Female circumcision

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Encyclopedia for Global Bioethics

Circumcision. Female

Mahmoud F. Fathalla, MD, PhD, Department of Obstetrics and

Gynaecology, Assiut University, Egypt

Abstract

Female circumcision (otherwise called female genital

mutilation or female genital cutting) refers to all procedures

involving partial or total removal of the external female genitalia

or other injury to the female genital organs for non-medical

reasons. More than 125 million girls and women alive today have

been cut in the 29 countries in Africa and Middle East where the

practice is concentrated. The procedure varies from an

insignificant cut to a major mutilation. However, it has been shown

to have no health benefits, can harm girls and women; and it

therefore raises ethical concerns about the right of the child and

dignity of the woman. In its cultural context, ensuring that a

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daughter undergoes genital cutting as a child or teenager is a

parental loving act meant to make certain of her marriageability.

This is particularly important in societies where there is little

economic viability for women outside marriage. The health

profession faces ethical issues and challenges about medicalization

of the procedure, medical alternative rituals, obstetric care for

women who have had the procedure, and responding to requests

for re- suturing after delivery. The elimination of this harmful

traditional practice may be promoted less effectively by insensitive

enforcement of criminal laws than by the counseling and education

of patients and communities.

Keywords

Female circumcision, female genital cutting, ethics

Introduction

Female circumcision (otherwise known as female genital

mutilation FGM or female genital cutting FGC) refers to all

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procedures involving partial or total removal of the external female

genitalia or other injury to the female genital organs for non-

medical reasons. The practice is most common in the western,

eastern, and north-eastern regions of Africa, in some countries in

Asia and the Middle East, and among certain immigrant

communities in North America and Europe. The World Health

Organization estimated that more than 125 million girls and

women alive today have been cut in the 29 countries in Africa and

Middle East where FGC is concentrated (WHO, 2014a). In Africa,

more than three million girls have been estimated to be at risk for

FGC annually. The percentage of women ages 15 to 49 who have

undergone genital cutting in the countries of northeast Africa

(Egypt, Eritrea, Ethiopia, and Sudan), ranges from 80 to 97 per

cent, while in East Africa (Kenya and Tanzania) it is markedly

lower and ranges from 18 to 32 per cent (UNICEF 2013). Overall,

the chance that a girl will be cut today is lower than it was around

three decades ago, but the pace of change is uneven, both within

and among countries.

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FGC is commonly carried out on young girls sometime

between infancy and age 15. The practice is mostly carried out by

traditional circumcisers, who often play other central roles in

communities such as attending childbirths. However, WHO

estimates that more than 18% of all FGC are being performed by

health care providers, and the trend towards medicalization is

increasing (WHO, 2014a).

Conceptual clarification/definition

The terminology used to describe this practice varies. The

term ‘female circumcision’ has been used historically. However, as

the harm that such procedures caused to girls and women became

increasingly recognized, and because this procedure, in whatever

form it is practiced, is not at all analogous to male circumcision,

the term ‘female circumcision’ gave way to the term ‘female

genital mutilation’. The term ‘female genital mutilation’ (FGM)

has been adopted by many women’s health organizations and by

intergovernmental organizations, such as the World Health

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Organization and UNICEF. However, the use of the term female

genital mutilation may offend women who have undergone the

procedure and do not consider themselves mutilated or their

families as mutilators. Consequently, the term ‘female genital

cutting’ is used in an attempt to find language that is value neutral,

but which adequately describes the nature of the procedure.

It is important to note that FGC bears little or no relationship with

male circumcision. In male circumcision, the part removed is the

prepuce, and this has possible health benefits such as protection

against HIV infection, and carries little risk of harm (Tobian et al.,

2014). The degree of cutting in the female procedure is

anatomically much more extensive than male circumcision. The

anatomical male equivalent of the female procedure in which all or

part of the clitoris is usually removed, would be the cutting off of

most of the penis. In addition, the procedure carries no health

benefit, and can be associated with physical and psychological

harm. Unlike male circumcision, FGC is neither supported by any

religion nor bears any relationship to the geographical distribution

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of any religion. A religious justification has commonly been

offered in some Muslim communities, in order to bestow some sort

of sanctity on the practice. An authoritative review published by

the World Health Organization lends no support to such

justification (Al-Sabbagh. 1996).

