On Saturday 18th June 2016, the Economist published an article entitled ‘Female Genital Mutilation: an agonising choice’. In the article, the author (anonymous, in the Economist style) claimed that since efforts by campaigners against FGM, in the last three decades have not resulted in eliminating the practice, it is time for ‘a new approach’. The author suggests that governments should ban the ‘worst forms’ of female genital mutilation (FGM) and instead ‘try to persuade parents to choose the least nasty version’, concluding that ‘it is better to have a symbolic nick from a trained health worker than to be butchered in a back room by a village elder.’
This is not the first time an attempt has been made to promote the medicalisation of FGM. In 2010 the American Academy of Paediatrics supported the idea of a symbolic nick (entaille in French) as an alternative. Earlier this year, two gynaecologists wrote a paper in the Journal of Medical Ethics arguing that some types of cutting do not harm physical functioning and should not be described as “mutilation”.
As a midwife and executive director of GAMS Belgium, (a community-based organisation working towards the abolition of FGM), with several years of experience in Africa (Somalia, Kenya, Burkina Faso, Mali and Liberia, among others) and as someone who sees patients every week in a FGM Clinic, I would like to explain why I am against medicalisation of FGM:
- Performing these ‘symbolic nicks’ would mean denying that FGM is a violation of human and children’s rights and that it is a recognised form of gender-based violence, irrespective of the degree of harm caused or the medical qualifications of the person performing it. All forms of FGM are a violation of human rights and the right to physical, mental and psychological integrity.
- When one compares a program for the exchange of needles for drug users, with medicalisation of FGM, I argue that this is not the same. The majority of drug users are adults or at an age when they are capable of taking a decision; usually they have, besides needle-exchange programs, access to programs to help them stop using drugs, and both choices are reversible. Girls who are cut are babies or infants, cannot escape. They have no choice and they can’t reverse their statute. They are cut forever; even if reconstructive surgery of the clitoris is now available in some countries, it will never be the same. FGM is not an addiction that they can stop. It is an act that mutilates the bodies of women, at an age when they have no say. It is an abuse of power of parents and communities on their bodies.
- Symbolic pricks do not prevent extensive cutting in the future. Therefore, such policy will fail in communities that are not convinced of the abandoning of the practice. For example, at the FGM clinic, I attend, I see women from Guinea Conakry who have been cut twice: because the first time was not well done “ce n’était pas propre” (it was not clean). In Guinea Conakry, more than 30% of the FGM in girls (0-14y) are performed by health professionals (most of them are midwives). They cut less than the traditional circumcisers but the girls are then “re-excised” a second time in the village when checked by aunties or grandmothers, leading to double suffering. Where is the benefit here? To replace one practice by another without convincing the communities of the harm of the practice will not stop it.
- “Minor types” of FGM as some pro-medicalisation people call them, does not automatically mean minor impact. The health consequences of FGM depend not only on the type of FGM performed, but on the expertise of the circumciser, the hygienic conditions under which it is conducted, the age at which it is undertaken and the degree of resistance of the girl at the time of the operation. However, any type of FGM can have serious physical and psychological consequences. It is therefore important to listen to an individual woman’s concerns and symptoms without making assumptions based on the type of FGM she has experienced. Some women with FGM Type-I can have PTSD linked to the brutality and the pain of the contention during the act: four of five women are holding the child on the floor while the excisor cuts the girl without any explanation. This can be even more traumatic than the cut itself.
UN agencies and the WHO have taken a stand against medicalisation at various occasions, but without great success. They have not succeeded in stopping pro-medicalisation and here is why:
- Neither the UN agencies, nor the WHO dare to take a stand on baby and infant male circumcision. So all their arguments against pricking or medicalisation of less invasive forms of FGM are not credible. Because cutting, albeit male or female, is the same violation of corporal integrity and abuse of authority by the parents: it is done on babies and children without their consent, they cannot escape; they cannot refuse. In the US alone, between 200 and 500 boys die every year due to male circumcision done without a medical reason. HIV prevention through male circumcision (another controversial debate which we will not start here) does not apply to babies and infants who haven’t started their sexual lives.
- One cannot be against pricking of the clitoris on baby girls and at the same time be pro circumcision on baby boys. This makes no sense. Pricking of the clitoris could be less harmful than circumcision of the whole prepuce (with the ablation of the frenulum) of a baby boy (the prepuce being the most innerved part of the male penis, and therefore affecting the sexuality of the man he will become). I am against pricking/nicking of the clitoris and any medicalisation of “minor types” of FGM because I am also against male circumcision and any attempt to the physical integrity of children.
- It is also hypocritical to be against the pricking or nicking of the clitoris while allowing other surgery on the genitalia. Reduction of the labia minora is becoming more common, without medical justification. Why is the WHO silent about this? Why should it be acceptable for white women, and be considered a mutilation for black women? The specific law against FGM in Belgium (article 409 of the penal code) says that even with the consent of women, the cutting of the external genitalia is considered a mutilation. Consequently they should also condemn any surgery on the genitalia without medical reason. It is a business for a lot of aesthetic doctors in our Western countries: instead of taking time to explain to adolescents the variety of anatomy of external genitalia and reassure them about their appearance, they cut their genitalia and sometimes are even reimbursed by the social security system, because there is no regulation and norm about what is considered as an abnormal vulva or hypertrophy of the labia minora (the main official reason of performing nymphoplasty). The work of McCartney with his Great Wall of the Vagina (a sculpture made from plaster casts of 400 women’s vulvas) is an example of education and acknowledgment of the diversity and differences in human bodies.
My conclusion is that we should be against any cutting or transformation of the genitalia of babies and infants who are in no position to defend themselves. It is clearly an abuse by adults on children’s rights. This applies to any type of surgery/intervention done without medical reason: female cutting of the external genitalia, but also male circumcision and surgery of intersex babies (before the child has reached an age to say what he or she wants). The Council of Europe made a courageous attempt in 2013 (resolution 1952), but as soon as the resolution was out, Jewish and Muslims organisations joined together to ask the council of Europe to review their text about circumcision (resolution 2076). Few organisations, like Droit au corps in France, have moved away from a single focus on only FGM, towards a more holistic approach and fight against all forms of sexual mutilation (male circumcision, female genital cutting and intersex surgery before age of consent).
A way forward?
Definition and Classification of FGM (2007)
Definition: Female genital mutilation comprises all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons (WHO, UNICEF, UNFPA, 1997).
Type I: Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
Type II: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Type III: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
Type IV: All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.