Few topics can rouse a group of students at 9:00 am and even fewer can stir up a heated emotional debate as did the issue of female genital cutting (FGC) in one of the health and development (H&D) sessions. By the end of the session, almost every female student had adopted a protective body language, with legs firmly crossed and expressions normally displayed watching a horror film. How could parents that claim they love their daughter, mutilate her genitalia in the name of culture? However, issues concerning FGC and people are rarely as straightforward as discovered by researching the topic further.
Illustration 1: Four common types of FGC (4)
The procedure is performed usually during the female’s adolescence however it can be and is performed at any age (5). Commonly, FGC is often performed without anaesthesia using unsterilized razors, scissors, stones, or glass by traditional practitioners who lack formal medical training (6). Thus, some have called for the medicalisation of FGC to reduce the risks associated with the procedure; however, others argue against any medical intervention as they deem it would legitimatise a practice that is a form of violence against females (7). This paper seeks to consider whether healthcare workers should be trained to perform FGC by considering the cardinal principles of medical ethics (8), the harm reduction approach, whilst taking into consideration learning objectives of the H&D course. The paper will conclude with a self-reflection.
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Reasons for FGC continuance
Before instinctively labelling societies that condone such practices as barbaric, it is necessary to examine the purpose and rationale such a practice fulfills. Such an understanding seeks not to justify the practice but rather assist in the development of effective strategies for intervention. Reasons vary amongst communities as to why they practice FGC, with the main reasons depicted below:
Illustration 2: Different rationales used to ensure FGC’s continuity (9)
The common thread amongst these reasons appears to be that FGC upholds family honour through providing evidence of a girl’s chastity up to her marriage, thus shouldering an enormous amount of burden on members in these communities to conform or be outcasts. Parents, who decide when they want their daughters to undergo the procedure, believe they are acting in good faith and for the female’s benefit (10), (11).
Core principles of medical ethics and FGC
Given the above, FGC can be analysed vis-à-vis the core principles of medical ethics, namely beneficence, non-maleficence, autonomy, and justice. What is unanimous in FGC literature is that there are no known therapeutic benefits derived from removing some or all healthy tissue and organ (2). As there is no medical benefit derived from this procedure it does not fulfill the beneficence criterion.
Conversely, FGC is associated with numerous negative consequences to the health of the circumcised. The consequences can range from mild to severe depending on the type of FGC performed, whether the procedure is being carried out by healthcare professionals or by traditional circumcisers and the general health status of the individual who is being circumcised (12). The potential ill health effects can be categorized into immediate and long-term effects, as summarized in the table below (13), (5); (14) :
Infection (e.g. tetanus)
If FGC involves stitching, urinary retention and recurrent infections
Pain on intercourse
Urinary and or fecal incontinence
Increase risk of maternal death
Thus, based on the above FGC clearly violates the non-maleficence principle. However, those who have undergone the procedure may not perceive themselves to be suffering from ill health as a direct result of the procedure. In one study, a circumcised individual was asked if she had any problem with urination, she replied no but when asked how long it took her to empty her bladder, she stated 15 minutes (3). In additional to the above adverse effects, FGC is associated with a range of psychological and psychosomatic effects on an individual: eating, sleeping, and concentration disorders (13). Nonetheless, a systematic review done on research on FGC-related health consequences found that most of the studies were flawed in their design or did not take into account confounding factors such as socioeconomic status (12). The review came to the conclusion that FGC did not pose a health hazard that is statistically significant (12). However, recent study carried by WHO, which took into account confounding factors and did not collapse the different types of FGC as one variable, found that babies born to women who underwent FGC suffered a higher rate of neonatal death and stillbirth compared with non-FGC women(13). In addition, 25% of newborns to circumcised mothers had lower birth weight or serious infection, factors associated with an increased risk of prenatal death (13), (15). There are no reliable figures on the correlation between death rates and FGC due to the secrecy of the practice, as usually if the procedure goes wrong, the blame is often levelled at the female for being weak or on supernatural phenomena .
Given the risks of FGC, proponents of medicalisation argue that doctors have a duty of care to those who will undergo the procedure, which includes providing access to medical facilities, equipment, and expertise. As without medical intervention, circumcision is likely to be performed by the medically unqualified. It is trite to state that all healthcare professionals are subject to the principle of duty of care, including providing treatment if there is a complication from FGC irrespective of their personal views on the practice. However, irrespective of whether FGC if performed by a healthcare professional, it will carry risk, albeit the risk is mitigated to some degree. Nonetheless, risks associated with a heart transplant are acceptable given the alternative, but as FGC has no therapeutic value, it is unreasonable to accept the risks associated with it. Healthcare professionals are not obligated to provide for all requested service (16).