History and background

The origin of the practice of cutting parts of the external

genitalia of girls or young women, including the clitoris, is lost in

antiquity. The clitoris is, to the outward appearance, a tiny organ

which even the woman to whom it belongs may find difficulty in

seeing. When erotically stimulated the clitoris becomes engorged

and erectile. Perceptions of, and attitudes towards, the clitoris,

reflect wider societal attitudes to female sexuality. The clitoris has

been a “victim” of assault in African and non-African societies. It

was the subject of assault in Western countries in the past

(Fathalla, 2000). Excision of the clitoris was performed by

Western gynaecological surgeons in the second half of the

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nineteenth century and early twentieth century on allegedly

medical grounds. It was considered necessary not only to cure such

sexual deviations as nymphomania but also to prevent

masturbation and to cure a number of disorders, some of which

were alleged to be caused by masturbation, such as hysteria,

epilepsy, melancholia and insanity. Also, it was unthinkable at the

time that any decent woman should derive pleasure from sex and it

was clear that conception did not require female sexual

satisfaction.

FGC varies from an insignificant cut to a major mutilation. It

is commonly performed by non-professionals who may not

adequately know the anatomy of the female genitalia. Based on

observation of women who have undergone a version of these

procedures, an attempt has been made to classify different forms or

degrees of female genital cutting (WHO, 2014a). Most procedures

involve partial or total removal of the clitoris. They may also

involve excision of the labia minora. In extreme forms, known as

infibulations, the clitoris, labia minora and sometimes labia majora

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are removed, and the raw surfaces are either stitched together or

kept closely in contact to adhere by tying the legs together. This

seals the vagina, leaving only a small opening for the flow of urine

and menstrual blood.

Health concerns

Apart from the effect on sexual life of the woman, and the

psychological trauma to the child, there are health hazards, largely

related to the fact that the procedure is performed outside health

care facilities by non-professionals, and varying according to the

extent of the excision in the procedure. WHO affirms that FGC has

no health benefits, and it harms girls and women in many ways

(WHO, 2000). FGC interferes with the natural functions of girls'

and women's bodies. Immediate complications can include severe

pain, shock, haemorrhage, tetanus or sepsis, urine retention, open

sores in the genital region and injury to nearby genital tissue.

Long-term consequences can include recurrent bladder and urinary

tract infections, cysts, infertility, an increased risk of childbirth

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complications and newborn deaths, and the need for later surgeries.

Procedures that seal or narrow the vaginal opening need to be cut

open later to allow for sexual intercourse and childbirth. They may

be stitched again after each childbirth, with repeated exposure to

immediate and long-term risks.

Ethical issues and the cultural context

It is important to understand why parents want genital cutting

for their daughters. Within their communities young girls may not

be eligible for marriage if “uncircumcised”. Ensuring that a

daughter undergoes genital cutting as a child or teenager is a

loving act to make certain of her marriageability, particularly in

societies where there is little economic viability for women outside

marriage. This distinguishes FGC from most other forms of child

abuse. The practice is also common where premarital virginity is

required, often as an indication of a family’s honour. FGC is

associated in these cultures with personal and familial purity.

Removal of the folds of skin of the labia may also maintain a

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childlike, innocent cosmetic appearance. The need to maintain

virginity may explain infibulations. For FGC procedures involving

excision of the clitoris, there is a supposed role of FGC in

attenuating the sexual desire in women. Removal of women’s

drive for sexual satisfaction is thus supposed to reduce the

likelihood of a woman’s voluntary surrender of virginity before

marriage, and may also ease her demands for sexual attention that

her husband may be unwilling or unable to provide.

A wider societal role for FGC may be seen as a quest of

control of women’s sexuality in male-dominated communities,

which is a feature of many traditional societies of various religious

faiths. Women’s sexuality is seen to endanger social order and

virtue, and morality requires that women’s sexual and other

empowerment must be suppressed.

Other normative issues associated with FGC include those

related to autonomy and cultural paternalism, how education can

shape these issues in societies where FGC is practiced, and

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whether female children at risk for being subject to FGC can be

categorized as vulnerable.

Voices of women

In the rhetoric about FGC, the voices of women who have

been subjected to the practice are often not heard. It should be

understood that deep rooted traditions die hard. Although the

procedure is painful and may result in adverse health

consequences, for women in some communities, not having the

procedure may be psychologically more disturbing than having it,

and women in certain cultures may not be unhappy that they were

“circumcised”.

