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Health care providers' and mothers' perceptions about the medicalization of female genital mutilation or cutting in Egypt: a cross-sectional qualitative study

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Background: Female genital mutilation/cutting (FGM/C) is a traditional harmful practice that has been prevalent in Egypt for many years. The medicalization of FGM/C has been increasing significantly in Egypt making it the country with the highest rate of medicalization. In this qualitative study, we explored the drivers and motives behind why healthcare professionals perform FGM/C and why mothers rely on them to perform the practice on their daughters. Methods: The study drew on a "mystery client" approach, coupled with in-depth interviews (IDIs) and focus group discussions (FGDs) with health care providers (i.e. physicians and nurses) and mothers. It was conducted in three geographic areas in Egypt: Cairo, Assiut and Al Gharbeya. Results: Study findings suggest that parents who seek medicalized cutting often do so to minimize health risks while conforming to social expectations. Thus, the factors that support FGM/C overlap with the factors that support medicalization. For many mothers and healthcare providers, adherence to community customs and traditions was the most important motive to practice FGM/C. Also, the social construction of girls' well-being and bodily beauty makes FGM/C a perceived necessity which lays the ground for stigmatization against uncut girls. Finally, the language around FGM/C is being reframed by many healthcare providers as a cosmetic surgery. Such reframing may be one way for providers to overcome the law against FGM/C and market the operation to the clients. Conclusion: These contradictions and contestations highlighted in this study among mothers and healthcare providers suggest that legal, moral and social norms that underpin FGM/C practice are not harmonized and would thus lead to a further rise in the medicalization of FGM/C. This also highlights the critical role that health providers can play in efforts to drive the abandonment of FGM/C in Egypt.
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R E S E A R C H A R T I C L E Open Access
Health care providersand mothers
perceptions about the medicalization of
female genital mutilation or cutting in
Egypt: a cross-sectional qualitative study
Omaima El-Gibaly
1*
, Mirette Aziz
1
and Salma Abou Hussein
2
Abstract
Background: Female genital mutilation/cutting (FGM/C) is a traditional harmful practice that has been prevalent in
Egypt for many years. The medicalization of FGM/C has been increasing significantly in Egypt making it the country
with the highest rate of medicalization. In this qualitative study, we explored the drivers and motives behind why
healthcare professionals perform FGM/C and why mothers rely on them to perform the practice on their daughters.
Methods: The study drew on a mystery clientapproach, coupled with in-depth interviews (IDIs) and focus group
discussions (FGDs) with health care providers (i.e. physicians and nurses) and mothers. It was conducted in three
geographic areas in Egypt: Cairo, Assiut and Al Gharbeya.
Results: Study findings suggest that parents who seek medicalized cutting often do so to minimize health risks
while conforming to social expectations. Thus, the factors that support FGM/C overlap with the factors that support
medicalization. For many mothers and healthcare providers, adherence to community customs and traditions was
the most important motive to practice FGM/C. Also, the social construction of girlswell-being and bodily beauty
makes FGM/C a perceived necessity which lays the ground for stigmatization against uncut girls. Finally, the
language around FGM/C is being reframed by many healthcare providers as a cosmetic surgery. Such reframing
may be one way for providers to overcome the law against FGM/C and market the operation to the clients.
Conclusion: These contradictions and contestations highlighted in this study among mothers and healthcare
providers suggest that legal, moral and social norms that underpin FGM/C practice are not harmonized and would
thus lead to a further rise in the medicalization of FGM/C. This also highlights the critical role that health providers
can play in efforts to drive the abandonment of FGM/C in Egypt.
Keywords: Female genital mutilation/cutting, Medicalization, Egypt, Gender equity, Sexual and reproductive health
rights
Background
Approximately 200 million women and girls in 30 coun-
tries have undergone female genital mutilation/ cutting
(FGM/C) [1]. FGM/C is defined as all procedures in-
volving partial or total removal of the external female
genitalia or other injury to the female genital organs for
non-medical reasons[2]. Most women and girls who
are cut live in Africa and Asia. Universally considered a
violation of human rights, FGM/C not only physically
harms women and girls, but it also causes psychological
problems because of the traumatic experiences the vic-
tims undergo.
To reduce the incidence of these complications whilst
complying with a cultural demand, and as a response to
the emphasis on the health risks characterized in anti-
FGM/C campaigns, FGM/C is increasingly carried out
by health care providers medicalization. The World
Health Organization (WHO) defines medicalization as
the situation in which FGM/C is practiced by any
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(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: oelgibaly@aun.edu.eg
1
Assiut University, Assiut, Egypt
Full list of author information is available at the end of the article
El-Gibaly et al. BMC International Health and Human Rights (2019) 19:26
https://doi.org/10.1186/s12914-019-0202-x
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
category of healthcare provider, whether in a public or a
private clinic, at home or elsewhere[3]. These medical
health professionals may include physicians, nurses and/
or midwives. Demographic and Health Surveys (DHS)
data shows that medicalization has increased particularly
in Egypt, Sudan, Kenya, Nigeria, Guinea, Yemen and,
more recently, in Indonesia. In many of these countries
at least one-third of women reported that their daugh-
ters were cut by a trained healthcare provider [46].
Further, a higher number of younger women compared
with older women have been cut by medical personnel,
demonstrating a trend toward medicalization [7].
With this rising trend, understanding why healthcare
providers perform the practice and why women/families
rely on them has become essential. In an integrative re-
view of the literature on the motivations behind health
practitioners performing FGM/C in many practicing
countries as well as host countries [8], the main reasons
highlighted were; (1) the belief that having a health prac-
titioner performing FGM/C on a girl would be less
harmful than being performed by a traditional birth at-
tendant (i.e. harm reduction); (2) the belief that FGM/C
is a cultural practice; (3) the financial gains of perform-
ing the practice and (4) feeling pressured by the commu-
nity to perform the practice. Such reasons may vary,
however, from one country to the other.
Looking at Egypt, FGM/C is a deeply rooted practice,
where the prevalence of FGM/C among women and girls
ages 15 to 49 years old was 87% in 2015 [7]). However,
daughters of younger ages are less likely to be cut; 68%
among girls ages 1819 years [9]. Regarding age, trad-
itionally girls are cut slightly before or at puberty [9,10].
Although the practice has become illegal in 2008 and
rates are declining, Egypt continues to witness a drastic
surge in FGM/C medicalization over the past 20 years,
making it the country with the highest rate of
medicalization. According to Egypt Demographic and
Health Survey (EDHS) data, the rate of medicalization
among girls and young women ages 19 years and youn-
ger rose from 55% in 1995 [11] to 74% in 2014 [9]. This
increase could be attributed to a 1994 medical decree is-
sued by MoHP that allowed FGM/C to be performed
only by physicians in designated facilities at fixed times
and cost [12]. The decree was initially issued with the
intention of reducing complications and, eventually, end-
ing the practice. However, the subsequent deaths of girls
who were excised in hospitals pressured the ministry to
reissue a ban on the practice in all hospitals.
With increasing awareness of the adverse health con-
sequences and greater access to health care services,
healthcare providers have become increasingly involved
in performing FGM/C. Campaigns to abandon FGM/C
in Egypt gained momentum in the 1990s where many of
the messages conveyed and primarily highlighted the
immediate physical harms of FGM/C which may have
partly contributed to the rising medicalization of FGM/
C. Also, according to a study conducted in Qalyubeya
[13], mothers chose for their daughters to be cut by a
health care provider to mitigate risks. The main reason
given for having daughters cut by health care providers
rather than dayas (traditional birth attendants) was that
medical professionals had better training and knowledge
about performing FGM/C and, consequently, girls faced
lower risks of health complications. Mothers also reported
that they sought physiciansopinion on whether their
daughters needed FGM/C and, in some cases, physicians
recommended cutting [13]. Similarly, a study on
medicalization in Egypt found that 51% of physicians who
performed FGM/C operations reportedly did so out of
conviction and belief, while 30% did so for profit. The rest
claimed the reason was harm reduction by preventing par-
ents from sending their daughters to dayas [14]. Thus,
physicians may not merely respond to patientsdemands,
but may believe that FGM/C is medically indicated for
some girls (WHO 2010). The trust and credibility con-
ferred in them, because of their profession, has concerning
implications for the prospects of abandonment.
Another study examined medical studentsattitudes
and knowledge about FGM/C and found that only 31%
had a good level of knowledge. Fifty-nine percent of stu-
dents favored discontinuation, with a greater proportion
of females than males favoring discontinuation (76% ver-
sus 39%). The study found that men, who lived in Upper
Egypt, and who were of rural origin, and women who
were cut were more likely to support FGM/C compared
to women from Lower Egypt, of urban origin, and uncut
women, respectively. Students in pre-clinical studies
were also more likely to support FGM/C than those in
medical study [15]. The low levels of knowledge among
medical students suggests a need to understand and
analyze the kinds of information they receive during
their training and studies in medical school.
Although medicalization of FGM/C has been well-
documented in Egypt, a deeper understanding of the
drivers of medicalization is needed to inform the
conceptualization and development of appropriate inter-
ventions geared toward the abandonment of the practice.