Even if facilities are provided, poverty leads to an inability to afford healthcare (17) due to a number of reasons: direct user charges, transportation to healthcare facilities which are often located in urban not rural areas, and opportunity costs of time and travel spent not on economic activity. Where there is access to healthcare, often the quality of care is suboptimal. For example, one of the complications of FGC is a fistula, which can lead to fecal or urinary incontinence which can be surgically treated but often is not due to understaffed hospitals and lack of availability of simple medicines such as anaesthesia (9). Moreover, due to the legal status of FGC in many countries, families may be reluctant to seek medical advice for children due to fear of prosecution.
The third cardinal principle of medical ethics is autonomy i.e. the patient has the right to be in control of his or her treatment. Proponents of medicalisation argue that everyone has a right to decide for themselves what is in his or her best medical interest. Much to the dismay of western audiences, there are females who look forward to having the procedure done (18). There is the pain but following the pain is acceptance and new conferred status in the community. However, most of those who undergo circumcision are children. Children can be easily swayed by parental and societal influences and may not have formed full capacity to make rational decisions (19), (17). The decision is not a trivial matter, FGC is permanent.
As often is the case, parents are the decision makers, and in societies that value virginity before marriage, the pressures to conform are immense. Some would argue that parents act as proxy decisions makers for their child’s health throughout the world including the western world (except Gillet’s competence). However, even a parent’s decision can be overruled if it is at odds of what is in the child’s best interest. In addition, given that children and many parents are not fully informed, their consent may be deemed invalid. However, if armed with knowledge of all the adverse health implications of FGC, parents still favour FGC, as has been found in many communities where health campaigns have been waged against circumcision, does this support its medicalisation? By not tackling the underlying reasons for the existence of the practice, information of only adverse health implications only drives people to make the practice medically safer not questioning its foundations (20).
The fourth cardinal principle of medical ethics is justice. It is the duty of the providers of healthcare of any nation to manage and distribute scarce resources whilst providing equitable care for all. This is even more pertinent in developing countries. According to WHO, “cardiovascular diseases are the leading cause of death in low income countries, but infectious diseases as a whole account for more deaths (above all HIV/AIDS, lung infections, tuberculosis, diarrhoeal diseases and malaria)” (21). It is also said that “complications of pregnancy and childbirth together continue to be a leading cause of death, claiming the lives of both infants and mothers”(21). Could time, energy, resources, and human capital be spent more effectively elsewhere rather than on a procedure with no known health benefits, such as FGC?
In addition, this practice is not a one-off cost as future investments for flow-on care are needed such as during child delivery due to the complications associated with the procedure. Doctors have a monopoly on medical practice and attached to this great privilege are responsibilities. Most people expect, doctors to base their practice on sound scientific evidence. It is perceived that doctors if perform FGC procedure, they may be inadvertently sending a message that FGC is beneficial for the individual and society.
Revisiting beneficence principle…doing good by reducing harm?
Recently, the harm reduction approach is being used to deal with a range of health issues that involve risky behaviours such as drug addictions, safer sex practices, and the fight to eradicate HIV/AIDS (18). Rather than top down strategies, harm reduction seeks to involve community members to design strategies that are acceptable to those who engage in risky behaviour such as FGC. This is important in lieu of many reports from those working on the ground albeit without yet scientific research backing the claims that FGM practiced by traditional circumcisers may facilitate the spread HIV/AIDS (5).
However, there is no evidence than moving towards a lesser cut prevents the long-term and obstetrical complications associated with the practice (22). Some argue, by allowing anaesthesia, it would encourage more cutting; however, if medical staff were given clear guidelines which were enforced, this is unlikely to be a problem (3). Harm reduction also involves education about the dangers of the more severe types of circumcision. One of the least severe forms of FGC which is practiced in Malaysia and Indonesia involves pricking of the clitoris to shed a small amount of blood under anaesthetised conditions with no removal of any tissue (23). If the types I, II, and III FGC continue to be illegal but symbolic pricking type of FGC be made legal, families might be willing to have their girls undergo a type of circumcision that is legal (3).
