9 May 2013

What is the impact of the increasing trend for the medicalistion of female genital mutilation (FGM)?

Guest blog by Laura McKeever, studying Medical Science and Humanities at Swansea University.

In 2012 significant advances were made in the battle against FGM as the United Nations prepared the first-ever draft resolution against the practice. In addition to this, some nations decided to abandon the practice -  most notably Somalia included a ban on FGM in its new constitution. While progress has been made, push back has arrived in the form of Dr Mohammed Kandil of Egypt denouncing the idea that FGM is medically harmful. In addition to this, his comments and support from the Moslem brotherhood have given rise to the proposal of reversing the national ban on FGM that was introduced in Egypt in 2012 following the death of a 12-year-old girl.

The proposed medicalisation of FGM began with a literature review focusing on the dangers associated with the practice. This literature review was headed by Dr Kandil. Initially, the rather inflammatory title of 'Female genital cutting is a harmful practice: where is the harm?'. This was later changed to 'Female circumcision: Limiting the harm' to bring in the proposed medicalisation of FGM under the ruse of making the practice safer.

The paper claims that, upon searching just one medical database and Google scholar, that there is insufficient evidence to suggest that FGM is harmful when practised in a clinical environment. The proposal is that by making FGM clinical practice, and limiting it to type I, that the harms associated with it can be eliminated. However, it ignores—and even falsely repudiates—some of the harms associated with FGM. It is important to highlight what the proposed medicalisation of FGM could continue to subject girls and women to.

Type I FGM an Keloids

Dr. Kandil falsely claims that keloids (cheloids) can be managed in a medical setting. This is untrue. The NHS (2012) clearly states 'You can't stop a keloid from happening, but you can avoid any deliberate cuts or breaks in the skin'. A keloid is an abnormal growth of tissue following a wound, and is more likely to occur in those of African descent. It can be physically uncomfortable for girls who have undergone FGM, and psychologically harmful.

The Clitoral Artery and Haemorrhage

Haemorrhage of the clitoral artery continues to be a risk associated with Type I FGM. This haemorrhage can cause shock, and death (Bikoo and Berry, 2007). The only way to prevent haemorrhage, is to prevent unnecessarily removing the clitoris. A study by Kaplan et al (2012) focused on 870 cases of FGM in women age 15-43. This study found that 28% of type I cases experienced immediate haemorrhage, 89% suffered from infection, and 41% suffered from anaemia. Later in life, 86% suffered from abnmormal scarring. There is no evidence that these things could be avoided, as the clitoral artery is hard to avoid, infection is partially dependent on patient-led care, and as we have seen, abnormal scarring cannot be avoided. The best approach is to not perform a clitorodectomy.

FGM and Sexual Sensation

Using rudimentary studies, those wanting to continue FGM have claimed that sexual desire and sensation are retained. However, these studies are not without bias, an they do not make the important distinction between those who had sexual experiences before undergoing the procedure. In a case control study by Andersson et al (2012), the experiences of women before and after FGM were examined. The study used the Sexual Quality of Life score, and found there was a significant reduction. It is also worth noting that Puppo (2013) claims that, anatomically, the G spot and vaginal orgasm are myths. Therefore, removal of the clitoris does reduce and eliminate sexual sensation.

Reversing Progress

Medicalising FGM will reverse progress. Between the 2007 ban on FGM in Egypt and 2011, some areas have experienced a 6% reduction in incidence (Hassain et al 2013). This progress is significant, and should not needlessly be reversed.

Conducting FGM in a medical setting ignores the psychological and social consequences associated with the practice. FGM is carried out as a means of female control. Women cannot be expected to further themselves in society, while this procedure is continued. This procedure tells them that they are inferior, and that is a great psychological weight to bear. In addition to this having to go through the post-operative pain of having your clitoris removed , against your will, with no known benefits, as a young age can be psychologically damaging in itself .Socially, it eliminates choice for women when it comes to the most biologically important aspect of their bodies. 

The argument that FGM is not harmful when limited to type I, and carried out in a clinical environment, ignores the fact that there are no benefits. Why should a procedure be carried out without consent, when the woman does not stand to benefit from it? Medicalising the practice could lead to a slippery slope in which there is a continuation of FGM in unsanitary conditions. Medicalising the practice sends out the wrong message. 

Finally, the medicalisation of FGM ignore several human rights violations. Young girls should have the right to determine their sexuality and their image. No child should have their genitals altered when they do not have the capability to comprehend the future risks, or the capability to resist such a procedure. Medicalising FGM does not ignore the fact that it removes the right to self-determination, that it is degrading, and that it can create significant pain against another individual's will. Contrary to what any doctor claims medicalising FGM benefits nobody. What it does do is ensure the continuation of a harmful practice that carry significant biological, social, and psychological harms. There is no way to make FGM safer, the only way forward is to eradicate it altogether.

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Anderson, S., et al. (2012) Sexual quality of life in women who have undergone female genital Mutilation: a case–control study. BJOG, 119 (13), p.1606-1611.

Bikoo, M. and Berry, L. (2007) Female genital mutilation: classification and management.. Nursing Standard, 22 (7), p.43-50.

Hassainn, I., et al. (2013) Impact of the complete ban on female genital cutting on the attitude of educated women from Upper Egypt toward the practice. International Journal of Obstetrics and Gynaecology, 120 (3).

Kaplan, A. (2011) Health consequences of female genital mutilation/cutting in the Gambia, evidence into action. Reproductive Health Journal, 8 (26).

Nhs.uk (n.d.) Keloid scarring - Live Well - NHS Choices. [online] Available at: http://www.nhs.uk/Livewell/skin/Pages/Keloidscarring.aspx [Accessed: 30 Apr 2013].

Puppo, V. (2012) Anatomy and physiology of the clitoris, vestibular bulbs, and labia minora with a review of the female orgasm and the prevention of female sexual dysfunction. Clinical Anatomy, 26 (1), p.134-152.