Little is known about healthcare providers(i.e., physi-
cians and nurses) beliefs and motivations around the
practice, and about the demand for medicalized FGM/C.
To address this need, this study sought to identify the
factors that support the continuation or questioning of
FGM/C and the reliance on health care providers to
perform FGM/C.
Methods
We conducted a qualitative study among healthcare pro-
viders and mothers to identify the drivers and motives
El-Gibaly et al. BMC International Health and Human Rights (2019) 19:26 Page 2 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
behind the shift in the medicalization of FGM/C. The
study drew on a mystery clientapproach, coupled with
in-depth interviews (IDIs) and focus group discussions
(FGDs) with health care providers (i.e. physicians and
nurses) and mothers.
Study sites and population
To capture possible geographic variability, data were
collected in three governorates: Assiut, Cairo, and Al
Gharbeya. Cairo and Al Gharbeya are governorates in
Lower Egypt, while Assiut is a governorate in Upper Egypt.
Populations in these governorates have different socio-eco-
nomic and socio-demographic characteristics as well as
variable customs and traditions. Levels of medicalization of
FGM/C are also variable. In 2014, about 39% of ever-mar-
ried cut women and girls ages 15 to 49 in Lower Egypt
were cut by a health care provider, compared with 34% in
Upper Egypt [9].
The target population comprised physicians (males
and females), nurses and mothers of cut daughters. We
aimed to recruit physicians and nurses comprising a mix
of rural and urban-based practitioners, and young/older
physicians with different expertise levels. A total of 100
physicians and 36 nurses participated in the study. Phy-
sicians were general surgeons, gynecologists or general
practitioners. All nurses, by default, are women in Egypt.
Health care providers with these criteria (physicians and
nurses) were recruited by health directorates in the three
governorates via invitations sent to different primary
health care units, district and general hospitals.
Thirty mystery client visits were carried out; 20 visits
in private clinics in Assiut (n= 10) and AlGharbeya (n =
10) and in NGOs clinics in Cairo (n = 10). The selected
physicians were either general surgeons or gynecologists.
Key informants; community health workers or nurses
identified the popular physicians in the communities to
be visited. All were selected from a larger pool of physi-
cians who signed an informed consent of accepting be-
ing visited by a mystery clientsent by the governorates
health directorates to assess quality of reproductive health
counseling for research purpose only, with ensured confi-
dentiality. In Assiut and AlGharbeya, five of the selected
physicians were known by the key informants to perform
FGM/C while the other five were randomly selected sur-
geons and/or obstetricians/gynecologists. In Cairo, visits
were only made to public clinics run by NGOs because of
difficulties obtaining consent from physicians working in
private clinics. The timing of the visit was not disclosed.
The study included 39 women from the three gover-
norates: 18 from Assiut, 11 from Al Gharbeya and 10
from Cairo. Mothers were eligible to participate if they
had a daughter aged 14 years or younger who had been
cut within the two years preceding data collection. They
were recruited by NGOs personnel working at the grass
root level in the study sites.
Data collection
Data were collected between December 2016 and Febru-
ary 2017 using three different methods:
Mystery client visits Mystery client visits were used to
understand physiciansresponses towards mothers who
were seeking to have their daughters cut and those who
were ambivalent about FGM/C and were seeking advice.
Four research assistants were trained to present an-
onymously at each physicians clinic and to act out two
scenarios. One scenario involved an undecided mother
who wanted to cut her 18-year-old daughter on her
daughters fiancés request but was afraid of its compli-
cations. The other involved a mother who was deter-
mined to cut her 12-year-old daughter and visited the
physician to set an appointment for the procedure and
asked about technicalities/logistics (i.e., timing, venue
and cost). These scenarios were constructed based on
the findings of the performed FGDs with physicians who
mentioned that they are usually asked to cut girls at the
age of 1012 or asked to cut older girls about to get
married. Mothers also in the FGDs mentioned that they
seek the consultation of physicians either for cutting
their girls at the age of puberty or when asked by their
daughters fiancée or his family to cut the bride as a pre-
requisite for marriage. Both scenarios were discussed
and agreed upon by the advisory committee of the
National Population Council in Egypt to explore the re-
sponses of physicians when they face both situations.
The mystery clients were trained to ask questions re-
lated to the conditions that necessitated FGM/C, the ad-
vantages and disadvantages of FGM/C, complications of
FGM/C, consequences on marital sexual relations, the
immediate risks of the operation, the cost, any precau-
tions prior to the encounter, place of performing the
procedure, using anesthesia and healing time.
The research assistants visited the clinics in pairs.
During the visit one of them acted as a mother seeking
consultation on FGM/C and the other acted as an
accompanying relative. Appointments were made ahead
of the visits via telephone. The research assistants docu-
mented the discussion that had taken place with the
physician immediately after the visit. The debrief in-
cluded the physicians response to the request to per-
form FGM/C; his or her opinion about the importance
of FGM practice and whether FGM/C was indicated or
not; the physicians beliefs about the most suitable age
for performing FGM/C; feedback on the effects of FGM/
C on marital sexual relations; discussions on the ad-
vantages, disadvantages and expected complications of
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FGM/C, place and time of conducting the operation,
using anesthesia and the cost of the operation.
Focus group discussions Four focus group discussions
(FGDs) were performed in each governorate: three FGDs
with health care providers (male and female physicians,
and nurses) and one FGD with mothers. FGDs with health
care providers were designed to explore their attitudes re-
garding FGM/C, medicalization of FGM/C, gender norms,
perceptions of female sexuality and its links to FGM/C, as
well as their level of preparedness to consult couples on
sexual health issues (i.e. sexual health knowledge, gender
issues related to rights of men and women, etc.). FGDs
with mothers of cut girls aimed to understand their moti-
vations for FGM/C and their choice of health care pro-
vider. FGDs also explored the mothersunderstanding of
the messages against FGM/C and the role of their social
network on making the decision to cut their girls.
Each FGD lasted between 90 and 120 min. Discus-
sions were guided by a semi-structured discussion
guide that was designed for this study and were audio-
recorded [16] (Additional file 1). The FGDs were tran-
scribed by note takers while preserving the anonymity
of the participants.
In depth interviews Six in-depth interviews (IDIs) were
conducted with physicians. In each governorate, one
male and one female physician were interviewed. The in-
terviews explored sensitive issues related to female and
male sexual health problems and sexuality and FGM/C
in medical practice. Interviews were guided by a semi-
structured interview guide that was designed for this
study [16] (Additional file 1). All IDIs were audiotaped
and lasted between 60 and 90 min.
Ethical considerations
Ethical approvals were obtained from the Ministry of
Health and Population, the Institutional Review Board
(IRB) of Assiut University, and the Population Councils
IRB. The letter of approval from the Ministry of Health
and Population clearly stated that the identities of the
health providers would not be shared with the Ministry
or any other entity/individual. The Ministry was respon-
sible for informing physicians that there was a study
assessing the deficits of providing reproductive health
counseling to mothers/parents. Forty physicians in
Assiut and Al Gharbeya governorates and physicians of
two NGOspublic clinics in Cairo consented in writing
to the mystery client visits. Physicians were informed
during the consenting process that their clinics may or
may not be sampled. However, the exact timing of the
study/visit was not disclosed. The confidentiality of the
performed visits was protected by replacing the names
of physicians by numbers and obscuring the location of
the visited clinics in the transcripts. Any personal infor-
mation which might disclose the identity of the partici-
pants was not inserted in the manuscripts.
FGD participants were informed about the objective
of the study and how their confidentiality would be
protected. All participants were assured that their
participation in the study was completely voluntary
and that they could withdraw at any point in the
study. Written informed consent and permission for
digital recording were sought. Confidentiality of the
participants was preserved by removing all names
from the transcribed files and using numbers or different
names. The recorded digital tapes were kept only with the
researcher.
Analysis
Audio files and notes from the IDIs, FGDs and mystery
client visits were transcribed in Arabic. Data analysis was
performed using the inductive thematic analysis method-
ology [17]). The transcripts were read repeatedly, and the
raw data were coded thematically. Codes and labels were
attached to portions of the text related to a specific theme,
leading to a set of descriptive themes and sub-themes
for each transcript. Data units were constantly com-
pared to identify similarities and variations within
categories. All codes were then clustered into themes
and sub-themes. The themes were confirmed, modified
or discarded from the ongoing analysis by re-examina-
tions of earlier data and considerations of subsequent
data collection.
