstract and full-text screening, quality assessment, and data extraction were undertaken by two reviewers. Only nationally representative studies were included in the meta-analysis. Pooled FGM/C prevalence was estimated by random-effects meta-analysis using generalised linear mixed models (GLMM). FGM/C prevalence with 95% confidence intervals (CI), prediction intervals (PI) and FGM/C type were presented separately by women aged 15-49 years and girls aged 0-14 years. Findings 161 studies met the inclusion criteria and 28 were included in the meta-analysis, of which 22 were from the WHO African region (AFR), 5 Eastern Mediterranean region (EMR), and 1 South-East Asia (SEAR) region. These studies included data from 397,683 women across 28 countries and 283,437 girls across 23 countries; the pooled prevalence estimate of FGM/C amongst women aged 15-49 years was 38.3% (95% CI: 20.8–59.5%; PI:0.48–98.8%), and 7.25% (95% CI:3.1–16.0%; PI: 0.1-88.9%) amongst girls aged 0-14 years. Amongst included countries, this gave a total estimated prevalence of 86,080,915 women (95%CI: 46,736,701–133,693,929) and 11,982,031 girls with FGM/C (95% CI: 5,123,351–26,476,156). Somalia had the highest FGM/C prevalence amongst women (99.2%) and Mali had the highest amongst girls (72.7%). The most common type of FGM/C amongst women was “flesh removed” (Type I or II) in 19 countries, and “not sewn closed” (Type I, II, or IV) amongst girls in 9 countries. Among repeated nationally representative studies, FGM/C decreased for women and girls in 23 and 24 countries respectively, although in several countries there was a minor decrease (0-3%) or increase in prevalence. Discussion In this study, we observed large variation in FGM/C prevalence between countries, and the prevalence appears to be declining in many countries, which is encouraging as it minimises physical and physiological harm for a future generation of women. This prevalence estimate is lower than the actual global prevalence of FGM/C due to data gaps, non-comparable denominators, and unavailable surveys. Yet, considerable policy and community-level interventions are required in many countries to meet the SDG target 5.3. Funding None
Article
Reinfibulation is performed on women previously subjected to infibulation and who have given birth. To investigate the practice and attitudes concerning reinfibulation, we randomly selected for interviews 60 young women and grandmothers in a rural village in central Sudan. Reinfibulation was widely practised in this area. The main motive for performing reinfibulation was to satisfy the husband sexually. The young women saw themselves as passive in the decision process, claiming that the midwife and female relatives were behind the decision. Men were not involved in decisions to perform reinfibulation but seemed to play a supportive role when decisions were made not to perform it. Some young women had decided to break the pattern and not be reinfibulated. Through the interviews, we found that the practice carries the risk of several serious complications, which demonstrates that reinfibulation is an important health issue.
Article
Reinfibulation is resuturing after delivery or gynecological procedures of the incised scar tissue resulting from infibulation. Despite the global fight against female genital mutilation/cutting (FGM/C), reinfibulation of previously mutilated or circumcised women is still performed in various countries around the world. A good estimate of the prevalence of reinfibulation is difficult to obtain, but it can be inferred that 6.5-10.4million women are likely to have been reinfibulated worldwide. Women who undergo reinfibulation have little influence on the decision-making and are usually persuaded by the midwife or birth attendant to undergo the procedure immediately following labor or gynecological operation. Although medicalization of reinfibulation may reduce its immediate risks, it has no effect on the incidence of long-term risks. Reinfibulation is performed mainly for the financial benefit of the operator, and cultural values that have been perpetuated for generations. Reinfibulation has no benefits and is associated with complications for the woman and the unborn child. Its medicalization violates the medical code of ethics and should be abandoned. International and national efforts should be combined to eradicate this practice.