Legal aspects

A growing number of countries are enacting laws to prohibit FGC

(Cook, Dickens and Fathalla, 2002). Significantly, many are

African countries in which the practice has been widely prevalent.

Other countries with relatively high prevalence consider existing

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laws against aggravated assault to govern FGC that lacks subjects’

legally competent consent. Countries may also apply their laws

against child abuse. Practice among immigrant communities in

Europe, North America and Australia has resulted in the enactment

of prohibition of female circumcision acts. In the absence of

specific ways of reporting, there are legal constraints to the

enforcement of these laws.

While the religious justification of FGC is contestable, there

has been no medical benefits demonstrated for the practice. Indeed,

parental consent no longer holds sufficient grounds to render it

lawful. In addition, it is increasingly considered to constitute

unlawful child abuse, and a violation of the right of the child. The

UN Convention on the Rights of the Child article 19(1), for

instance, requires “measures to protect the child from all forms of

physical or mental violence, injury or abuse,” and Article 24(1)

protects “the right of the child to the enjoyment of the highest

attainable standard of health.” (UN Convention on the Rights of

the Child, 1989). The African Charter on the Rights and Welfare of

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the Child calls on States Parties to take specific measures to protect

the child from all forms of torture, inhuman or degrading treatment

(African charter on the rights and welfare of the child, 1999)

Parents’ power to impose their preference on young daughters

denies the girls their right to autonomy in their future adult lives,

and denies them immediate defence as children against parental

insistence on the performance of a non-therapeutic, irreversible

and risk-laden procedure.

It should, however, be realized that elimination of FGC may

be promoted less effectively by insensitive enforcement of criminal

laws than by the counseling and education of patients and

communities. It was agreed by the world government community

at the International Conference on Population and Development,

Cairo 1994, that “Governments are urged to prohibit female genital

mutilation wherever it exists and to give vigorous support to efforts

among non-governmental and community organizations and

religious institutions to eliminate such practices” (United Nations

1994).

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Ethics and medicalization of FGC

Medical complications of FGC are partly the result of its

being performed by unqualified people in unsafe settings. One

proposed approach to address these complications could be to

ensure that FGC is done by qualified people in safe settings. The

argument in favour of medical involvement is utilitarian, namely

that injuries and risks of heavy bleeding and other complications

would be reduced through skilled medical management of FGC

when the alternative is that procedures would be undertaken by

unskilled traditional practitioners, who use primitive means. The

argument against is one of principle, pitched at the societal or

macro-ethical level. While this approach might reduce the medical

harm to a particular individual, it still causes a profound social

injury to women more generally. Performing any type of FGC is

considered an approval of the practice of societal control of

women’s sexuality and an affront to women’s bodily integrity and

dignity of the person. Even if FGC did not present risks of physical

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and psychological harm, it would still constitute a violation of

women’s human rights. The claim that physicians should

participate in order to limit injury, since if physicians refuse to

perform such procedures they may be performed more harmfully

by unqualified persons, is rejected, in much the same way that

medical professional organizations prohibit medical participation

in such inhumane practices as capital and corporal punishment,

judicially-ordered amputation, or physically invasive means of

police or prison interrogation torture and execution of judicial

sentences of flogging, amputation and death.

The stand of the medical profession

The ethical approach taken by the medical profession, as

indicated in resolutions of the International Federation of

Gynaecology and Obstetrics (FIGO) and the World Health

Organization (WHO), is that FGC is individually and socially

harmful to women’s and girls’ health and dignity, and of no

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compensating medical advantage. In 1994, the FIGO General

Assembly, meeting in Montreal, passed a resolution on FGC:

“Recognizing that female genital mutilation is a

violation of human rights, as a harmful procedure

performed on a child who cannot give informed

consent, FIGO recommends that obstetricians and

gynecologists OPPOSE any attempt to medicalize

the procedure or to allow its performance, under

any circumstances, in health establishments or by

health professionals” (FIGO 1994).

In a more recent statement, on the occasion of “The International

Day of Zero Tolerance to Female Genital Mutilation FGM” held

each 6 February, FIGO re-iterated its position that “medicalization

of FGM - encouraged by some healthcare professionals - is not an

acceptable practice, and all efforts should be made to prevent this

by the presence of ethical guidelines and regulatory rules” (FIGO

2014). The World Health Organization has consistently and

unequivocally advised that female genital cutting in any form

should not be practiced by health professionals in any setting-

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including hospitals or other health establishments. WHO's position

rests on the basic ethics of health care whereby unnecessary body

mutilation cannot be condoned by health providers. Medicalization

is also considered inappropriate as it reinforces the continuation of

the practice by seeming to legitimize it (WHO, 2008).