Some agencies seek to educate traditional practitioners to practice their trade safely by encouraging them to use prophylactic antibiotics, use one blade per cut, and cut less tissue (24). It is important to not vilify those traditional practitioners who perform FGC. Often, they are born from the same destitute environment in which this practice thrives. Providing alternative means of income generation for traditional circumcisers has been met with mixed success (25). The rationale for this is that if you stop those who perform the procedure, then the practice will end. It’s not surprising how this initiative on its own will be unsuccessful as removing supply doesn’t curb demand – another circumciser will do the procedure or a healthcare worker will perform the procedure where a vacuum exists. Moreover, by focussing on the individual, one reinforces the idea that FGC is simply a crime acted by one individual over another rather than understanding the social control that is involved in regulating individual behaviour (18).
Maintaining cultural identities
In correlation with justice, it is argued women in these societies have the right to the practice their culture. However, culture is a living and ever changing entity. Embedded in culture, are unequal power relationships, which need to be exposed and corrected not preserved. It is important to highlight that within international legislation, there is a hierarchy of rights and the right to culture are superseded by right to life and free from bodily harm (26). FGC is just one part of the ritual, other parts of the ritual can still be preserved as demonstrated by alternative rites of passage ceremonies for females who do not get the circumcision performed (24). Where, FGC is practiced as part of a rite of passage of a girl becoming a woman, alternative rites of passage allow communities to maintain certain traditions whilst abandoning destructive aspects. Thus, females who are not circumcised can still be celebrated, with a modified rites of passage ceremony into womanhood which excludes FGC but includes social gathering, imparting of knowledge as potentially future mothers, and dance and song celebrations (6). Alternative rites of passage as practiced by grassroot organisations such as “Excision by Words”, which operate in Kenya has had growing success (27).
Some feminists argue that the core roots of gender stratification (girls can only be future wives and mothers) remains unaddressed by simply removing overt forms of oppression. There is something to be said of this argument but alternative rights of passages is one means of ensuring interventions are acceptable to the community (28) and at the same time, empowering those women who do not undergo circumcision. As often, there is no real element of choice for females who do not want to have the procedure done, thus alternative rite of passage makes a tangible difference in their lives.
There is a case to make FGC legal and thus, opening access to medical care if the decision has been by fully informed consenting adults only. Some argue those who agree to FGC regardless of age can never give consent as they are exercising false consciousness. This argument however, should apply equally to western society where cosmetic surgery such as designer vaginas is legal. Women who choose to have cosmetic surgery done such as breast enhancement surgery are believed to have given informed consent free from social pressures to conform to ideas of beauty or the libertarian argument of individual rights is evoked (29), (30), (31). It must be stated that cosmetic surgery for non therapeutic reasons is available by private funds as in most cases there is no recourse to public funds; therefore, the medical principle of justice may still override any medicalisation of the practice due to scarce resources especially in developing countries.
Western cultural biases are brought to the forefront in the case of non-therapeutic male circumcision, a practice that is legal in many western countries such as the UK can be condoned whilst less severe type of FGC that remove an equivalent amount of tissue are not.
Governments such as Kenya provide antibiotics, anaesthesia, and medical personnel for male circumcision and not for FGC (32). Indeed, the medical ethic arguments used against FGC above can be easily used to be against medicalisation of male circumcision. Male circumcision is often performed for religious reasons such as in Islam and Judaism. Unlike male circumcision, FGC is not explicitly promoted by any religion and is practiced across religious communities (33).
In communities, where FGC is practiced on a religious belief, gaining the support of religious leaders is effective as they incorporate anti-FGC messages into their congregations. According to the WHO, Protestant leaders have assisted tremendously in reducing FGM practices in Burkina Faso (9). In fact in Egypt, religious reasons along with health risks associated with the practice have proven successful in reducing the rates of circumcision than using the women rights are human rights approach (34).
Many countries in which FGC is practiced are signatories to The International Declaration of Human Rights, The Convention on the Rights of the Child, and the Convention Against all Forms of Discrimination Against Women (35). Moreover, in many countries there are national laws against FGC, which would provide support to advocacy groups; however, they are poorly enforced (24). Due to the practice becoming illegal in many places the practice is driven underground. Strategies to eradicate FGC have to be as diverse as the reasons for the practice. Participatory approaches involve gaining a range of people and groups perspectives on an issue. Not everybody within a community holds the same views on FGC and not all views are considered equal. Solutions must ultimately come from within community itself – interventions are far more likely to be of success if those whose lives are concerned are involved (35)
Role of development workers
Development workers from the West go to developing countries because of many reasons but generally they feel that there is a need that is not being met, which they want to help fill. Development workers who might hear of FGC for the first time, when they are on placement, need to resist the temptation of viewing this practice as mindless violence but violence nonetheless. Many resist abandoning FGC because they regard it as another imposition of the West asserting its moral and cultural superiority (11), (36). Thus, rather than preaching, one needs to provide assistance in promoting education and empowerment so to enable a situation whereby a non-FGC female is acceptable in a community. Only a third of FGC organisations have involved in consulting the targeted audience (9), thus there have been shortcomings.