Results
FGM/C is perceived to be entrenched in custom and
tradition
As expected in the study context, respondents consi-
dered FGM/C an important cultural obligation. Across
the board, the compulsion to adhere to community cus-
toms and traditions was revealed to be mothers, particu-
larly those who were older, most important motivation
for cutting their daughters. Findings from the IDIs and
FGDs suggest that mothers see FGM/C as an essential
practice and therefore end up cutting their daughters
without critically assessing their decision to do so. Pres-
sure from female family members and other community
members may further reinforce the practice. These views
are highlighted in the following quotes;
We grew up finding our grandmothers, mothers and
all people circumcising; [it is] a tradition that you
have to do.Mother, Cairo
Circumcision has no advantages, but we grew up and
found our folks that way.Mother, Cairo
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I circumcised my daughters [so] that my conscience
would be in peace, to be like all other people.Nurse,
Assiut
As further testament to the extent of social pressure
faced by mothers, many participants were not particular
about the type or extent of the cut. They accepted the
removal of just a tiny part of the external genitalia for
their daughters to be considered cutas illustrated in
the following quote;
I brought the doctor to my home and he said no
need, so I replied saying just for the people here, take
a tiny scrap for the talks.Nurse, Assiut
The mystery client exercise unearthed similar findings,
as demonstrated by this quote from a male physician in
Al Gharbeya;
We cut her. Whats the problem? There are no
problems from circumcision now, bring your daughter
today and if needed I will cut her immediately
tomorrow. We can cut a small part just for her
mother-in-law.
Narratives from study participants suggest that health
practitioners are not immune to the societal pressure to
perform FGM/C on their clients. This pressure is
brought about by the perceived entrenchment of this
customary practice. In rural areas in particular, refusal
to perform FGM/C by health providers (especially recent
graduates) was reported to pose reputational risk and
was said to result in a loss of community trust. Physi-
cians who refuse to perform FGM/C were reported to
have lower client loads and, therefore, reduced income.
As a male physician in Cairo explained;
Doctors in the villages practice a lot (of circumcision)
because if he does not do it, the people will be upset
with him and no one will come to him, even for a
cough. He will be marked.
Beyond reputational risk, health practitioners pointed
out that they were also members of the communities in
which they practiced. This reality posed challenges for
maintaining professional distance from the customary
entrenchment of FGM/C. Despite having a medical edu-
cation, physicians themselves, especially those who were
from rural areas, were also affected by the prevailing cul-
tural norms and beliefs of their community. The pres-
sure to conform to cultural norms sometimes meant
that they performed FGM/C although they were aware
about the medical risks involved. The following quotes
from health providers illustrate these points;
Doctors are part of the people, part of society and
people who are convinced do it in particular because
we didnt come across it in our medical education.
Male physician, Cairo
When my daughter was 12, I know that this is
not good, but I have fears for her and people
would talk [gossip]. I refused to inspect her, so I
told her I am going to take you to a colleague of
mine just to have a look. She was crying all the
way from home until we went to the doctor and
asked me, Mama, what are the advantages of
circumcision?Look, I am going to tell you
something. Sometimes you know that this thing
is wrong, but you do it out of fear. Do you
understand?Female physician, Cairo
Performing FGM/C has financial benefits for providers
According to some physicians, financial benefits were
the most important motivator for physicians to perform
FGM/C. The narratives from physicians suggested that
those who performed the practice due to the financial
benefit may understand its hazards and illegality, but still
perform it in secrecy. These views are articulated in the
following quotations;
More than 50 percent of the doctors in the rural
areas do these things for several reasons. First for
financial gains and trust of people that he [the doctor]
responded to their needs and they will come to him for
other matters. And if he does not do it he will be
stigmatized.Male physician, Cairo
Believe me, FGM/C in Egypt is not because people ask
for it, but it is driven by physicians and nurses. I swear
if it wasnt for the financial benefits out of it, no girl
would have been circumcised in Egypt. People get
easily convinced by health care providers.Female
physician, Al Gharbeya
When mystery clients asked about the cost and
the charges for FGM/C they were given varying
amounts ranging from 250 Egyptian Pounds (LE)
(US$14) to 1500 LE (US$85). The requested charges
were higher for older girls. Physicians noted that
they ask for high prices because of the cost of the
anesthesia and hospital fees, when performed in a
private hospital. As illustrated in the following quote
from a male physician in Al Gharbeya, the costs
were also reportedly affected by how extensive the
procedure was, When I see her (examine her) and I
know how much I will remove, I will tell you how
much I will take.
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Some providers view the performance of FGM/C as their
religious duty
Providers noted that in some cases, providersreligious
convictions around FGM/C influenced their decision to
perform FGM/C. They noted that, in some cases, physi-
cians who are convinced about its importance may per-
form it for women during delivery, even without being
requested to do so.
There are people who do it (FGM/C) and are strongly
convinced about it, people who are (I dont want to
classify them) Muslim Brotherhood, Sunni, especially
the Sunnis, those with beards, and those religiously
fanatic, these ones do it out of religious conviction,
even if they do not take money. The one who does it
for money can cut ten people and the one who does it
for religion, can cut a hundred.Male physician, Al
Gharbeya
Some physicians in Assiut and Al Gharbeya believed
that performing FGM/C was a religious obligation des-
pite being condemned by Al-Azhar (Highest Muslim Re-
ligious Authority). Other physicians considered FGM/C
as Sunna”–that is, not mandatory, while others refuted
a religious basis for FGM/C. Physicians based in Assiut
and Al Gharbeya were more likely to believe that there
were religious indications for performing FGM/C than
physicians based in the other study sites, which may
reflect the more conservative culture in Upper Egypt.
If it [circumcision] were forbidden, why was it done
originally? Okay, why was it done in many Islamic
countries? If it was forbidden and haram [religiously
wrong], why was it done from the time of my
grandmother and your grandmother before us?
Female physician, Al Gharbeya
As illustrated by the following quotes, some physicians
and nurses also believed that Sunna circumcisionis of
the first degree and did not have any negative conse-
quences on marital sexual relations.
I may perform FGM/C when needed for the girl,
andtoavoidtheproblemswhichwouldhappenif
she was not cut. The Muslim Prophet, when asked
about female circumcision, said shorten but dont
over-excise, which means performing a minor cut for
the cosmetic appearance.Female physician,
Al Gharbeya
It is okay to cut a small part, just for beautifying the
clitoris, and the Prophet said shorten but dont over-
excise, which means that we shouldnt cut much.
Nurse, Assiut
FGM/C is not included in the medical training of health
care providers
Despite the high prevalence of FGM/C in Egypt, physi-
cians indicated that FGM/C did not feature in their
medical school curriculum or training. Almost all of
them mentioned that they only studied the anatomy of
the female genital system. Only a few physicians stated
they had some exposure to the prevalence of FGM/C in
Egypt in the public health curriculum or the reproduct-
ive health postgraduate curriculum. As intimated by a
male physician in Assiut, I never took anything deep
about FGM/C. We took the anatomy of the female
system. That is the information I have.
Given the lack of medical training for performing
FGM/C, providers who perform it mentioned that they
learned about the practice from their colleagues. They
also mentioned that physicians used different techniques
because they had no reference. As a male physician in
Assiut noted, Nothing in medicine taught us how to
[perform FGM/C], and I didnt study it during my years
of education. Whether cutting from the right or from the
left, it is personal.
Most physicians and nurses further indicated that
except for training on the anatomy and physiology of
the female genital organs, they had received no training
on sexual health. Their knowledge about sexual health
was limited to what they had learned from self-reading
and internet searches. These views are illustrated in the
following quotes from health care providers;
We had obstetrics/gynecology in the fourth year of
medical school and it was one lecture on sex and that
year this lecture was removed for political reasons.
Male physician, Assiut
We took physiology and histology but not sexuality. In
Assiut University, they talked about the science of
orgasm and functions but not sexuality.Male
physician, Assiut
What I know about sexual health comes from the
time I was in secondary school when the Always
(sanitary pads) company came and gave us a brochure
on periods, the body, the monthly ova and drawing of
the uterus. That is it. I still have a copy [of the
brochure].Nurse, Al Gharbeya
Few physicians had correct knowledge that sexual
health is a broad term encompassing physical and psy-
chosexual aspects, while most providers mentioned
incorrect definitions of sexual health. Most of them
stated that sexual health only encompasses sexual inter-
course. Unsurprisingly, therefore, some physicians re-
ferred erroneously to the presence of smegma between
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labia minora and labia majora as an indication for FGM/
C (i.e., cutting the labia minora), as it could be a predis-
posing factor for cancer. In line with this gap in sexual
health training, physicians felt ill-equipped to provide
counseling on sexuality and sexual health despite the
admitted demand for it from their patients. Physicians
spoke of their experiences handling clients with sexual
health problems. Some stated that they were too embar-
rassed to discuss sexual health issues with their clients,
mentioning that they usually used medical management
and failed to provide any counseling.
We are not prepared at all. Really, we are asked a lot
and we are being exposed to many situations as
gynecologists. For example, patients with sexual
dysfunction come and say this happens with me and
this does not. I am not prepared to respond but it is a
basic part of our practice.Male physician, Assiut
If a newly married woman came seeking my
consultation, I cant tell her anything, not because of
embarrassment, just because I dont know, and I tell
her to ask someone else better than me.Female
physician, Assiut
Sexual health? I dont know what that means. We
treat medical issues, but we dont know how to do
sexual health consultations.Female physician, Assiut
Sexual health consultation is a doctors own effort.
None of us learned it. Everyone learns by himself.
Patients come to us to ask us about sexual health. I
tell them, you tell me.Female physician, Al Gharbeya
Some physicians also felt that providing sexual
health counseling could be unacceptable to the com-
munity, especially when provided by an unmarried fe-
male physician.