Medical licensing authorities and professional associations in

many countries, particularly Western countries, have condemned

action that would present FGC as an authentic medical procedure,

and have considered that it constitutes professional misconduct.

The European Academy of Paediatrics (EAP) in a recent statement

indicated that “The whole community of paediatricians in Europe,

as represented by the EAP, strongly condemns female genital

mutilation and councils its members not to perform such

procedures” (European Academy of Paediatrics 2014).

The health profession thus remains unpersuaded by the fact that in

some cultures the procedure is considered beneficial and described

as ‘purification,’ with the inference that women and girls not

subjected to it are in some way impure. Accordingly, the ethical

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opinion of organized medicine is that physicians and health

facilities should not participate in this procedure, since it

implicates healthcare providers in a procedure of unrelieved harm

(WHO 2010). However, there are no specific sanctions in place for

those who violate extant anti-FGC Codes and resolutions

Ethics of a medical alternative ritual to FGC

Some physicians, who work closely with immigrant populations in

which FGC is the norm, have voiced concern about the adverse

effects of criminalization of the practice (American Academy of

Pediatrics, 2010). They proposed an alternative ceremonial ritual

involving only pricking or incising the clitoral skin as sufficient to

satisfy cultural requirements. This alternative is proposed as a last

resort option for the women who did not accept to abandon the

practice. A concern was that parents who are denied the

cooperation of a physician will send their girls back to their home

country for a much more severe and dangerous procedure or use

the services of a non–medically trained persons.

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In contrast, it has been argued that such a practice would

mean legitimizing the cultural belief system behind it, making it

more difficult to eradicate. Many anti-FGC activists in the West,

including women from African countries, strongly oppose any

compromise that would legitimize even the most minimal

procedure. The European Academy of Paediatrics took a firm stand

that “The practice of offering a “clitoral nick”, a minimal pinprick,

must also be condemned as an unnecessary and extremely painful

procedure” (European Academy of Paediatrics, 2010). The option

of offering a “ritual nick” is currently precluded by US federal law,

which makes criminal any non-medical procedure performed on

the genitals of a female minor (American Academy of Paediatrics,

2010).

Ethical issues in obstetric care for women who had FGC

Obstetric care for women who had FGC can be a new challenge to

health care workers in Western countries with large immigrant

communities. With globalization and the increased movement of

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the people across countries, health professionals have to equip

themselves to deal with health situations prevalent in other

countries. Women who have been subjected to FGC may seek

health care for pregnancy and childbirth in countries where this

practice is little known. Caring for women with FGC requires

sensitivity and cultural awareness. Birthing process may not be

detrimentally affected directly by FGC. What women may miss

and need more is psychosocially sensitive support. Innocent little

girls who did no harm, but were obedient to their parents and

elders, deserve tender loving culturally sensitive care from their

health care providers and not just technically sound clinical care. A

recent WHO statement highlighted that many women, in general,

experience disrespectful and abusive treatment during childbirth in

facilities worldwide (WHO, 2014b).

Ethics of re-infibulation

A difficult challenge may arise when an infibulated adult patient,

having been de-infibulated in order to give birth, asks to be re-

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infibulated (Abdulcadir et al., 2011). On one hand, this is a

request by a person, who enjoys competence and free will, for

what she considers a cosmetic reinstatement of her pre-delivery

condition. In communities where FGC is virtually universal, even

if re-suturing is refused after delivery, it is likely that the woman

will be re-sutured at some later date, often as a result of direct or

indirect pressure from her husband or from immediate family. On

the other hand, the same professional objection applies as to initial

FGC, namely that it is a medically unnecessary, socially contrived

procedure which should not be given respectability by

medicalization. Accordingly, demands for re-suturing to recreate a

small vaginal opening (“re-infibulation”) should be resisted and the

potential future health problems of such a procedure should be

explained.

The recent practice of female genital cosmetic surgery in the West

raises issues on what relationship it may have with FGC and

genital re-infibulation, and whether a double morality is being

applied (Essén and Johnsdotter, 2004). Cosmetic surgery, although

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its benefit and ethics may be questionable, is performed on a

requesting competent person, for the purpose of enhancing (not

suppressing) sexuality, by qualified surgeons.

