Global Health Award 2016 Entries: Rosie Pelham (2)

The ethics of Female Genital Mutilation: Human Rights versus Human Rites

The term Female Genital Mutilation refers to all procedures in which female genital organs are injured for non-medical reasons and is estimated to have been carried out on approximately 100 million women and girls worldwide (WHO, 2008). Here I will discuss the complications associated with FGM, why it occurs, the ethical and political controversy surrounding the practice and touch on what, if anything, should be done to bring about the ending of the practice.

The issue of Female Genital Mutilation has come under much scrutiny and been at the centre of international debate for about thirty years. Our increasingly interconnected world has made the practice a global reality. Due to mobility through asylum and immigration, Lockhat (2004) states that the practice of FGM has been brought to Europe and the USA and as a result is not solely characteristic of non-western societies. The issue of FGM is fraught with ethical complexity; according to Mangan in his article ‘Rights and Wrongs’ (2006) it ‘lies as the heart of the contested possibility of a universal human rights, invoking questions of cultural sovereignty’. How far should cultural practices be outlawed in the pursuit of human rights?

Issues with naming such a sensitive issue almost inspire as much controversy as the practice itself. The term ‘Female Genital Mutilation’ was recommended for use by the World Health Organisation (WHO) in 1991, subsequently it has been used in WHO and United Nations (UN) documents and become widely accepted. Since then critics of the term have argued that the word ‘mutilation’ implies an evil intent and is offensive to the cultures in which FGM is embedded (Gruenbaum 2001, p.3). Another commonly used term is ‘Female circumcision’, but this has been condemned for erring in the other direction and not effectively conveying the destructive nature of the act. Calling the practice ‘circumcision’ euphemistically likens the act to male circumcision whereas in reality FGM is much more damaging. Here I will mostly use the term FGM so as not to condone the procedure or understate the suffering involved. In addition to the controversy surrounding the naming of the practice itself , words such as ‘culture’ and ‘rights’ are loaded with context and individual interpretation. The FGM debate highlights the slippery boundaries between what is considered ‘medical’ and what is ‘cultural’. FGM is just one example of a practice that occurs globally and is by some considered desirable and by others unethical. In this country a patient’s autonomy is considered of the highest importance in medical decision making, elsewhere however a family-centred approach is the norm. Globally, individual beliefs about health and culture vary enormously.

As already explained FGM is a broad term encompassing all removal or injury to external female genitalia for non-therapeutic purposes. The practices are broadly classified into types I to IV (WHO 1997). Type I, or clitoridectomy, is the mildest form and involves total or partial removal of the clitoris. Type II comprises of excision of the clitoris with partial or total removal of the labia minora. Type III is also known as infibulation or Pharaonic circumcision and is classified as excision of part or all of the external genitalia and narrowing of the vaginal opening. Type IV includes all other harmful procedures, including scraping, cauterizing and piercing. Current estimates indicate around 90% of FGM is type I or II and approximately 10% is type III (WHO 2008).

Although now particularly associated with African countries, the practice of FGM has appeared in all the continents of the world and is known to date back at least 2000 years. According to Herodotus the practice occurred among the Ethiopians, Phoenicians and Hittites, and some believe it was practiced in Ancient Egypt as a sign of status. In fact according to Lockhat (2004, p.12) type IV FGM is known as Pharoanic circumcision because it is believed to have been practiced ‘between 2850-525 BC amongst Egyptian Females of the ruling classes, who could only inherit property if they had been circumcised’.

However Gruenbaum (2001, p.9) states that female genital surgeries have not just been limited to ‘a few countries of the world, nor have they always been linked to cultural tradition’; there is evidence that FGM was practised in the UK as recently as the 19th century to control the sexuality of women diagnosed as mentally ill. In the 1980s it came to light that some private clinics in London were performing surgeries on girls from overseas, and this caused the government to bring in the 1985 Female Circumcision Act (Lockhat 2004). This however did not eliminate the practice, greater numbers of refugees and asylum seekers from African nations brought with them their cultural traditions and sometimes the complications from previous surgeries. Due to ever increasing global mobility, FGM is no longer solely an issue in non-Western countries.

