Female Genital Mutilation (FGM) is a procedure of historical, cultural and religious derivation that continues its practice worldwide, involving partial or total removal of the external female genitalia.   The stand of many international bodies, including the United Nations, is that it epitomises a violation of the human rights of girls and women. Australian state and territorial law prohibits and categorises FGM as a criminal offence, as do RANZCOG guidelines  for  medical  practitioners.  Reducing  the  practice  of FGM worldwide encompasses involvement in awareness and education programs at an individual and societal level, beginning with local communities, elders/leaders, young men and women, and traditional health practitioners. Approaching the request for FGM or reinfibulation in an Australian healthcare setting requires an understanding of the socio-cultural influences surrounding the practice and empathy towards the needs of the patient and their cultural identity. It also requires a comprehensive understanding of the myriad physical and psychological health risks posed by FGM.

Introduction

The  continued  worldwide  practice  of  female  genital  mutilation (FGM) or traditionally, ‘circumcision’ is one that has sparked much controversy within the ethics of Western medicine. Is the centuries old socio-cultural ritual a violation of the rights of a woman or child hiding behind the label of ‘custom’? Or has the Western world perceived ‘degradation’ where there is only an exercising of free will that is perhaps  unfathomable  but  not  necessarily  unethical?  How  much of ‘free will’ is truly an expression of an individual’s autonomy? To what extent does culture impinge upon it? And how do we as health practitioners balance this societal commentary with the bioethical principles underlying medical practice? These are questions that have come to the forefront of the FGM debate and that will be examined here. Perhaps, one of the more overarching issues we should also ponder is this: are and should the principles of what is ‘ethical’ be derived from socio-cultural forces?

According to the World Health Organisation (WHO), female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for  non-medical  reasons.[1] The current position of the WHO is that ‘FGM is a violation of the human rights of girls and women’.[1]

The World Health Organisation (WHO) estimates 100-140 million women worldwide are affected by female genital mutilation.[1] 28 countries of Africa, as well as a few countries of Middle East and Asia have documented practice of FGM.[1] Of these, the four countries with highest prevalence are Somalia, Sudan, Guinea and Djibouti (>90% of women). 1] In Australia, there have been an increasing number of migrants from countries practising FGM, particular over the past decade.[2]

The current laws and guidelines surrounding FGM

Under NSW Law, FGM is prohibited; Section 45 of the 1900 NSW Crimes Act extensively covers prohibition of female genital mutilation. [3] In fact, in all jurisdictions of Australia (though covered exclusively by differing states and territories), FGM is considered a criminal offence. [3] Current Royal Australian and New Zealand College of Obstetricians and Gynaecologists’ (RANZCOG) guidelines strongly recommend that all health practitioners do not acquiesce to the requests for elective reinfibulation or indeed other forms of FGM.[2] The United Nations has, as of December 2012, passed a resolution banning the practice of FGM worldwide, as a violation of human rights and dignity.[1]

The arguments ‘for’ prohibition of FGM

In terms of establishing a perspective on the matter, the tone of the commentary to follow is ultimately averse to the practice of FGM. At the forefront of this argument are the adverse health effects. A study by Hosken et al showed that 83 percent of women who had undergone FGM would require medical attention at some point in their lives for a condition resulting from the procedure.[4] In terms of a statistical look at the associated health problems, according to a survey of 55 health providers in the Nyamira District of Kenya, 49.1% reported obstructed labour, dyspareunia, bleeding, urinary problems, and fear and anxiety. [5] The World Health Organisation (WHO) estimates that women who have undergone FGM are twice as likely to die during childbirth and are more likely to give birth to a stillborn child when compared to those women who have not undergone FGM.[1]

Central to the argument is that it confers no health benefit to a woman, and contrarily presents a myriad collection of damaging consequences upon one’s health. Proponents of prohibiting the practice, such as Toubia et al, suggest that non-therapeutically excising an otherwise functioning body  part  is  not  simply  abhorrent;  it  is  a  violation of the codes of medical practice and an obstruction to the bioethical principles of non-maleficence and beneficence.[6]

An important detail is that the procedure is often performed on children (a large proportion pre-pubertal), who by virtue of medical ethics are not able to provide informed consent. But what of consenting adults? Whilst it is difficult to ignore the requests made by consenting adults in a sterile, medical environment within the healthcare systems of the Western World, this could condone the practice worldwide.[6] In many instances FGM has (despite it being a social custom of historical derivation) signified the degradation of the rights and dignity of women internationally.[1,6,7] Many argue that if health practitioners do not perform the procedure in a safe sterile manner, women will seek infibulation/reinfibulation from an untrained and often medically unsafe source.[8] However, the underlying point remains that it is the responsibility of the medical profession to uphold certain ethical principles of beneficence, non-maleficence and justice that are violated by FGM. The harm minimisation of performing re-infibulation/ infibulation sterilely as opposed to at the hands of a non-medical entity is ultimately not outweighed by the consequences of condoning said practice and failing to reduce the practice worldwide.[6,7]