There is no sexual education and the society
disapproves of that, and what we know is from our
own personal effort, but we didnt learn it [in medical
school].Female physician, Assiut
If she is single [a virgin], even if she is a doctor, they
will not accept her consultation. In other words, doctor
[X] will be accepted but I wont be. They would say it
is disgraceful, it is unacceptable for a girl to talk
about sexual health, even if she is a doctor.Female
physician, Assiut
This gap in training and knowledge arguably helps sus-
tain the practice of FGM/C. If providers do not recognize
sexual health as a fundamental part of overall health, and
if they do not make the possible connections between
poor sexual health and FGM/C, then they are less likely to
work towards the abandonment of the practice.
Mothers, on the other hand, are unaware of health
care providerslack of knowledge and training on FGM/
C and underscored their preference to have their daugh-
ter cut by health providers rather than dayas. They
stated that health providers were a trusted source of
health care and highlighted the clean environment in
health facilities and the use of sterile equipment.
Mothers also reported that health care providers were
better trained, cut less tissue, used anesthesia and
followed up with patients. Having the procedure per-
formed by trained practitioners, and preferably in a
clinic or a hospital, was thought to minimize the health
risks, pain, and, even, marital sexual problems, while
sustaining the practice to meet cultural norms.
The doctor has experience and has been educated.
A daya is fine but education is good, a daya would
spray an anesthetic but a doctor gives an injection of
anesthesia in the side and the girl feels nothing but
can see.Mother, Cairo
Women who have problems with their husbands
because they were circumcised by a daya. If it were a
doctor, it would be different. I have been circumcised
by a doctor. My sisters by a daya. They have problems
and I dont.Mother, Assiut
Social construction of girlswell-being makes FGM/C a
perceived necessity
Further analysis of respondentsnarratives suggests that
the practice of FGM/C is driven by the social construc-
tion of girlswell-being in the study setting. Participants
narratives reveal various concerns that mothers have for
their daughtershealth and happiness, and comfort in
Egyptian society. The narratives demonstrate that girls
well-being is constructed around how they are viewed by
others in the community. Attributes such as propriety
and bodily beauty afford a girl respect from the commu-
nity. These attributes also increase a girls marriageabi-
lity, particularly in the rural areas. A lack of such
characteristics is associated with being uncut a status
that is stigmatized. Understandably, therefore, mothers
have a shared goal of ensuring their daughters meet
community standards (and therefore undergo FGM/C),
thus attaining better life chances in general.
Sexual purity, for instance, was a key construct that
participants referred to in their conceptualization of
girlswell-being. When referred to, sexual purity for girls
was often framed in terms of low (or a total lack of)
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libido, which was also viewed as evidence of good
behavior.Respondents in Cairo and Al Gharbeya were
more likely than their Assiut peers to express these opin-
ions. These views are illustrated in the following quotes
from mothers;
She would have more sexual desire than her husband
if left uncircumcised that is why they say circumcision
is good for girls.Mother, Assiut
In villages, they say the uncircumcised girl would
have much more sexual desire, would like to talk to
men all the time instead of girls and would play
mainly with boys. So, her behavior would not be good.
Mother, Assiut
I had a daughter her body was hot[sexually excited].
When I circumcised her, she calmed down. I used to
tell her you are agitated, but she became good and
came back to her mind when I circumcised her. My
mother-in-law told me to circumcise her. I sent her to
Fayoum because my sister-in-law is a nurse at a
doctors clinic and she circumcised her.Mother, Cairo
Some mothers, physicians, and nurses disputed any as-
sociations between FGM/C and girlssexual excitement
and behavior, however, contending that sexual arousal is
a complex biological and neurological process, or point-
ing out the effect of environmental and relational factors
on sexual behavior.
Interviews and discussions with study participants
demonstrate that girlswell-being is also linked to their
bodily beauty in the study context. Indeed, most mothers
in Assiut, for example, did not link FGM/C to sexual be-
havior, but rather to genital hygiene and cosmoses. Most
of them reportedly cut their girls to ensure that they did
not have a protruded clitoris that would be erect during
sexual intercourse, which they considered unacceptable.
Uncut girls were considered to have similar organs to
men, which was considered unfeminine and unattractive.
These perceptions are illustrated in the following quotes;
They say a girl if left uncircumcised would be like a
man. We have to cut these things. How can a girl be
like a man? If she would not be circumcised, she would
be like her husband. This is not right. At the same
time, it is cleanliness for her too.Mother, Assiut
There was a doctor and I heard him saying I was
assisting a woman in her delivery and her genitalia
looked so ugly from beneath. If I am a doctor and not
her husband and see it this way, what does her
husband do with her?And I heard the same doctor
saying we need to set up a committee of obstetricians/
gynaecologists and Al-Azhar to do a medical
examination for the girl to decide whether she needs it
or not.Nurse, Al Gharbeya
I saw a girl who has large things, skin protruding
down and long and the whole thing looks very bad. I
saw many cases like that. I work in rural areas. If you are
working in the urban areas, you have not seen anything. I
stayed 20 years in rural areas and saw a lot of cases that
had to be done [circumcised].Male physician, Assiut
The mystery client exercise reinforced these findings, as
female and male providers alike repeatedly referred to
beautyand uglinessin regard to girlsgenitalia. As dem-
onstrated below, their words were usually set in the con-
text of assistance and support to ensure the best outcome
for the girls concerned within marriage and otherwise:
Yeah, there are girls God created them looking
normal and beautiful from underneath [genitalia],
and there are girls who have large organs. As the
prophet said, dont overdo it and cut a little, from the
clitoris; we cut a small part because if it [protruding
genitalia] is long, it causes problems and looks very
ugly.Female physician, Al Gharbeya
Bring her. Ill take a look (examine her) and then Ill
decide. If it [genitalia] looks ugly and will affect
marriage, we cut it and if it is okay, we leave it. By the
way, there are married women who come for us to do
corrections for them. I just have to see what is there. I
havent seen anything...you are telling me something
vague. I have to see with my own eyes and will do
what is needed for her.Male physician, Cairo
Nurses in Al Gharbeya were more likely to support the
cosmetic and hygienic indications of FGM/C than providers
in other settings. Providersfocus on enhancing bodily
beauty is arguably linked to issues that are perceived to en-
sure girlswell-being, including their marriageability. In
some rural areas, uncut girls were reportedly required by
their fiancés to undergo FGM/C. Moreover, some mothers
mentioned that husbands would force uncut wives to get
cut to avoid shame or to ensure their wivesfidelity. The
views are illustrated in the quotes below;
A man from Upper Egypt married a woman from
Lower Egypt and he swore not to consummate the
marriage unless she is circumcised.Nurse, Assiut
People would repeatedly tell him your wife is
uncircumcised. The whole village knows each other
and knows who is and who isnt circumcised.
Mother, Assiut
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The discursive (re)framing of FGM/C by the medical
community casts the practice in a positive light
Findings demonstrate how the language around FGM/C
is being reframed by health care providers. As shown in
the following quotes, many physicians who performed
FGM/C denied that they practiced FGM/C, preferring to
refer to the procedure as a cosmetic operationinstead.
It is plausible that providers rely on such terms to free
themselves of the blame directed to the physicians when
cutting girls. Providers claimed that in most cases, they
only cut the labia minora and not the clitoris, except
when the clitoris was enlarged and protruded out of the
labia minora.
A doctor in Assiut in a training workshop said we
beautify women, although he has a high scientific
degree and knows this practice is harmful.Female
physician, Assiut
Idontcallitcircumcision,Icallitrefinement.
For me, as a doctor, I dont do this case as female
circumcision, I do it as a technical case. For
example, after the age of 16 to 17, when everything
is clear and there are problems from it, so I do this
refinement or cosmetic operation.Male physician,
Al Gharbeya
There is a woman doctor who told me that many
people come to ask for this operation. They say they
feel that the labia minora is large and she does it to
them, but she does not come close to the clitoris. I told
her that is circumcision, she said no. People ask for it
as a cosmetic need, she considers it cosmetic and not
circumcision because it is the labia minora only.
Female physician, Assiut
This is not considered circumcision with the common
meaning that we remove the clitoris, but you are
beautifying the labia. Its normal. I have patients who
are married and do it after marriage and birth too.
Female physician, Al Gharbeya
In speaking about FGM/C, providers described female
genitalia as either normalor abnormal,depending on
the extent of labial protrusion. Provider narratives cast
labial protrusion in a negative light. Most physicians and
nurses mentioned that they had female patients with
oversized genitalia, which they thought should be re-
moved. They mentioned that they examined girls
genitalia and classified them into indicatedand non-
indicatedcases for cosmetic correction to the normal
shape, which they considered non-protrusion of the
clitoris out of the labia minora. They mentioned several
complications of non-removal, such as repeated
infection, bad odors, bleeding, sexual excitement and
dyspareunia. Some of them considered these cases to be
congenital anomaliesthus providing further rationale
for performing FGM/C.