For example, anti-FGC posters that show young girls being forcibly undergoing the procedure including a blood covered knife have been found to be not effective as “in reality it only shocks westerners since an excision is a normal event and thus neutral for most Ethiopian.” (9). On the other hand, having a native female who is educated, married and has refused FGC is a far more powerful and credible voice to young girls who are not wanting FGC (6). In the case of FGC, a practice that requires behaviour and social change, temporary development projects are unlikely to have long lasting effects and should instead those who are kindly coming from abroad to help should focus on long term projects that are largely controlled by the local citizens so that when they are not there the work still continues.
In Egypt, peer-training about FGC has been piloted amongst physicians as not all physicians were aware of the ill effects of FGC (37). One initiative has been to incorporate in healthcare provider curricula to help healthcare professionals be aware of the negative consequences of FGC, how they can treat any complications of it, and how to counsel families who are contemplating whether to have the procedure done to their child, or who are suffering from psychosomatic effects of FGC themselves (38). Even if healthcare workers don’t intend to work abroad, they need to informed about FGC, especially those working in areas with a large ethnic minority population. According to HM government report, “over 20,000 girls under the age of 15 are at high risk of FGM in the UK each year and that 66,000 women in the UK are living with the consequences. (39).”
The issue for those against the practice becomes whether a zero tolerance policy to FGC is the way forward or is medicalisation informed by harm reduction strategy a valuable tool we are ignoring at the detriment of those lives who we seek to help? This can only be answered by field work and not by sitting behind a desk.
Given the sheer volume of statistics spewed during various topics, I realised I was becoming immune to their emotional and shock value. However, as soon as the statistic is linked with a person and given context, suddenly that statistic is a living person with dreams, future plans, a family and friends. When, the excerpt was read about a young girl sharing her fears on FGC, the girl became real and not just another statistic. When the figures about the low rate of doctor to patient ratio in Mozambique and the number of HIV patients in the area were read – it was a passing moment for me. However, when the professor asked us to compare those rates to the doctor-patient ratio in Leicester and the number of diabetes patients here, I realized the gravity of the situation in Mozambique. I have learnt now to make statistics mean something, it is useful to compare them with a familiar context. To illustrate, life expectancy in Zimbabwe is 36 years compared to the west where I can expect to live up to my late 80s (40). In Zimbabwe, I effectively would have less than 10 years to live further, a grim realisation which make me reflect on my priorities.
Prior to commencing the health and development course, I was sceptical about pharmaceutical representatives, who I felt had sold their souls. Individuals working in the pharmaceutical industry are not, by virtue of their profession, bad people intentionally denying the poor access to medication. They are however part of the global economic institutions that in my opinion, under the current status quo, make it more unlikely that access to care will be available to those who need it the most. While, society is greater than the sum of its parts, it is amenable to change. While most people of the world want a safer, freer, and more equitable world, we often fiercely contest on how to achieve such outcomes as evidenced through the various discussions we had in the course,.
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We all chuckled when the guest lecturer on education and empowerment shared with us a story of how a NGO implemented new toilets in homes of poor people in an Indian village but found that nobody was using them. Amusing as this story was it highlights the serious shortcomings, when those we seek to help are regarded as an afterthought and not involved in all aspects of developmental projects. I also realized even when scientific explanations are not available people try to make sense of what is happening around or to them by other means. For example, some mothers in India that were not exposed to scientific explanations of infectious diarrhoea, thought by restricting fluids to their child, it would cure the diarrhoea. To stop more from coming out of one end, it made sense putting less in. I had underestimated, or rather had a superficial grasp, of how education can make such a difference to health. The course highlighted to me that value and the importance of prevention of illness.
The content explored in the H&D course has reinforced my belief that health is not all about medicine and healthcare workers are not the only stakeholders. For example, engineers working on establishing safe water pumps, builders making better roads, and teachers providing education means fewer infections, easier access healthcare facilities, and patients who can make more informed choices about their health. As, the illustration depicts:
Illustration 3: Determinants of Health (41)
What I appreciated most about how this course was delivered was that, despite all the issues facing the world today, nobody resorted to cynicism. There were sceptics but cynicism does no one good and thus, the course has reaffirmed my desire to work in an underdeveloped area whether at home or abroad.
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