Article
Every year, three million girls and women are subjected to genital mutilation/cutting, a dangerous and potentially life-threatening procedure that causes unspeakable pain and suffering. Not only is it practiced among communities in Africa and the Middle East, but also in immigrant communities throughout the world. Moreover, recent data reveal that it occurs on a much larger scale than previously thought. It continues to be one of the most persistent, pervasive and silently endured human rights violations. This Innocenti Digest examines the prevalence of FGM/C and its social dynamics. It provides an explanation as to why the practice persists and of the elements necessary for its abandonment. It also takes stock of progress to date, identifies what works and what does not, and provides direction regarding the most successful strategies to promote the abandonment of FGM/C. Combining concrete field experience with tested academic theory, the Digest provides a practical tool to bring about positive change for girls and women.
Article
The practice of circumcision began in antiquity. Female circumcision is common in many African countries, such as Egypt and Sudan. In Egypt, the practice is legal if carried out by a doctor. The Egyptian Organization of Human Rights recently reported that up to 3600 girls were circumcised daily in the country, such that 95% of girls under age 16 years in rural areas and 73% of girls in Cairo had been circumcised. There are three types of female circumcision. The Sunna type involves excising the prepuce of the clitoris. In clitoridectomy, the clitoris is removed with or without the labia minora, while infibulation involves removing the clitoris, labia minora, and the internal faces of the labia majora. Complications are common with all types. Three cases in which women underwent an Aladal operation are described; two of the women died following their operation. The Aladal procedure involves refashioning of the original circumcision with the intent of narrowing the introitus to restore a virgin-like state. In the cases presented, the women were either preparing for marriage or to go on a holy pilgrimage. The Aladal operation is usually performed by a local midwife, under local anesthesia. A fresh incision is made involving the original circumcision area. Both edges are cut longitudinally and extended posteriorly. The edges of the incision are then sutured with any available material. Healing is often poor in such a previously scarred area and depends upon factors such as the involvement of the urethra and the time interval before the resumption of intercourse. Infection is common, and the availability of sterile materials and antibiotics is often limited. Vaginal atrophy in postmenopausal women may also slow the healing process. It is likely that the Aladal operation is as old as circumcision. The author notes that doctors need to be aware of female circumcision and its complications as well as this associated practice of Aladal and the serious sequelae which may result.
Article
The literature on female genital mutilation (also known as female circumcision) within a feminist theoretical context is discussed. Issues of culture, politics and religion in the literature will be examined in relation to feminist thought and the paper will also assess the effects of female genital mutilation on women's health and status within developing societies. Parallels with other similar practices in developed and developing countries will be drawn and policy strategies discussed.
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In recent decades the practice of female "circumcision" has come under intense international scrutiny, often conceptualized as a violation of women's basic right to health. Although the adverse health consequences of female "circumcision" form the basis of opposition to the practice, anti-circumcision activists, as well as many international medical associations, largely oppose measures to improve its safety. The debate over medicalization of female "circumcision" has, up until now, been cast as a moral dilemma: to protect women's health at the expense of legitimating a destructive practice? Or to hasten the elimination of a dangerous practice while allowing women to die from preventable conditions? This paper seeks to re-examine this debate by conceptualizing medicalization of female "circumcision" as a harm-reduction strategy. Harm reduction is a new paradigm in the field of public health that aims to minimize the health hazards associated with risky behaviors, such as intravenous drug use and high-risk sexual behavior, by encouraging safer alternatives, including, but not limited to abstinence. Harm reduction considers a wide range of alternatives, and promotes the alternative that is culturally acceptable and bears the least amount of harm. This paper evaluates the applicability of harm reduction principles to medical interventions for female "circumcision," and draws parallels to other harm reduction programs. In this light, arguments for opposing medicalization of female "circumcision", including the assertion that it counteracts efforts to eliminate the practice, are critically evaluated, revealing that there is not sufficient evidence to support staunch opposition to medicalization. Rather, it appears that medicalization, if implemented as a harm-reduction strategy, may be a sound and compassionate approach to improving women's health in settings where abandonment of the practice of "circumcision" is not immediately attainable.