There are cases that are in need [of cutting]. If I have
an extra finger, I will accept it but others might not
especially those who live with me. We dont remove it
completely. We make it normal, the extras [skin] are
not normal. If someone is going to do something
[FGM/C], he has to know, understand and then decide
that this has to be removed.Male physician, Assiut
If anatomically the girl is all right, there is no
problem. But if she is not, she should be circumcised.
Otherwise, if she does not observe hygiene, she can get
a fungal infection. She can also bleed from the extreme
friction, and it could cause her pain in sexual
intercourse and result in divorce. It has happened in
our village that people got divorced because of this
issue.Male physician, Al Gharbeya
Look, the normal size is that when the labia majora
are closed. Nothing is protruding from them. That one
does not need it but if there are protrusions outside the
labia majora, there would be a need [to cut the girl].
Female physician, Al Gharbeya
Responses of the physicians to clientsrequests to
perform FGM
When physicians were visited in their clinics by the
mystery client (an actor mother) and were requested to
perform FGM/C to the daughter, they had different re-
sponses. Four physicians accepted to perform FGM imme-
diately, and asked the actor motherto bring the girl for
the operation. They were very supportive to FGM and
even convinced the hesitated mothers about its impor-
tance regarding the cosmetic and hygienic indications.
Almost half of the physicians (14 out of 30 physicians)
asked for examining the girl before taking a decision
whether to accept or not to perform such practice. They
mentioned that they would decide the need according to
the size of the clitoris and labia minora. We cant con-
clude what would happen after examination. They could
have done so to prepare her for the procedure or to con-
vince the mothers that their girls arent in need for such
practice, as mentioned by some physicians in the FGDs.
I will give you my decision after examining the girl, as
circumcision could be indicated for some cases and not
for others. Some girls have a large clitoris which needs
to be cut. If not, it is not indicated for this case.Male
physician, Al Gharbeya
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Six physicians refused to perform FGM but referred
the cases to other colleagues who are known to perform
such practice. They refused performing FGM either due
to being against the practice or because their clinics
were not equipped for performing such procedure. Only
six physicians were very determined in refusing to
perform FGM and also refused to recommend other
colleague for performing it.
I will be honest with you. I never perform female
circumcision, but I will tell you about a trusted
colleague who would perform it. This procedure needs
to be performed in a private hospital, not a clinic, even
if it is more expensive.Female physician, Cairo
I dont circumcise girls. First, this is criminalized by
law and the penalty has been also increased recently.
Second, it has no indications and has nothing to do
with sexual purity. You should better discuss her
fiancée and convince him with what I told you.
Female physician, Assiut
Discussion
After more than 30 years of investments in FGM/C
abandonment interventions in Egypt, an alarmingly high
number of physicians in Egypt perform FGM/C. This is
despite legal sanctions against the practice, being bound
by the Hippocratic Oath to do no harm and the declar-
ation of Al-Azharthe highest religious authority in
Egyptthat FGM/C is not part of Islam. Study findings
suggest that FGM/C continues to be widely practiced
primarily because it protectsfemales by limiting their
sexual desire and enables them to behave in culturally
appropriate ways. However, continued discourse around
FGM/C, as well as womens own experiences, are fueling
change to the practice with FGM/C now being per-
formed primarily by health care providers, particularly
physicians and nurses, for health reasons. Study findings
also suggest that legal, religious, moral and social norms
relevant to abandonment of FGM/C practice are not
harmonized and result in a mosaic picture of FGM/C
practice among the health care workers (physicians and
nurses) as well as clients (mothers).
The results show that the drivers of FGM/C practice
overlap with drivers of medicalization. The practice of
FGM/C among daughters of health care providers,
whether nurses or physicians, is an important finding,
even if not as common as in the wider community, as it
strongly reflects how social norms outweigh the law and
medical ethics. This group of providers may perpetuate
the practice and drive its continuation. Many of the re-
ported reasons for maintaining the practice by health
care providers are consistent with what is reported in
the literature: the belief that it is a cultural or religious
obligation, harm reduction, physicians perceived by
parents (mothers) as offering more safety and better
handling of complications, and financial benefit.
Study findings suggest that most nurses and some
physicians are still strongly influenced by their own cul-
tural group convictions and report practicing FGM/C in
their own families because they still consider it a cultural
obligation to which they must adhere. This has been re-
ported by other studies in different African countries
[18,19]. Other than practicing FGM/C in their own
families, culture affects the practice of FGM/C by physi-
cians in different ways. First, physicians face social
sanctions (loss of respect and trust) if they refuse to cut
girls in rural communities with possible financial con-
sequences. For some of them these sanctions have a
stronger influence than moral and legal norms for aban-
donment of FGM/C. Second, some physicians tolerate
the practice even if they themselves do not believe it in
it and, therefore, are willing to refer parents to practicing
providers. This suggests that many providers do not
understand that the practice is a criminal act against a
child or that FGM/C has consequences on female health
and sexuality.
Study findings underscore three issues that should be
addressed in FGM/C abandonment efforts: renaming
FGM/C as a cosmetic operation and not cutting; justify-
ing a Sunna typeof FGM/C by health care providers;
and the gap in undergraduate medical and nursing edu-
cation on FGM/C and female sexuality and sexual
health. Reframing FGM/C as cosmetic surgery is prob-
lematic because it legitimizes the practice. The law
against FGM/C in Egypt has been repeatedly modified
but has not dealt with female genital cosmetic surgery
(FGCS) among young adult females more than 18 years
old. FGCS is a global phenomenon that has triggered
feminist activism [20]. Although professional bodies,
such as the American College of Obstetrics and
Gynecology (ACOG) issued a statement in 2007 indicat-
ing these procedures were not medically indicated, nor
is there documentation of their safety and effectiveness,
it was not decisive on sanctions against surgeons prac-
ticing or advertising such surgeries [21]. In a country
such as the United States, where the FGM/C socio-cul-
tural context and its medicalization is different, FGCS
may not be a significant issue, but in Egypt, with high
FGM/C prevalence and widespread medicalization,
FGCS can have extensive negative consequences and
needs to be addressed by professional and legal bodies.
In a context marked by significant gender inequality,
young adult females in Egypt may consent to such
operations underestimating the long-term consequences
on their sexual health. Cosmetic surgery is also an
implicit way to market FGM/C to mothers of children.
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The framing of FGM/C as Sunnais also problematic.
The word Sunnafor Muslims means following the
Prophets practices. Sunna circumcision for Muslims is a
requirement for boys, but not for girls, and it entails
removal of the prepuce of the penis. Abandonment
activities against FGM/C must clearly state that there is
no form of FGM/C that is Sunna type. Doing so, will
ensure the separation of FGM/C from any religious
connotations.
Study implications
With the culture of FGM/C still strong, tackling
medicalization would only be possible by addressing
both the demand for it by the community, as well as its
supply by medical professionals. Sexual education should
be included in school curriculum and integrated in so-
cial marketing campaigns for FGM/C abandonment. It
should tackle not only FGM/C as a practice, but also
correct its associated misconceptions. Moreover, infor-
mation on FGM/C health and legal consequences should
be integrated within the medical school curriculum
framing FGM/C within a wider sexual health discourse.
This will help in changing the mindset of medical practi-
tioners to see the long-term effects of FGM/C. A team
of experts would be instrumental in ensuring that the
topic is tackled from all different perspectives.
Health care providers need to be equipped with the
appropriate counseling skills on FGM/C to be better
able to convince clients to abandon the practice. The
use of innovative methods in training and role plays with
well-prepared scenarios of different customersrequests
of FGM/C and how to deal with each should be inte-
grated in training sessions. Religious, moral and legal as-
pects of FGM/C need to be included in training sessions
and in awareness raising activities to ensure the delivery
of a holistic multi-dimensional message. Furthermore,
the medical syndicate should take punitive measures
against physicians who practice FGM/C by revoking
their license.
Study limitations and strengths
The study has some limitations. The study was con-
ducted in 3 different governorates in an attempt to
capture as much variability as possible. However, like
any qualitative research the sample is not representative
to the whole population. However, much strength exist
in the study as it is the first study in Egypt highlighting
the medicalization of FGM/C from perspective of both
supply and demand side in various geographic areas
(Upper Egypt, Lower Egypt, and Metropolitan Cairo) of
Egypt that show differences in the practice. The mys-
tery clientsapproach illustrated the real life responses
of physicians regarding FGM/C performance.
Conclusions
As suggested in the study findings, there remains to be a
wide diversity of opinions regarding the medicalization
of FGM/C in Egypt. This creates a culture of hesitation
and further uncertainty which may motivate more
mothers to seek a healthcare professionals advice on
cutting her daughter. It may thus cause a further rise in
medicalization as long as social, moral and legal norms
are not harmonized.
To the best of our knowledge, this is the first study to
explore the reasons related to the involvement of health-
care professionals in the medicalization of FGM/C in
Egypt from a qualitative perspective. However, the mag-
nitude of the practice of FGM/C in health care pro-
vidersfamilies should be a focus of research, as they can
never be agents of change if they continue the practice
in their own families. Further research is also needed to
document the number of health care providers who per-
form the practice. However, such a suggestion may be
challenging given that FGM/C is criminalized in Egypt
and the practice is being driven underground. Neverthe-
less, the use of technology and innovative methodologies
may assist in extracting such data which in return will
allow for better policy and programmatic responses to
the issue of medicalization, and FGM/C in general.