Today the highest incident rates are found in 28 African countries, although the practice also occurs in Asia and the Middle East (WHO 2010). There are an estimated 3 million girls in Africa alone who are at risk of undergoing FGM every year (WHO 2008). Just seven countries in northeast Africa: Egypt, Sudan, Eritrea, Ethiopia, Djibouti, Somalia and Kenya account for half of Africa’s total of circumcised women and girls (Gruenbaum 2001). These countries have between 90 and 99% prevalence. Although the amount of data available is growing, there are still inadequacies with data collection due to the rural location of many of the communities and, in some countries, the illegal nature of these practices. Many national governments have recognised the problem of FGM and several have passed laws prohibiting the practice, including the Gambia which according Magoha and Magoha (2000) has made any form of the practice illegal. Health data may be inaccurate as some areas of these developing countries have very little access to health care. Due to the difficulties of data collection, it may be hard to map changes in incidence due to public health efforts to stem the practice, and so gauge how effective they have been.

The consequences of female genital surgery may be varied and severe. The surgery is painful and often traumatic having physical and psychosexual effects. In many cases the procedure is carried out in unhygienic conditions by those with no medical training. Short term complications therefore include potentially fatal infection, haemorrhage and shock. The same instruments may be used for a number of women or girls, and as such transmission of HIV could take place. Long term complications include impaired urinary and menstrual flow, pelvic inflammatory disease (causing chronic pain), infertility, incontinence from vesico-vaginal fistula, ulcers, and vaginal stenosis from scar tissue. Findings from a WHO multi-country study in which over 28,000 women participated showed that those who had undergone FGM had significantly increased risks for adverse events during childbirth. Comfort Momoh discusses the ‘three feminine sorrows’ associated with infibulation: the day it takes place, the night of the wedding (cutting prior to intercourse), and during birth of the first child (vaginal opening too narrow for safe delivery). According to Momoh (2005) for 10% of girls the short-term complications have fatal consequences and a further 25% die in the long term as a result of recurrent urinary and vaginal infections and complications during childbirth.

Considering that FGM has severe consequences, why then is it still carried out in the millions every year? One of the most common reasons is tradition. In many nations girls are circumcised as a rite of passage and it is considered necessary for a girl to enter into adulthood, a prerequisite for acceptance. Overwhelmingly the practice is linked to the family’s fear that without the procedure their daughter will be unmarriageable. As Kristof and WuDunn simply say ‘the aim is to minimize a woman’s sexual pleasure and hence make her less likely to be promiscuous’ (2010, p.245), ensuring virtue before and after marriage. This fulfilment of community based desires contrasts sharply with western notions of autonomy in health, where a patient’s choice is the primary concern. How can an individual’s autonomy be best respected when it stems from group traditions that cause irreversible harm?

According to Momoh (2005) clitoridectomy in Egypt and Sudan is believed to increase male sexual pleasure. In some cultures the clitoris is removed for aesthetic reasons, because it is ‘unsightly’; there may also be the belief that the clitoris, if present, harms the baby during delivery. The presence of scarring as a result of infibulation however, poses a much more real risk during childbirth. From a feminist perspective female genital mutilation is the victimization of women by a patriarchal authority that prioritises male pleasure. As Susan Moller Okin explains, ‘many culturally based customs aim to control women and render them, especially sexually and reproductively, servile to men’s desires and interests’; Female Genital mutilation is one such practice reducing sex to a marital obligation and a woman’s role to care for her husband, children and their house. Critics have said this view portrays many of Africa’s women as helpless victims or as torturers of their children. The surgeries are performed by women, to women; to outsiders FGM is oppressive to women but within the community it is an act of love, removing a ‘masculine’ organ, in order to embrace the role of wife and mother.

Religion is sometimes cited as the reason behind the practice, despite the fact that the practice predates Christianity, Judaism and Islam. Incidences of FGM however tend to follow cultural rather than religious patterns of distribution; there is no reference to FGM in the Koran and FGM is not practiced in most Islamic countries. Religion can form an important part of one’s culture, but the two are distinguished as separate. Religion is often used in culture to express the moral ideas of good and evil. Other factors may contribute to an individuals’ understanding of their culture; customs, rules and behaviours for example might play a part. For this reason, the boundaries and pattern of distribution of religious and cultural groups are not necessarily the same.

The WHO document, ‘eliminating female genital mutilation’ describes FGM as a manifestation of gender inequality ‘deeply entrenched in social, economic and political structures’ (2008); analysis of UNICEF data shows a correlation between a woman’s control over her life and her belief that female circumcision should be ended (UNICEF 2005). This correlation may reflect that in societies where female genital cutting is important, marriage is often the only economically viable option for women. Here I think it might be appropriate to highlight the mainstream ethical concepts that underlie WHO policy, those of equity, justice and human rights. WHO policy makes the assumption that there should be a basic, shared standard of human rights, strong cultural relativists may deny this is the case.