Elchalal et al, in Female Genital Mutilation: the peril remains, consolidated the views of Toubia et al, in elucidating that societies and countries that promote the practice of FGM should seek to empower their women (over time) and symbolise social acceptance and respectability in practices that do not confer such negative health risks and psychological trauma.[6,7] What must be highlighted is the importance placed on healthcare workers to utilise their position of trust and objectivity, when relaying the health risks associated with FGM to patients.[6,7]

The arguments ‘against’ prohibition of FGM

It is important that whilst being in support of eradicating FGM, one examines the counter arguments. Those who defend the practice, hold the value of social integration and cultural importance to the sense of identity held by many consenting adult women, in a higher regard. [8,9] Bronnit et al identifies the psychological health benefits that can be derived from compliance with the practice of FGM, as often outweighing the adverse health risks.[8] Defenders of FGM question the betterment of the cultural and ritualistic component of mental health as being a valid justification for performing FGM.[8,9]

Whilst many commentators also refuse to condone the practice on children, Bronnit states that in denying requests for reinfibulation/ infibulation to consenting adults, you risk retreating to the ‘archaic’ models of paternalism.[8] It is an interesting argument to consider here: what of the adult woman who, in full knowledge of the risks of the procedure, requests it as it holds importance to her cultural and personal identity? It is undeniably difficult to criticise the respect for patient autonomy.

In response to this argument, the facet of autonomy that can be questioned  in  these  scenarios  is  whether  the  request  for  FGM  is a product of cultural embedding. [1,2,5,6] This does not mean to demean the cultural background of the patient. It instead allows us to contemplate the possibility that what is desired by the patient is the sociocultural integration and acceptance FGM affords them.[1,2,5] There is anecdotal evidence in current literature to suggest that fear of rejection by family and community is a potent driving force in desiring FGM.[1,5] It is difficult to assess what component of the request is entrenched in a socio-cultural need for assimilation, and this could impede the voluntariness of consent. It is important to assert that fear is no justification for condoning what is unquestionably a practice with harmful health consequences. The solution is not to acquiesce to pressure to perform FGM but to educate the community as to the risks and impacts of FGM.

Some commentators reinforce that if patient autonomy is stated to be an adequate justification for performing female cosmetic genital surgery, it should also apply as adequate justification for medically performed FGM.[8,9] Many advocates of similarly banning labioplasty argue that certain forms of cosmetic surgery on female genitalia pose similar health risks to FGM. [10] However, perhaps what this should invoke is a questioning of the ethical soundness of female genital cosmetic surgery. Despite said assertions that the legal permitting of labioplasty should likewise permit FGM, the converse can and must be argued. Performing one potentially unethical procedure should not allow the medical practice of other unethical procedures.

The final stance

It is of great interest in finally evaluating this argument, to return to a question posed at the beginning of this paper: should ethics be removed from socio-cultural standpoints?  The answer is yes, and herein lies the core opposition to the practice of FGM. Ethics are

grounded in the basic human rights and preservation of the dignity of a person. As E.H Kluge postulates in Female Genital Mutilation, Cultural Values and Ethics, ethics apply to the nature of what it is to be human, and consequently apply to all human beings irrespective of their background or belief system.[11] Therefore, if cultural frameworks fail to meet these universal standards, they can be subject to ethical critique.[11] Consequently despite having respect for the autonomy of the patient, this writer holds the opinion, as do several international bodies, that FGM has led to worldwide incidences of violations of the  rights  of  a  woman,  and  degradation  of  their  inherent  dignity and should be prohibited.[1] Also as health practitioners objectively upholding what is in the best health interests of the patient, we cannot ignore the high risks of varying adverse physical and psychological health outcomes that are often inevitable with FGM.[1,4,5]

Reducing the practice of FGM internationally

Legislation that is effective in countries condoning FGM is well and good, but how does one begin to turn a centuries old wheel? International organisations, such as UNICEF, have mapped out goals for eliminating FGM internationally.[12] These are mainly aimed at affecting change at an individual and societal level by challenging age-old customs. [12] Koso-Thomas et al found, in examining populations and countries that practice FGM, levels of education and literacy were inversely proportional to rates of FGM, so these are areas to be addressed in terms of empowering women to have the correct educational tools for informed decision making.[13] Community based interventions, which bring together leaders and elders of local communities as well as women and their families, are one method. They can permit open discourse and awareness programs to take effect.[12,13] An intriguing concept in implementing strategies for change is that of decreasing the