Additional file
Additional file 1: The Focus Group Discussion and In-depth Interview
Guides file includes the English language version of the guides that were
designed specifically for the purpose of this study and were tailored for
mothers as well as nurses and doctors to understand their perceptions
pertaining to the medicalization of FGM/C. (DOCX 18 kb)
Abbreviations
EDHS: Egypt demographic and health survey; FGCS : Female genital
cosmetic surgery; FGD: Focus group discussion; FGM/C : Female genital
mutilation/cutting; HCP: Healthcare provider; IDIs: In-depth interviews;
IRB: Institutional review board; LE: Egyptian pounds; MoHP: Ministry of health
and population; NGO: Non-governmental organization; UNICEF: United
nations childrens fund; WHO: World Health Organization
Acknowledgements
The authors would like to thank the Population Council and the Evidence to
End FGM/C research programme for supporting this study technically and
financially. We give special thanks to Chi-Chi Undie, Caroline Kabiru and
Bettina Shell-Duncan for their reviews and comments on this report. We
acknowledge the role of the Population Council-Cairo office, especially Dr.
Nahla Abdel Tawab for her support through-out the study and field work.
We would never have been able to conduct this study without the political
commitment to end FGM/C and support of our colleagues in the Ministry of
Health and Population (MoHP) in Assiut and in national and grassroot level
NGOs working in this field. We will continue our fight towards abandonment
of FGM/C in Egypt and provide evidence that is needed to support the
positive change. Thanks to all the mothers, nurses and physicians who
shared their life experiences in this study, which resulted in this report that
deepens our insights on FGM/C and the design of interventions.
Authorscontributions
OEG and MA designed and carried out the study as well as analyzed the
findings and wrote this manuscript. SAH contributed to the implementation
El-Gibaly et al. BMC International Health and Human Rights (2019) 19:26 Page 11 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
of the research, the data collection and the writing of the manuscript. All
authors have read and approved the final version of the manuscript.
Funding
Funding for this work was provided by UK Aid and the UK Government
through the Department for International Development funded project,
Evidence to End FGM/C: Research to Help Girls and Women Thrive,
coordinated by Population Council. The funding bodies provided feedback
that would help refine and strengthen the design of the study at the
preliminary phase as well as the interpretation of the data and the writing of
this manuscript after the study was conducted.
Availability of data and materials
The datasets used and/or analyzed during the current study are available
from the corresponding author on reasonable request.
Ethics approval and consent to participate
Ethical approvals were obtained from, the Institutional Review Board of
Assiut University, and the Population Councils Institutional Review Board.
This study was given a full IRB approval by the Population Council in August
2016, under Protocol No 751.
Written informed consent was obtained from all participants.
Consent for publication
The authors of this study obtained verbal consent from all the participants
who took part in the focus groups, in-depth interviews or the mystery clients
for direct quotes made by them to be used in this manuscript. The consent
clarified that the data obtained will be analyzed and published in an
academic journal.
Competing interests
OEG and MA were both consultants for the Evidence to End FGM/C research
programme, coordinated by Population Council to conduct this study in
Egypt. SAH is an employee of the Population Council-Cairo office, under
which this study was carried out.
Author details
1
Assiut University, Assiut, Egypt.
2
Population Council, Cairo, Egypt.
Received: 30 October 2018 Accepted: 20 May 2019
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... Practicing and justifying FGM reflect the cultural and social dimensions of the community where it is practiced. The cultural ideals of beauty and cleanliness of the circumcised genital organs is deeply entrenched in some communities [5,6]. Gender inequality norms also urges the practice of FGM to control women's sexuality and safeguard the honor of the family by ensuring virginity among young girls and marital fidelity among married women [7]. ...
... It was found that about 62% and 65% of mothers and fathers who have participated in EHIS believed that FGM should continue. Several other studies in Egypt have also shown the continued community support for the practice of FGM whoever the perpetrator [5,[19][20][21]. A variety of social and cultural reasons for supporting FGM are reported, including female cleanliness, cultural identity, protection of virginity, prevention of immorality, better marriage prospects, greater pleasure for the husband and improvement of fertility [4,22]. ...
... This could be attributed to the acceptance of FGM as an entrenched tradition and social norm in the poor communities where illiteracy prevails [28, 29]. Furthermore, the poor and less educated are ignorant about the negative consequences of FGM and don't consider women's sexual rights [5,29]. These findings were consistent with other studies [17, 30,31] as wealth is usually connected with other social parameters (e.g., place of residence and/or household level of education). ...
Article
Full-text available
Background: Despite the observed decrease in female genital mutilation (FGM) prevalence, it is increasingly being medicalized. We examined the attitudes of both parents towards the FGM practice in Egypt, and highlighted the effect of fathers' decision making and attitudes towards FGM and violence on FGM practice and medicalization. Methods: This study is a secondary analysis of Egypt Health Issues Survey (EHIS), 2015. The 2015 EHIS involved a systematic random selection of a subsample of 614 Shiakhas/villages out of the 884 shiakhas/villages that had been chosen as Primary Sampling Units in the 2014 EDHS. Descriptive statistics of the study sample and parents' attitudes was performed. Three indices were created describing; mothers' and fathers' attitudes towards FGM, decision making and rejecting violence against women. Bivariate and multivariable analyses were conducted to identify predictors of FGM practice and medicalization. Results: A considerable proportion of EHIS girls; 16.4% were circumcised and 36% of girls were expected to be circumcised. More than two thirds of circumcised girls were circumcised by a physician; namely 67% and 13.5% by nurses. The majority of mothers (88.4%) and fathers (84.8%) believed that FGM practice should continue. They believed that FGM is a religious obligation (72.3% of mothers and 73% of fathers). Parents believed that husbands prefer a circumcised wife (81.1% and 82.5% of mothers and fathers respectively). Being in the poorest wealth quintile (OR = 4.2, p < 0.001) and living in rural Upper Egypt (OR = 4.55, p < 0.001) were the predictors of FGM practice, while medicalization was more likely among the rich and educated parents. Parents' attitudes supporting FGM was significantly associated with its practice (OR = 1.97, p < 0.001, for mothers and OR = 1.27, p < 0.001, for fathers). Rejecting violence against women was associated with less likelihood of practicing FGM (OR = 0.89, p < 0.05) and more likelihood of its medicalization (OR = 1.25, p < 0.01). Conclusion: More attention should be paid to enforce the laws against FGM practice by health care providers. Raising the community awareness on girls' human rights and elimination of FGM practice which is a severe form of violence against women and gender inequality in sexual rights should be prioritized with targeting men in FGM programs.
... A. Shahvisi by "backward" peoples. In fact, a large and growing proportion of FGC in high-prevalence settings is performed by surgeons under clinical conditions, in much the same manner as FGCS [14]. This ought to be unsurprising: prevalence rates are upward of ninety percent in some contexts, and no parent would tolerate a perilous procedure for their child where safer options are accessible. ...
... In a recent study, one doctor said "I don't call it circumcision, I call it 'refinement' […] you are beautifying the labia. It's normal" [14]. ...
Article
Full-text available
In this article, I argue that the moral and legal distinction between “female genital cutting” and “female genital cosmetic surgeries” cannot be maintained without recourse to racist distinctions between the consent capacities of white women and women of colour. The physical procedures involved in these surgeries have significant overlap, as do their motivations, yet they are treated differently in everyday discourse and the law. This paper lays bare this double standard and presents and interrogates some of the reasons commonly given to justify their separate treatment. It concludes with the recommendation that the distinction be dropped in favour of more consistent consent-based stance, which avoids the racism and ethnocentrism that underwrites the present regime. According to this position, the only defensible moral and legal distinction is between those who can consent to these procedures, and those who cannot.
... According to Kimani (2020), some healthcare providers suggested that medicalization inhibits the abandonment of the practice and instead "modernised" it, boosting healthcare providers' income, and incentivizing parents to cut their daughters [26]. Scholars have argued that medicalisation is a tacit approval for FGM/C, which creates the impression that FGM/C can be performed safely, and that it is condoned by respected health care professionals and institutions, thus reducing families' motivation to abandon the practice [27,28]. ...
Article
Full-text available
Although female genital mutilation/cutting (FGM/C) is a prevalent practice in Liberia, healthcare workers lack the capacity to provide adequate care for FGM/C survivors. Therefore, Liberian nurses, physician assistants, midwives and trained traditional midwives were trained in sexual, obstetric and psychosocial care for FGM/C survivors in 2019. Through questionnaires, we assessed knowledge acquisition, trainee attitudes towards FGM/C care and acceptability to implement WHO-endorsed recommendations. The questionnaires were analyzed using descriptive statistics for quantitative data and an inductive approach for qualitative data. A total of 99 female and 34 male trainees participated. Most trainees perceived FGM/C as harmful to women’s health, as a violation of women’s rights and showed a willingness to change their clinical practice. While 82.8% (n = 74/90) perceived their role in advocating against FGM/C, 10.0% (n = 9/90) felt that they should train traditional circumcisers to practice FGM/C safely. The pre-training FGM/C knowledge test demonstrated higher scores among physician assistants (13.86 ± 3.02 points) than among nurses (12.11 ± 3.12 points) and midwives (11.75 ± 2.27 points). After the training, the mean test score increased by 1.69 points, from 12.18 (±2.91) points to 13.87 (±2.65) points. The trainings successfully increased theoretical knowledge of FGM/C-caused health effects and healthcare workers’ demonstrated willingness to implement evidence-based guidelines when providing care to FMG/C survivors.