Where it is practised, female genital mutilation is usually supported by both men and women even if its harmful effects are known. FGM is considered a social norm, and to deviate from this may result in ostracism and condemnation. While this is the case, a consequentialist may argue that it is not in the best interests of the women and girls involved to abstain from the practice. A deontologist may challenge this, saying that it is not the outcome but the motivation for an action that determines its’ moral value. Participants often point out that FGM should not be criminalised as it is seen as an act of protection for their daughter’s future. The debate of FGM captures the tension between outcome and principles based approach to ethics.

An issue central to the FGM debate is whether health care workers should perform the surgery. According to the WHO document ‘Eliminating Female Genital Mutilation’ (2008) studies show that in some countries one-third or more of women chose to have a trained health professional perform the procedures on their daughter. In some countries re-infibulation after childbirth is a common procedure amongst healthcare professionals and in countries where cultural groups have emigrated the procedures maybe performed by health professionals in an attempt to maintain the patient’s culture. A practitioner in London for example could be presented with a mother asking for her children to be circumcised under anaesthetic in sterile conditions. Legally this would not be allowed, but greater harm may be done to the children if the surgery was not carried out away from sanitary conditions with a trained professional. On one side of the debate are those that believe professionals performing the procedure contravenes the basic medical ethic ‘do no harm’; and on the other side are those that believe that medicalisation of FGM will reduce chances of infection or other serious and possibly debilitating side-effects. The International Federation of Gynaecology and Obstetrics (FIGO) passed a resolution in 1994 opposing ‘any attempt to medicalise the procedure or allow its performance, under any circumstances’. Momoh’s position is just as clear: ‘health professionals must not carry out FGM, as it runs against the basic ethics of healthcare’. The basic ethic of non-maleficence has its roots in the guidelines of duty used by ancient figures at the dawn of the medical profession. Age or tradition does not make them incontestable, or the same would apply to the ancient ritual of female circumcision. Different cultures have their own definitions of ‘good’ and ‘evil’ and this is key to the question of whether ‘do no harm’ has the same implications in different cultures. The Female Genital Mutilation Act of 2003 closed the loop hole in the 1985 Prohibition of Female Circumcision Act and made it illegal for children to be taken abroad to be circumcised. Aside from directly carrying out genital surgeries, health care workers in the UK may be in a position where they suspect a family is travelling abroad with the intention of having the procedure performed on a child. Current legislation makes it a duty to report this, but perhaps in an effort to not to be perceived as racist and due to the uncomfortable nature of discussing such a sensitive matter, very few notifications have ever been made. It is surely more convenient to ignore suspicion, but some practitioners may feel the maintenance of trust with the patient may increase the likelihood that they will be more receptive to future care for the physical, sexual and physiological side effects of the procedure.

The matter of human rights is central to the controversy surrounding FGM. Since the matter of FGM became more widely publicised many United Nations human rights monitoring bodies have addressed the issue of cultural genital cutting. There is strong support for the protection of women’s rights in national and international treaties including The Universal Declaration of Human Rights (1948); The United Nations Convention on the Elimination of All Forms of Discrimination against Women (1992) and The African Charter on the Rights and Welfare of the Child (1990). Personally I think that, now more than ever, globalisation requires a globally shared ethic; humans should be recognised as equally deserving of basic human rights. Although I think there should be universal human rights, how they are practically implemented, and the place cultural rights have alongside individual rights is far from simple. Human rights do not propose one cultural identity, but a minimum standard of protection. According to Abusharaf in ‘Female Circumcision’ the practice is considered a violation because it contravenes three basically accepted rights: the right to health, the right to bodily integrity and crucially the rights of the child. As already discussed the effects of female genital surgeries are varied depending on factors such as the type of surgery, conditions before and after and proficiency of the circumciser. The physical and psychological health problems may be severe. Unlike male circumcision which has been ‘shown to lower men’s risk for HIV acquisition by about 60%’ (WHO, 2008), FGM has no know health benefits only severe risks and may result in death due to haemorrhage, infection or complications during childbirth. When considering the right to bodily integrity FGM can be seen as a form of castration that violates fundamental human rights. Gerard Zwang reported in his article ‘Functional and Erotic Consequences of Sexual Mutilations’ that ‘Ablation of the clitoris during the infancy prevents the establishment of the reflex circuit, and the woman will never be able to experience clitoral or vaginal pleasure’ (1996). As the vast majority of FGM is practiced on children one of the central issues are the rights of the child. One of the primary principles of the United Nations Convention on the Rights of the Child is the consideration of ‘the best interests of the child’ (1959). FGM can be seen as child abuse as children have no ability to speak out against it and their personal choice is not taken into consideration by their parents or those doing the surgery. The Conventions on the Rights of the Child talks about the children’s capacity to make decisions about matter affecting them, however even if the children do consent can the decision to undergo FGM be called free and informed when it is the result of social convention and a desire to conform?

