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Ethical Analysis of Female Genital Mutilation

Cindy Earle

Concordia University, Seward, Nebraska

Female Genital Mutilation

Female Genital Mutilation (FMG) is a practice that has drawn more and more attention from the global public health community over the last few decades. It is a social and health concern in the practicing countries and is becoming a public health concern in the West due to emigration. Understanding the social dynamics and ethical implications behind the practice is essential for public health practitioners as they work towards eradicating this inhumane procedure that violates basic human rights.



Overview

Female genital mutilation, also known as female genital cutting or female circumcision, is a procedure that is usually executed at some point between infancy and age 15 and is performed by a midwife, healthcare professional, family member, or traditional circumcisers within a community. It involves partial or total removal of the external female genitalia or other injury to the female genital organs (such as pricking, piercing, incising, scraping and cauterization) for non-medical reasons (World Health Organization [WHO], 2008). Between 100 million to 140 million girls and women alive today have undergone some extent of this procedure in Africa and Middle East (where FGM is most prevalent) and it is estimated that 15 million additional girls will be exposed to it by 2030 (United Nations Population Fund, [UNPF] n.d.). FGM is known to occur in 29 countries, including Asia and certain immigrant communities in Europe, and shockingly the number of females at risk for FGM in the United States (U.S.) has more than doubled in the last decade due to African and Middle Eastern immigration. According to the Centers for Disease Control, 513,000 women and girls are living with FGM in the U.S. today, with the highest concentration in California with 56,872, New York with 48,418 and Minnesota with 44,293 (Westcott, 2015). Although the practice of FGM itself has not increased in the U.S., there is a practice known as “vacation cutting” that involves sending a girl back to their country of origin to have the procedure, or having a cutter sent to the U.S. to perform it.



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Classifications and Consequences

FGM is painful and traumatic and many times is performed outside of a medical facility, with blunt tools such as penknives, fragments of glass or tin cans, and without any type of anesthesia. The WHO, UNICEF, UNFPA Joint Statement developed four different types of classifications of procedures, with Type I and II being the most common. The primary factor for determining the type of procedure done is ethnicity.

The classifications are:

Type 1

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 the labia minora and /or the labia majora, with or without the 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.

(WHO, 2008)

There are no health benefits to FGM, but there are multiple harms. Simply by removing healthy tissue, the procedure itself impedes the natural tasks of the female body since personal hygiene becomes more difficult and keloid scar formation can become so severe that it interferes with walking. Some of the immediate complications that can occur include severe pain, shock, hemorrhage, infection, open wounds, and urinary retention. Long-term consequences can include infertility, increased risk for childbirth complications and newborn deaths, psychiatric disorders, recurrent urinary tract infections, loss of sensation during sex and cysts. In addition, the woman that has had a FGM will need more surgeries in the future if she had a Type III procedure to allow for sexual intercourse and childbirth. Sometimes, the FGM is repeated after childbirth (WHO, 2008).



Causes

FGM has deep-seated cultural, religious, and social causes that contribute to its existence. One common denominator within all society’s that it is practiced is that FGM is a manifestation of gender inequality and represents society’s control over women (OHCHR et al., 2008). In this day in age, it is difficult to understand why this practice is being continued, however with understanding comes the wisdom to act.



Cultural Impact

FGM is considered a cultural tradition and is associated with femininity and modesty. For a girl to be clean and beautiful she must have her “male” or “unclean” body parts removed. Her family is responsible for making the decision for FGM since it is considered an obligatory step in a girl’s upbringing and the older women within the family unit make the arrangements to continue the tradition. Girls who have had FGM are proud and feel as if they are now members of a community and so the cycle continues. There is the belief that this procedure will prepare the woman for marriage and will enhance the husband’s sexual pleasure. Men are expected to marry only women who have had FGM, and women need to conform in order to fulfill that ideal of womanhood. Local authorities within the community promote the practice because in many cultures it is an important part of the cultural identity that they want to ensure continues and efforts to stop the practice are translated as an attack on their identity and culture. (OHCHR et al., 2008).



Religious Impact

Religious leaders are varied on the position of FGM as there is no religious script that promotes the practice. Some promote it, some consider it irrelevant to religion; and others contribute to its elimination (WHO, 2008). For many there is a religious connotation that the bleeding that occurs is a symbol of a stream that connects the woman to the rest of her community. Sometimes a religious revival movement can cause its spread into neighboring communities. Many communities believe that FGM will ensure marital fidelity and prevent sexual behavior that is considered deviant and immoral since it will reduce a woman’s libido and help her resist “illicit” sexual acts. Christians, Jews, and Muslims all practice FGM even though it predates both Christianity and Islam (OHCHR et al., 2008).