... In terms of physical implications, for instance, the level of harm or benefit caused by genital cutting is a function of several factors that do not reliably track biological sex categories. For example, it depends on the subtypes of cutting that have been adopted within a group and the extent to which each has been medicalized (that is, performed by a healthcare provider using sterile instruments, as is increasingly common for both male and female procedures in many contexts) [22][23][24]. Both types of cutting vary across cultures, with commensurate functional-anatomical effects in many cases [25][26][27][28][29][30][31][32]. ...
Article
Full-text available
According to the World Health Organization (WHO), customary female genital modification practices common in parts of Africa, South and Southeast Asia, and the Middle East are inherently patriarchal: They reflect deep-rooted inequality between the sexes characterized by male dominance and constitute an extreme form of discrimination against women. However, scholars have noted that while many societies have genital modification rites only for boys, with no equivalent rite for girls, the inverse does not hold. Rather, almost all societies that practice ritual female genital modification also practice ritual male genital modification, often for comparable reasons on children of similar ages, with the female rites led by women and the male rites led by men. In contrast, then, to the situation for boys in various cultures, girls are not singled out for genital modification on account of their sex or gender; nor do the social meanings of the female rites necessarily reflect a lower status. In some cases, the women’s rite serves to promote female within-sex bonding and network building—as the men’s rite typically does for males—thereby counterbalancing gendered asymmetries in political power and weakening male dominance in certain spheres. In such cases, and to that extent, the female rites can be described as counter-patriarchal. Selective efforts to discourage female genital modifications may thus inadvertently undermine women-centered communal networks while leaving male bonding rites intact. Scholars and activists should not rely on misleading generalizations from the WHO about the relationship between genital cutting and the social positioning of women as compared to men. To illustrate the complexity of this relationship, we compare patterns of practice across contemporary societies while also highlighting anthropological data regarding pre-industrial societies. Regarding the latter, we find no association between the presence of a female initiation rite and a key aspect of patriarchy as it is classically understood, namely, social endorsement of a gendered double-standard regarding premarital sexual activity. We situate this finding within the broader literature and discuss potential implications.
... The increase in the FGM prevalence among the wealthiest groups might also be related to the medicalization of FGM. With the greater access to healthcare services and increased awareness of the adverse health consequences of FGM, health professionals have become increasingly involved in performing FGM [34]. People with more financial ability might choose to medicalize FGM thinking that they avoid adverse health effects. ...
Article
Full-text available
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.
... Similarly, in some societies depriving a girl of her freedom or preventing her from going to school are not generally considered forms of violence, but rather a means to protect the girl ( Jamal 2016). FGM is another such example, it is done with the girl's ''best interest'' in mind (El-Gibaly et al. 2019;UNICEF 2015). Finally, what is considered violation of human rights by international standards could be considered acceptable or even desirable by the local culture. ...
Article
"In such a context, where VAW is a way of life, victims may not recognize themselves as such nor do perpetrators see themselves as abusive. Violence is ‘‘normalized’’ and ‘‘routinized,’’ safely immune from questioning and any coherent opposition, being so firmly couched in tradition, religion, or societal imperatives." The study aims to explore university students’ understanding and perception of violence against women (VAW). A total of 14 focus group discussions were conducted and stratified into 2 genders (men and women). Participants were undergraduate students (n = 75) from a public university in Cairo, Egypt. Findings revealed gender variations in the understanding of VAW. Although many considered VAW to essentially involve physical harm, female participants had a broader understanding of what constituted VAW. Most male participants were more conservative and emphasized the physical aspects of violence, whereas the majority of women participants considered that psychological and verbal abuse to be forms of VAW. Many participants expressed the belief that poor women are more likely to be victims of violence. The majority of the male participants recognized sexual harassment as a form of VAW but defined sexual harassment more narrowly than female participants. These gender disparities in understanding the meaning of VAW and perception of violence victims need to be taken into consideration when designing interventions and programs.
... They discovered that for several reasons, both mothers and health care workers considered FGC 'an important cultural obligation', but for my purpose, one finding stands out. Both male and female doctors 'repeatedly referred to 'beauty' and 'ugliness' in regard to girls' genitals' and indeed, 'many physicians who performed FGM/C denied that they practiced FGM/C, preferring to refer to the procedure as 'a cosmetic operation' instead' ( [134] As the authors note, this reframing of FGC as cosmetic surgery serves to legitimise the practice. It offers a way to promote it to mothers, and circumvent Egypt's law against FGM/ C, which does not penalise FGCS among young women over the age of 18 ([134]:10). ...
Article
Full-text available
Purpose of Review To examine the ‘zero tolerance’ policy for female genital cutting (FGM/C) in the international health community in light of the growing popularity of FGCS (female genital cosmetic surgery) worldwide. Recent Findings ‘Traditional’ FGM/C performed in Egypt and Sudan and cosmetic labiaplasty performed in Europe, the Americas, and Antipodes by medically trained gynaecologists and plastic surgeons are based on similar aesthetic logics: labia minora that protrude beyond the labia majora are deemed ugly, masculine, and ‘abnormal’. Drawing on the burgeoning medical, social science, and humanities literature surrounding labiaplasty, the paper documents the narrowing of aesthetic standards governing ‘normal’ genital appearance and finds that, in addition to adult women, thousands of (mainly Caucasian) adolescents have undergone these operations whose long-term health consequences are unknown. Summary Western heteronormativity, gender binarism, ageism, and the colonial association of protruding labia minora with animality contribute to body image insecurities and fuel the labiaplasty phenomenon, despite the ethical challenge that the procedures are clearly defined by the WHO as type II (a–c) female genital mutilations.
Article
This article provides information and care guidelines for healthcare providers who encounter pregnant women who have experienced type 3 female genital cutting, also known as infibulation, to help better understand how to provide informed, sensitive, nonjudgmental, culturally safe care.
Article
Full-text available
Representation, which is affected by global discourse about female circumci-sion, does not reflect the reality of the practice. This study focuses on female genital mutilation (FGM) in Egypt, particularly the gap between the representation of female circumcision and the local situation. Applying description design and based on the regional context, the study sheds light on problems pertaining to the representation of female circumcision according to two dimensions. The first dimension concerns data representation of female cir-cumcision from a cross-cultural perspective and the second dimension examines female circumcision with reference to the film Bein Bahrain. This study aims to contribute to research that provides a space for dialogue in relation to the cultural backgrounds of each region and to identify the policies that are appropriate for each region. It was found that there are treatments in the world that are not dissimilar to FGM. However, these treatments are not considered concerning in the same way that FGM by the United Nations. Thus, in addition to the four types of FGM classified by the World Health Organization (WHO), there are two types of female circumcision based on implementation: First World implementation and Third World implementation. Furthermore, it became clear that the media representation which promotes a zero-tolerance policy does not reflect the reality of FGM in Egypt. The study concludes that there is an urgent need to reconsider the zero tolerance policy to protect the lives of many girls.
Article
Full-text available
UK female genital mutilation laws discriminate against specific women and infantilise them. Female genital mutilation types accord with those of the politically partisan World Health Organisation, but new instances reported are genital piercings. Most female genital mutilation seen in the National Health Service is less severe than male circumcision, which is not illegal. The laws, monitoring and reporting systems need reviewing with a view to decriminalising female genital mutilation.
Article
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Purpose of Review Female genital cutting/mutilation (FGM/C) performed by health care professionals (medicalization) and reduced severity of cutting have been advanced as strategies for minimizing health risks, sparking acrimonious ongoing debates. This study summarizes key debates and critically assesses supporting evidence. Recent Findings While medicalization is concentrated in Africa, health professionals worldwide have faced requests to perform FGM/C. Whether medicalization is hindering the decline of FGM/C is unclear. Factors motivating medicalization include, but are not limited to, safety concerns. Involvement of health professionals in advocacy to end FGM/C can address both the supply and demand side of medicalization, but raises ethical concerns regarding dual loyalty. Ongoing debates need to address competing rights claims. Summary Polarizing debates have brought little resolution. We call for a focus on common goals of protecting the health and welfare of girls living in communities where FGM/C is upheld and encourage more informed and open dialog.