Conclusion

The ritual practice of FGC raises ethical concerns and

challenges to society generally and to the health professions in

particular. It must be realized that so-called “female circumcision”

is deeply enmeshed in local traditions and beliefs. Mothers who

bring their daughters for the procedure believe they are doing the

right thing for their welfare. Any change that requires a

readjustment of long-established social mores makes people highly

uncomfortable. While health professionals should be culturally

sensitive, they should also be aware of the ethical implications of

their actions. Counseling and education, of patients and

communities, of which caring healthcare professionals are capable,

is needed for the elimination of this harmful traditional practice.

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Cross references Abuse: Child Abuse

Behavior Modification

Benefit and Harm

Bioethics: Clinical

Children's Rights

Circumcision, Male

Codes of Conduct

Consent: Informed

Cultural Diversity

Feminist Ethics

Freedom of Treatment

Human Dignity

Human Rights

Indigenous Ethical Perspectives

Medicalisation

Religion and Global Bioethics

Respect for Autonomy

Responsibility: Social

Right to Health

Sexual Ethics

Social Ethics

Surgery: Cosmetic

Utilitarianism

Vulnerability

WHO

References

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Swiss Med Wkly 140:w13137

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24

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Accessed 6.1.2015

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Accessed 5.1.2015

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Minors

Pediatrics 125 (5): 1089. DOI: 10.1542/peds.2010-0187

http://pediatrics.aappublications.org/content/early/2010/04/26/

peds.2010-0187. Accessed 5.10.2014

Cook RJ, Dickens BM, Fathalla MF. 2002. Female genital

cutting (mutilation / circumcision): ethical and legal dimensions.

Int J Gynec Obstet 79 : 281-287

Essén B , Johnsdotter S. 2004. Female genital mutilation in

the West: traditional circumcision versus genital cosmetic surgery.

25

Acta Obstet Gynecol Scand. 83:611-613.

European Academy of Paediatrics.2014.. Female genital

mutilation: a hidden epidemic. European Journal of Pediatrics 173

(2): 237-238

Fathalla MF.2000. The girl child. Int J Gynec Obstet.

70(1):7-12

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Female Genital Mutilation.

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20International%20Day%20of%20Zero%20Tolerance%20to%20F

GM%20Feb%202014.pdf

Accessed 5.10.2014.

26

Tobian AA., Kacker S, Quinn TC. 2014. Male Circumcision:

A Globally Relevant but Under-Utilized Method for the Prevention

of HIV and Other Sexually Transmitted Infections Annual Review

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Accessed 5.10.2014

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Accessed 5.10.2014

27

World Health Organization. 2014a. Female genital mutilation

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Accessed 5.10.2014

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Accessed 5.10.2014

World Health Organization. 2008. WHO resolution Female

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World Health Organization. 2010. Global strategy to stop

health-care providers from performing female genital mutilation

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UNAIDS, UNDP, UNFPA, UNHCR, UNICEF, UNIFEM, WHO,

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Accessed 5.10.2014

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elimination of disrespect and abuse during facility-based

childbirth

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Accessed 5.10.2014

Further readings

Population Reference Bureau Wall chart 2010. Female

Genital Mutilation/Cutting: Data and Trends Update. PRB,

Washington DC.

http://www.prb.org/pdf08/fgm-wallchart.pdf

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Society of Obstetricians and Gynaecologists of Canada

Social Sexual Issues Committee and the Ethics Committee 2013.

Clinical Practice Guidelines. Female genital cutting. No. 299,

http://sogc.org/wp-content/uploads/2013/10/gui299CPG1311E.pdf

United Nations Children’s Fund UNICEF. Female Genital

Mutilation/Cutting: What might the future hold?, UNICEF, New

York, 2014.

http://www.unicef.org/media/files/FGM-

C_Report_7_15_Final_LR.pdf C_Report_7_15_Final_LR.pdf

World Health Organization 2008. Eliminating female genital

mutilation: an interagency statement UNAIDS, UNDP, UNECA,

UNESCO, UNFPA, UNHCHR, UNHCR, UNICEF, UNIFEM,

WHO. World Health Organization, Geneva.

http://whqlibdoc.who.int/publications/2008/9789241596442_eng.p

df