The view opposing the assertion that a universal standard of human rights should be upheld is cultural relativism. Gruenbaum describes the cultural relativist view as ‘judging each culture within its own context rather than by the values of others’ (2001), or alternatively as Robertson and James explain in the prologue to ‘Genital Cutting and Transnational Sisterhood’ ‘if it’s part of a group’s tradition, it’s all right’ (2005). John Ladd is an example of a relativist; in ‘Ethical Relativism’ he claims that ‘the moral rightness and wrongness of actions vary from society to society … there are not absolute universal moral standards … at all times’ (1973). Essentially FGM can only really be considered wrong by those outside the cultures of origin with the assumption that there is in fact a universal moral code. Maybe global history supports the relativist approach. Today to those with ‘Western values’ the concept of slavery, incest and polygamy seem inherently wrong. However in the society of Graeco-Roman Egypt marriage between full brothers and sisters was surprisingly common and is well documented; the abolition of the slave trade only occurred in 1807 and polygamy, although illegal in the United States of America, is often tolerated in Mormon fundamentalist communities. Crimes which today might be considered awful have occurred throughout history as cultural practices. Similarly ‘where it occurs FGM is not an aberration; it is entrenched in local cultures and permitted or required by local moral codes’ (Beitz in ‘Human Rights as a Common Concern’). If a set of moral codes is ingrained in human nature then how have such crimes occurred over centuries all across the globe, not always as crimes requiring punishment but as social norms accepted by a cultural group. If this is the case should the content of an individual’s human rights vary according to their cultural background?

However, ‘is it necessary to accept slavery or genocide as legitimate human institutions simply because certain cultures at particular historical junctions have justified them?’ (Gruenbaum, ‘The Female Circumcision Controversy’, page 27). I certainly don’t think that it is the case. I agree that rights to culture should end at the point they infringe on individual rights. Not all actions can be justified by their cultural context, but applying cultural relativism in the case of FGM allows the cause to be better understood and so may be a valuable tool to use. Approaching issues so embedded in cultural history as FGM with an understanding of the context and reasons behind the practice, and not outright condemnation, is surely a more useful angle from which to tackle practical prevention. Critical opposition is likely to be met with hostility. As Gruenbaum states, ‘utilizing relativism is often more fruitful because it requires contextualization and inhibits crude ethnocentric prejudices that interfere with effective dialogues’ (2001). The FGM debate is sometimes considered to be one of individual rights versus the rights of a group. ‘Most cultures are patriarchal … and many (though not all) of the cultural minorities that claim group rights are more patriarchal than the surrounding cultures’ (Susan Moller Okin, ‘Is multiculturalism Bad for Women?’, 1999). Female genital mutilation is a feature of societies that are strongly linked to control over women. Strong cultural relativists claim that to seek the change of other cultures is not justified, and that there is a ‘basic right of cultural self-determination’ (Gruenbaum, 2001). I reject the idea that cultures are fixed, evolution is natural, although if desired, must be sought sensitively. Allowing FGM continues practices that undermine women’s place in society; I do not think that the presence of group rights gives cultures justification to violate individual rights, after all, could women not also be considered a group?

