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Why we should be against the medicalisation of Female Genital Mutilation

By on July 15, 2016

Fabienne Richard is a Midwife, MSC and PhD in Public Health. She is the Executive Director of GAMS Belgium, Board member of the END FGM Network, Clinician at the FGM Clinics CeMAViE in University Hospital ST-Pierre in Brussels. She is also a Guest Researcher of the Institute of Tropical Medicine.  

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).

Typology:

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.

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11 Responses to “Why we should be against the medicalisation of Female Genital Mutilation”

  1. Moses Tetui

    Interesting article indeed. I am particularly intrigued by the last point on surgery of the female genitalia that is increasingly becoming popular in western countries. A few months ago I had the same argument made here about demonizing “FGM”that happens in “black settings’ and glorifying that which happens in “white settings.”
    My colleagues then thought I was simply paranoid but am glad this has come up again. I think there is a great need to harmonize the definitions of “evil” or human rights for that matter across all cultures if we should assume the privilege of promoting modern, safe, dignified and acceptable ways of life.

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  2. Solomon

    I completely agree with Dr Fabienne. The underlying reason for practicing FGM has to do with patriarchy. Male domination and control of female sexuality and body integrity. FGM is done on women but it’s done for men. There’s no benefit to women and girls whatsoever. There’s is also no reason why such a violent and oppressive practice should be allowed to continue. Although I agree all forms of circumcision should be banned anywhere in the world, I strongly believe we have to intensify our efforts to abondon the practice in Africa as FGM impacts the girls life negatively in more ways than one.

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  3. asiff

    The Economist is right. The anti-FGM movement has taken a turn for the worse by campaigning against Islamic female circumcision, which merely involves removing the prepuce of the clitoris, a procedure that has been shown to confer benefit to women in terms of hygiene as well to enhance sexual satisfaction.

    This stubborn attitude of the lobbyists has only made things worse. Indonesia moved to medicalise the procedure and define what needed to be removed, namely the clitoral prepuce. But even this was opposed by the lobbyists who wanted it overturned, as a result of which we are back to square one, with religious leaders calling for the practice to continue and traditional midwives continuing with their ways in unhygienic settings.

    Whatever the UN or anybody might say, we in the Muslim world believe the practice to be Islamic. There is a consensus of opinion on this by the classical scholars. The only dispute is whether it is obligatory or recommended. However the balance of evidence from the Prophet’s sayings indicate that it is indeed obligatory as it is for males. See:http://asiffhussein.com/2015/04/02/female-circumcision-the-hidden-truth/

    Reply
    • Fabienne Richard

      The practice of female genital cutting and male circumcision predates Islam. Female genital cutting is not practiced in Islamic countries such as Morocco, Algeria or Afghanistan but it is practiced by Christians and Animists in Burkina Faso or Sierra Leona. This is the proof that this is primarily a tradition that was much later claimed as a religious requirement in some countries.

      Reply
  4. John Milton

    Thank you for this very enlightening article! I think you have said it all. As long as some western surgeons continue to feed on the insecurities of young girls who feel bad about their genitals for no reasons, and as long as some people keep feeling OK about cutting boys for no other reason than tradition or so called “esthetic” and “hygienic” reasons, the fight against FGM just cannot get easier.

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  5. Jean-Christophe LURENBAUM

    You wrote : “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.” How can we explain this surprising claim from AAP ? Why not the same claim with European AP for example ?

    I suggest it’s because AAP is the only one AP in the world which advocates or doesn’t disapprove male circumcision, especially on babies, although everybody recognize now that circumcision ON BABIES has absolutly no medical benefits but only risks, short term risks (like hundreds of babies dying from circumcision as you wrote) and long term risks (sexual and psycological suffering). Then, because AAP tries to avoid the disapproval / prohibition of male circumcision in the US, they need to justify “little” sexual mutilation on females to justify male circumcision on babies, as a symmetry (and although male circumcision is not at all a “little” mutilation).

    And why AAP (or WHO) continues to advocate male corcumcision ? There are few reasons, but I think an important one is that US decision makers are adults themselves circumcised as a baby for 90% of them : they can’t recognize the harm on themselves. The day decision makers in the US will be a minority, the day it will be finished to promute circumcision around the world, the day it will be finished to advocate “little” sexual mutilations on females.

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  6. asiff

    Please do not confuse Female Circumcision with Female Genital Mutilation. These are two different things. The female circumcision which Islam requires is simply the removal of the prepuce of the clitoris (or hoodectomy as it is known in the US), which is a harmless procedure known to benefit women both in terms of genital hygiene as well as increasing sexual joy. See: http://asiffhussein.com/2015/04/02/female-circumcision-the-hidden-truth/

    Reply
    • Fabienne Richard

      Islam does not require female circumcision! I have a lot of Muslim friends, they are not cut and do not need to be cut to practice their religion.

      Reply
  7. Katy Wedderburn

    very interesting article, not something I’ve ever seen or really wanted to see in a clinical setting.

    the only point I had was that I would be hesitant to demonise the decisions adult women make about their own bodies, even unecessary surgical decisions. Most breast augmentations are not driven by need, but by personal preference, and if an adult woman of sound mind wishes to alter her labia she should have the right to access that procedure safely. As should any adult man who wishes to be circumcised.

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  8. John Milton

    Following my first comment I would like to point out that while it is true that Droit au Corps has moved away from a single focus on only FGM, they also have a very dogmatic and sectarian approach to the fight against sexual mutilations. You can see it only from the inside though. I have been a member of this association for one year, contributing articles, translating material, and and even meeting with Mikael Aktor from Intact Denmark on behalf of Droit au Corps. Part of Droit au Corps’ ideology consists in denying that genital integrity exists. Anyone against that stance is subjected to a lot of pressure or simply evicted, as I have learnt the hard way. Droit au Corps has indeed decided to evict me from their association over my constant refusal to deny that genital integrity and body integrity are valid concepts in the fight against sexual mutilations.

    Having been myself sexually mutilated, I can testify that the most influential board members of Droit au Corps place their ideology above the well being of victims of sexuel mutilations.

    The fight against sexual mutilations of all kind is very dear to me, and I will keep on fighting against it any way that I can. But this fight deserves better that such associations.

    Reply
  9. John Milton

    That being said, I wish nothing but success to this association, so they reach one of their main goals, i.e. the opening of a debate about the urgent need for informed consent whenever circumcision is performed. Let us just stay clear about how they currently work on the inside, how they deal with victims, and where they stand on certain issues.

    Reply

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