Technical Report
Full-text available
Background: Medicalized female genital mutilation/cutting (FGM/C), defined as cutting procedures performed by professional health care providers, and less extensive forms of FGM/C have been advanced to minimize the attendant health risks, despite decades of opposition by international organizations and anti-FGM/C activist. Oft-repeated assertions about trends in medicalization and its effects on the continuation of FGM/C have rarely been empirically investigated. Methods: Drawing on nationally-representative survey data (Demographic and Health Surveys and Multiple Indicator Cluster Surveys) from 25 countries, this study addresses the following questions: What are the major patterns and trends in medicalization? What is the association between medicalization and rates of change in prevalence of or support for the continuation of FGM/C? Is there an association between medicalization and shifts in the severity of cutting? Results: Among women between ages 15 and 49 years, and estimated 26% - totaling nearly 16 million girls and women – report having been cut by a health care professional. Medicalized cutting is concentrated in three countries; 93% of women who report having undergone medicalized FGM/C live in Egypt, Sudan and Nigeria. Elsewhere medicalized cutting is rare, or restricted to geographically defined pockets. Mother-daughter comparisons show rates of medicalization are increasing in several countries, most sharply in Egypt, where medicalization rates have more than doubled. Overall, there is no discernible correlation between medicalization and rates of decline in the prevalence of FGM/C or support for continuation of the practice. Rising medicalization rates are found in countries where FGM/C rates have declined modestly (Sudan, Egypt) or sharply (Kenya). Although data are limited, it appears that medicalization is associated with a trend toward a less severe form of cutting (nicking). Conclusion: Medicalization can occur alongside a declining prevalence in FGM/C, but whether it hinders change is unclear. Limited evidence show an association between medicalization and a shift to a less severe nicking form of cutting. Hence, a question also remains as to whether this shift represents reluctance to stop an intractable practice, or signifies openness to change that can be leveraged to promote abandonment. Further focused research is needed to address these unresolved issues.
Article
Full-text available
Background: Female genital mutilation (FGM) is a traditional harmful practice that can cause severe physical and psychological damages to girls and women. Increasingly, trained health-care providers carry out the practice at the request of families. It is important to understand the motivations of providers in order to reduce the medicalization of FGM. This integrative review identifies, appraises and summarizes qualitative and quantitative literature exploring the factors that are associated with the medicalization of FGM and/or re-infibulation. Methods: Literature searches were conducted in PubMed, CINAHL and grey literature databases. Hand searches of identified studies were also examined. The "CASP Qualitative Research Checklist" and the "STROBE Statement" were used to assess the methodological quality of the qualitative and quantitative studies respectively. A total of 354 articles were reviewed for inclusion. Results: Fourteen (14) studies, conducted in countries where FGM is largely practiced as well as in countries hosting migrants from these regions, were included. The main findings about the motivations of health-care providers to practice FGM were: (1) the belief that performing FGM would be less harmful for girls or women than the procedure being performed by a traditional practitioner (the so-called "harm reduction" perspective); (2) the belief that the practice was justified for cultural reasons; (3) the financial gains of performing the procedure; (4) responding to requests of the community or feeling pressured by the community to perform FGM. The main reasons given by health-care providers for not performing FGM were that they (1) are concerned about the risks that FGM can cause for girls' and women's health; (2) are preoccupied by the legal sanctions that might result from performing FGM; and (3) consider FGM to be a "bad practice". Conclusion: The findings of this review can inform public health program planners, policy makers and researchers to adapt or create strategies to end medicalization of FGM in countries with high prevalence of this practice, as well as in countries hosting immigrants from these regions. Given the methodological limitations in the included studies, it is clear that more robust in-depth qualitative studies are needed, in order to better tackle the complexity of this phenomenon and contribute to eradicating FGM throughout the world.
Article
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The act of female genital mutilation/cutting (FGM/C) is considered internationally as a violent act against girls and women and a violation of their human rights. This study sought to assess the awareness and predictors of FGM/C in young Egyptian health advocates. A cross-sectional study of 600 medical students from a total of 2,500 members of the International Federation of Medical Students' Associations (IFMSA)-Egypt, across all Egyptian medical schools, was conducted using a previously validated online Google survey. The overall prevalence of circumcision was 14.7/100 female students, with a significantly higher prevalence in students from rural areas (25%) than in non-rural areas (10.8%, P=0.001), and in those residing in Upper (southern) Egypt (20.6%) than in Lower (northern) Egypt (8.7%, P=0.003). The students' mean percentage score for knowledge about the negative health consequences of FGM/C was 53.50±29.07, reflecting a modest level of knowledge; only 30.5% had a good level of knowledge. The mean percentage score for the overall attitude toward discontinuation of the practice of FGM/C was 76.29±17.93, reflecting a neutral attitude; 58.7% had a favorable attitude/norms toward discontinuation of the practice. Of circumcised students, approximately one-half (46.8%) were unwilling to have their daughters circumcised, and 60% reported no harm from being circumcised. After controlling for confounders, a negative attitude toward FGM/C was significantly (P,0.001 in all cases) associated with male sex, residency in Upper Egypt, rural origin, previous circumcision, and the preclinical medical phase of education. The low level of knowledge among even future health professions in our study suggests that communication, rather than passive learning, is needed to convey the potentially negative consequences of FGM/C and to drive a change in attitude toward discontinuation of this harmful practice.
Article
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The medicalization of female genital cutting (FGC) has been increasing. This cross- sectional study estimated the determinants of the practice of FGC among Egyptian physicians. Responses from 193 physicians showed that while 88% of them knew at least one adverse physical or sexual consequence, 18% approved of it, mostly as a religious observation (82%). Almost one-fifth (19%) of physicians practised FGC, mostly due to conviction (51%) or for profit (30%). A negative correlation was found between knowledge of the adverse consequences of FGC and both approval and practice. Cultural influences were the highest determinant (81%) followed by lack of knowledge (35%).
Article
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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).
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The New View Campaign is a grassroots initiative begun in 1999 to challenge the over-medicalization of sex in the wake of publicity following the release of Viagra. This paper describes the history of the campaign and its activities, which started with analysing the construction of female sexual dysfunction, and moved on to develop a critical understanding of sexuality as a market for the pharmaceutical industry to exploit. The campaign has also had much to say about a positive model for sexuality, sex education, treatment of sex problems, and sex research. From 2006, we began to look at the new female cosmetic genital surgery industry. In 2008, we wrote letters to many government and medical professional groups expressing our concerns about female cosmetic genital surgery and asking for support. We also organised a demonstration outside the office of a New York surgeon who was doing this surgery and developed a webpage as a resource for students, scholars, journalists and activists. In 2009, we held an event in an art gallery that celebrated artists who support and encourage female sexual diversity. Supporters and colleagues of the campaign have published books and articles, and created visual and training materials, including a project called Vulvagraphics. Résumé La campagne New View est une initiative lancée au niveau de la communauté en 1999 pour remettre en question la surmédicalisation de la sexualité, conséquence de la publicité ayant suivi la commercialisation du Viagra. L’article décrit l’histoire de la campagne et ses activités. Nous avons commencé par analyser la construction de la dysfonction sexuelle féminine et sommes ensuite parvenus à une compréhension critique de la sexualité comme marché à exploiter pour l’industrie pharmaceutique. La campagne s’est également exprimée sur un modèle positif pour la sexualité, l’éducation sexuelle, le traitement des problèmes sexuels et la recherche en la matière. Dès 2006, nous nous sommes intéressés à la nouvelle industrie de la chirurgie plastique des organes génitaux féminins. En 2008, nous avons écrit à nombre d’autorités et de groupes professionnels médicaux pour leur faire part de notre inquiétude quant à ce type de chirurgie et demander un appui. Nous avons aussi organisé une manifestation devant le cabinet d’un chirurgien new-yorkais qui pratiquait ces opérations et avons créé un site Internet comme ressource pour les étudiants, les chercheurs, les journalistes et les militants. En 2009, dans une galerie d’art, nous avons fêté les artistes qui soutiennent et encouragent la diversité sexuelle féminine. Les sympathisants et les adhérents de la campagne ont publié des livres et des articles, et ont produit du matériel visuel et formatif, notamment un projet intitulé Vulvagraphics. Resumen La campaña New View es una iniciativa de base iniciada en 1999 para cuestionar la sobremedicalización de la sexualidad tras la publicidad después del lanzamiento de Viagra. En este artículo se describe la historia de la campaña y sus actividades, que comenzaron por analizar la construcción de la disfunción sexual femenina y de ahí formularon un entendimiento crítico de la sexualidad como mercado a ser explotado por la industria farmacéutica. La campaña también ha tenido mucho que decir en cuanto a un modelo positivo para la sexualidad, la educación sexual, el tratamiento de problemas sexuales y la investigación sexual. A partir de 2006, empezamos a estudiar la nueva industria de la cirugía cosmética genital femenina. En 2008, escribimos cartas a numerosos grupos de profesionales gubernamentales y médicos para expresar nuestras inquietudes respecto a dicha cirugía y solicitar apoyo. Además, organizamos una demostración fuera del consultorio de un cirujano de Nueva York, quien estaba efectuando esta cirugía y había creado una página Web como recurso para estudiantes, eruditos, periodistas y activistas. En 2009, organizamos un evento en una galería de arte, donde se celebraban a artistas que apoyan y fomentan la diversidad sexual femenina. Los defensores y colegas de la campaña han publicado libros y artículos, y han creado material visual y didáctico, incluso un proyecto llamado Vulvagraphics.
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