Social Impact

The social pressure to conform to tradition preserves the practice of FGM. It becomes a status symbol that the woman that has been cut is mentally strong and has the ability to be a responsible adult. Any woman that refuses this norm can face condemnation, harassment, and ostracism from their family and peers. Some communities will outwardly reward girls after they have had the procedure by celebrating them publicly and with gifts. Even though women know that it can harm themselves or their daughters, FGM continues because the social benefits outweigh its disadvantages.



Ethics

Throughout the world, FGM is recognized by many as violating basic human right principles and standards such as “do no harm” and “do not kill”. As a form of discrimination and cruel abuse it is associated with gender inequality (WHO, 2008). FGM does not provide any direct benefit to the women that receive it and inflicts undue harm to vulnerable children (in the name of social custom) who have not even consented to, nor do they understand, the procedure. FGM is irreversible, does not provide benefit, and should be a decision made by the person whose body is being affected. It is a violation of human rights to not recognize and respect autonomy for a procedure that could wait until the child is of legal age. Many of the women that volunteer for the procedure do so without a full understanding of the impact of their decision (Ahan, 2012).

The duty of a physician is to abide by the medical ethics principles of autonomy, beneficence, nonmaleficence and justice and to provide only services that are medically indicated. There is no scientific evidence backing up the medical necessity of FGM so there is no justification for a professional healthcare provider to perform this procedure. It is considered unethical for a health professional to damage a healthy organ because culture approves the practice (WHO, 2008). However as a social custom, physicians are “expected” to perform FGM within practicing countries because it is less harmful to the patient if a physician does the procedure rather than a community layperson. Hence an ethical dilemma for a physician is whether or not to perform the procedure in order to do “less harm” by decreasing the patient’s risk to post procedure consequences (due to the nature of his skill and knowledge, rather than a community layperson) and to prevent the child from being rejected by their community. However doing so, is a violation of medical ethics for which a practitioner can be prosecuted.

In Egypt around 77 percent of girls who undergo FGM are cut by a healthcare professional whose main source of income is performing this procedure (Westcott, 2015). Laypersons and midwives cannot legally perform surgery due to their lack of skill in this area; however do so thus increasing risk to the patient, causing unnecessary harm. Putting personal benefit over harm of others, the healthcare profession accepts the funds that the families are willing to pay (Elsayed, Elamin & Sulaiman, n.d.) Hence another ethical dilemma for the provider is whether or not to perform the procedure or disrespect and violate the social tradition of FGM and lose the community’s respect and support as a healthcare provider.

Using FGM to control sexual behavior of women is a violation of human rights. Everyone has the right to have control of their own body and to have a healthy sexual life. Damaging female genital organs in order to control a woman’s sexual behavior is not only barbaric but it is inhumane. FGM is practiced based on social ignorance of the female bodily functions as well as the ignorance that the male predominantly initiates adulteress behavior. Every human has a God-given sexual nature that should be respected and acknowledged and this procedure actually removes that natural gift of womanhood.

The Universal Declaration of Human Rights states that “everyone has the right to a standard of living adequate for health and wellbeing.” FGM violates the right to health and bodily integrity and is a life-threatening form of discrimination. It violates a person’s rights to security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life, when the procedure results in death. (OHCHR et al.,2008).



Actions

Medical professionals have an ethical responsibility and obligation to do their best to halt the practice of FGM by explaining their medical reasoning behind refusal to patients, families, national and local authorities, and religious leaders (Ahan, 2013). Physicians need to forgo tolerance and take a vocal stand against “normalizing FGM” as standard medical practice. Professional organizations such as the International Confederation of Midwives (ICM), the International Council of Nurses (ICN), the Federation of Gynecologist and Obstetricians and the World Health Organization have all blatantly confirmed that the medicalization of FGM is unethical and must never, under any circumstances, be performed by healthcare professionals (WHO, 2008).

Government has a duty to extinguish FGM in order to uphold the dignity of human beings however caution is required due to the risk of pushing the practice ‘underground’ which could promote higher mortality rates. Establishing a law against FGM creates a clear message to citizens that it is wrong and gives the right for professionals to intercede (WHO, 2008).

Sometimes the fear of persecution causes someone not to seek help if post-operative complications should arise. Burkina Faso, Central Africa Republic, Djibouti, Egypt, Ghana, Cote D’Ivoire, Senegal and Sudan have laws against FGM however implementation of the law is inconsistent. Some of the cultural beliefs are that FGM improves fertility; it prevents maternal and infant mortality; prevents promiscuity; helps to keep the genitalia clean; pleases husbands; is harmless and people should be able to continue; and is a religious obligation (WHO, 2008).