‘supply and demand’ of FGM.[12] This involves educating target groups such as the local health practitioners carrying out the infibulations.[12] It encompasses educating them as to the dangers of FGM or retraining practitioners of traditional medicine in women’s health and midwifery, hence providing them with a more ethically suitable position.[12,13] Educating young men and their families is also vital in terms of reducing the stigma surrounding women who do not receive FGM.[12] This will assist in challenging the association of FGM with marriageability.[12]

Managing requests for FGM in medical practice

The views of Elchalal et al and RANZCOG guidelines still hold; cultural sensitivity and probing the cross cultural barrier is necessary in providing comprehensive healthcare whilst denying the request of FGM. [2,7] Extensive antenatal/gynaecological counselling may allow a  healthcare  practitioner to  not  only  build  rapport  and  trust,  but also allow one to elicit details of what influences requests for the procedure.[2] This therefore reduces adverse mental health outcomes that may arise from a refusal of the request. The inclusion of family members  (whilst  carefully  documenting  their  views),  is  not  only in keeping with the desire of the patient; it allows you the unique opportunity to hear their opinions, understand their influence on the patient, and   incorporate them into your educational strategies.[2] The guidelines have stressed the vital importance of treating women who have undergone FGM without ‘alarm or prejudice’, as allowing them the confidence to access healthcare is an imperative outcome of treatment.[2] Educational outreach programs, namely the National Education Program on Female Genital Mutilation and FARREP (Family and Reproductive Rights Education Program) utilise both multilingual and multicultural health workers who can assist in offering culturally sensitive healthcare.[2] Ultimately, it is important to uphold the quality of life of the patient and identify the factors that contribute to it.

Acknowledgements

Dr. Vicki Langendyk for providing vital feedback about this topic for students undertaking the Obstetrics and Gynaecology ethics curriculum at the University of Western Sydney School of Medicine.

Conflict of interest

None declared.

Correspondence

N Vigneswaran: nilanthy.vigneswaran@gmail.com

References

[1]   World Health Organisation (WHO). Female Genital Mutilation Fact Sheet [Internet]. 2014  [Updated  2014  Feb,  Cited  2014  Jul  19].  Available  from:  http://www.who.int/mediacentre/factsheets/fs241/en/.

[2] Gilbert, E. Female Genital Mutilation: Information for Australian Health Professionals. The Royal Australian College of Obstetricians and Gynaecologist. Victoria. 1997.

[3] Australasian Legal Information Institute (AustLII): NSW Consolidated Acts. NSW Crimes Act 1900: Section 45 [Internet]. 2014. [Updated 2014 Jun 13, cited 2014 Jul 18]. Available from: http://www.austlii.edu.au/au/legis/nsw/consol_act/ca190082/.

[4] Hosken, F. The Hosken Report: Genital and Sexual Mutilation of Females, fourth edition. Lexington, MA: Women’s International Network. 1997; pp. 48.

[5] Program for Appropriate Technology in Health (PATH) and Seventh Day Adventist-Rural Health Services. “Qualitative Research Report on Health Workers’ Knowledge and Attitudes About Female Circumcision in Nyamira District, Kenya”. Nairobi. 1996; pp. 83.

[6]  Toubia  N.  Female genital  mutilation and  the responsibility  of  reproductive health professionals. International Journal of Gynecology & Obstetrics. 1994; 46:127-135.

[7 ] El Chalal, U, Ben-Ami B, Gillis R, Brzezinski A. Ritualistic Female Genital Mutilation: Current Status and Future Outlook. Obstetrical & Gynecological Survey.1997;52(10):643–651.

[8] Bronnit, S. Female genital mutilation: Reflections on law, medicine and human rights. Health Care Analysis. 1998; 6 (1):39-45.doi:10.1007/bf02678079

[9] Berer, M. Labia reduction for non-therapeutic reasons vs. female genital mutilation: contradictions in law and practice in Britain. Reproductive health matters. 2010; 18(35);106-110. doi: http://dx.doi.org/10.1016/S0968-8080 (10)35506-6.

[10] Selvaratnam, N. Concerns over female genital cosmetic surgery. SBS News Australia [Internet]. 2013 Aug 26 [cited 2014 Jul 19];Health; [1 screen]. Available here from: http://www.sbs.com.au/news/article/2012/12/27/concerns-over-female-cosmetic-genital-surgery

[11] Kluge, E. Female circumcision: when medical ethics confronts cultural values. CMAJ. 1993;148(2):288–289.

[12] UNICEF Somalia. Eradication of female genital mutilation [Internet]. 2004. [Updated 2014  Feb,  cited  2014  Jul  28].  Available  here  from:  http://www.unicef.org/somalia/resources_11628.html

[13] Koso-Thomas, O. The circumcision of women: a strategy for eradication. London, England, Zed Books, 1987. p109.