The belief that FGM upholds a woman’s ability to marry is significant and must be addressed within the culture if any progress is to be made to halt this practice of women inflicting damage upon other women in the name of financial and future security. Another stronghold within the culture that practices FGM is the belief that the mutilation of genitalia signifies that the child has become an adult and has a future right to passage into sexuality (Ahan, 2012). FGM has fundamental beliefs that relate to a girl’s womanhood, family honor, economic prosperity, and social identity and applying international ethical concepts to FGM’s local cultures poses great complexity because the practice holds great meaning for those that participate (Ahan, 2012).

Conclusion

Within practicing communities, FGM is ethically acceptable whereas in non-practicing communities opposing ethical standards dictate that action is ethically necessary to protect women and children from being coerced in having this operation against their will and without informed consent. Culture is very important in establishing norms within a society and FGM has become a means of social identity and cultural affirmation, a tradition if you will. The countries that practice this tradition have high poverty and illiteracy rates and the women are convinced that this is a normal practice. Cultural practices should only be acceptable if they withstand the ethical universal principle “filter” of basic human rights- culture does not justify inhumane treatment to others. Our understanding of right and wrong is embedded in our religious beliefs, social interactions and childhood, however fundamental ethical principles apply to all persons, regardless of their culture, religion, and social community because they are human beings (Ahan, 2012). Not to extinguish FGM violates the principle of autonomy and says that women and children do not deserve to be respected or treated equally-but need to be subordinate to male dominated and directed cultures. (Kluge, n.d.).

A long-term commitment is required to eradicate FGM because it requires cultural changes of behavior. However it is possible; after all, slavery and medical experiments in Nazi Camps were declared illegal and extinguished due to the realization that there was violation of human rights (Kluge, n.d.). Values and belief systems need to be changed, and many times, that requires a one-on-one interpersonal relationship built on trust and open communication with a professional. Religious leaders need to be vocal and take a stand against this inhumane torture.

Women and children need to be educated, their self-esteem improved and empowered so that they may make their own decisions and stand up for their own rights. Lobbying for women’s rights seems to be unacceptable in these countries however the women’s movement has been successful in many areas of the world and it can be there also. Appealing to a mother’s heart, women need to hear the message that FGM can harm their babies and be encouraged to take action to do what is on their best behalf. These prevention strategies could be engrained into women’s reproductive health programs as well as during regular doctor’s visits.

Also, the government has to be committed and consistent in implementing laws against FGM and provide resources to support women and children through the change, such as social services, family planning classes, and public education. Leaders of communities could create new traditions that substitute a different “rite of passage” ritual for women that doesn’t harm them, yet respects their particular culture.

Through all of this, the difficulty in pursuing an impactful action will be balancing respect for another’s culture while still being an activist against this practice (Ahan, 2012). The principles of ethical public health practice call for practitioners to have a duty to protect the health of individuals while respecting their rights, values, beliefs and cultures (Thomas, Sage, Dillenberg & Guillory, 2002). It is the moral responsibility of a public health practitioner not to excuse this practice, but to meet the challenge of its extinction head on and without hesitancy in order to protect two at risk special groups: women and children.

References

Ahan, F., (October 2012). Theories on female genital mutilation. Department of Cultural Anthroplogy. Uppsala University. Retrieved from http://www.academia.edu/3277459/Theories_on_Femal_Genital_Mutilation.

Elsayed, E., Elamin, R., & Sulaiman, S. (n.d.). Female genital mutilation and ethical issues. Brief Communications. Retrieved from http://www.sjph.net.sd/files/Vol6N2/Brief%20Communications1.pdf

Kluge, E. (n.d.). Female genital mutilation, cultural values and ethics. Journal of Obstetrics and Gynecology 16(2) 71-77. Retrieved from http://phil102moralproblems.weebly.com/uploads/1/2/8/7/12874574/kluge_-female_genital_mutilation.pdf

Thomas, J., Sage, M., Dillenberg, J., & Guillory, V. (July 2007), A code of ethics for public health. American Journal of Public Health. 92(7): 1057-1059. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/

United Nations Population Fund [UNFPA](n.d.). Female genital mutilation. Retrieved from http://www.unfpa.org/female-genital-mutilation



Westcott, L., (2015, February 6). Female genital mutilation on the rise in the U.S. Newsweek. Retrieved from http://www.newsweek.com/fgm-rates-have-doubled-us-2004-304773

World Health Organization [WHO], (2008). Eliminating female genital mutilation, an interagency statement. Retrieved from: http://


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