A popular counterargument is that western countries too ‘still practice many forms of sex discrimination’ (Moller Okin, ‘Is Multiculturalism Bad for Women?, 1999). Tamir in the article ‘Hands off clitoridectomy’ (1996) compares the procedure to ‘a wide range of painful, medically unnecessary, and potentially damaging processes –extreme diets … [and] silicone implants’. However I do not think that the line between mutilation and cosmetic enhancement is simply defined by one’s concept of beauty. Unlike the American dieting culture, female circumcision is irreversible and the health complications more acute and lifelong. In addition, although pressure from society is indeed a factor, the decision to undergo cosmetic surgery is a free choice to a greater extent. Maybe the gut reaction to these procedures is so different because Western culture finds them normal, but I think a dominant factor is that FGM is primarily performed on children and adolescent girls, often by force. Nussbaum in ‘Double Moral Standards’ (1996) responds directly to Tamir saying that the assumption that ‘it is morally wrong to criticize the practices of another culture unless one’s own culture has eradicated all evils of a comparable kind’ is not true. To ignore the plight of others because we are improving our own cultural circumstances seems ‘the very height of moral obtuseness’ (Nussbaum, 1996). Moller Okin claims that a key difference is that ‘most families in [more liberal] cultures … do not communicate to their daughters that they are of less value than boys, that their lives are to be confined to domesticity and service to men’ (1999). Personally I do not believe that Female Genital Mutilation is morally the same as the culture of plastic surgery and dieting in Western countries. FGM is carried out by force, irreversible, usually performed on young children and linked to serious side effects and lifelong complications.

The ethical debate surrounding Female Genital Mutilation is dominated by two opposing views. The stance of cultural relativism is ‘widely vilified for sanctioning violence under the guise of culture’ whereas those that advocate universal standards of human rights have been ‘reproved for its ethnocentric stance toward cultural rights’ (Abusharaf, ‘Female Circumcision’, 2006). FGM is not intended to cause harm but is practiced in order give daughters standing in society and hope for a good marriage. Good intentions however do not make it harmless, and I think this illustrates that moral principles do apply irrespective of motive or consequence. A 1996 statement by WHO, UNICEF and UN Population Fund states that ‘it is unacceptable that the international community remain passive in the name of a distorted vision of multiculturalism’, but action failing to understand cultural differences and being blinkered by one’s own cultural background is not right either. Care must be taken when pronouncing judgments as no one is unaffected by their own cultural background. Okin asks the question, what can be done when the claims of minority cultures or religions clash with the norm of gender equality endorsed by liberal states (1999)? Culture is not static but in constant evolution, I think it is possible to give up practices such as FGM and still retain the meaningful aspects of culture.

Gruenbaum in ‘The Female Circumcision Controversy’ discusses the place of FGM in the global order: ‘I see female genital cutting as connected to another, more basic form of ‘violence’ embedded in the disparities of human well-being … much unnecessary suffering and death is based on powerlessness and the inability to provide the means for health and survival’ (2001, p.201). If this is the case, and if those of us who are not starving are guilty for not recognizing how interconnected our lives are with those in Third World countries then how can this best be remedied? Gruenbaum suggests that empathy towards girls and women affected, rather than condemnation at the practice will be the first step toward developing an understanding of their lives, and the struggles involved. This might be an appropriate role for health care workers, simply bearing witness.

The practice of FGM has been performed for centuries and the reasons given are varied and complex. I think it is necessary to approach the issue with the understanding that a child’s parents will view the surgery as an act of love, for uncut girls may face ostracism from their community. But how can changes occur when the practices are seen as so important and ‘can outsiders effectively challenge them without challenging the cultural integrity of the people who practice them?’ (Gruenbaum, 2001).

Awareness of FGM began in the late 1970s and since then there have been international campaigns against cutting. In ‘Half the Sky’ Kristof and WuDunn describe that ‘laws against FGM were passed in fifteen African countries, articles were written, meetings were held – and not much changed on the ground’. To give an example, in the 1960s Guinea passed a law punishing female genital cutting with a lifetime of hard labour, yet no case has ever come to trial and 99% of Guinean women have been cut (2010). It appears that a ‘grassroots’ approach (education on a local scale) rather than ‘tree tops’ approach (national and international changes in law) has been most successful. Representatives from International organizations condemning cultural practices are unlikely to be met with thanks, as Gruenbaum writes, even ‘African women who are activists against the practice do not usually welcome outsiders preaching pompously against their societies’ traditions’.

‘Half the Sky’ uses the example of Tostan, a West African group that was started in Senegal in 1991 that places FGM ‘within a larger framework of community development’. Group meetings do not consist of Westerners lecturing local women but ‘encourages villagers to discuss the human rights and health issues related to cutting and then make their own choices’. Discussions of cutting are just one topic among a wider education program that includes teaching about health, human rights, democracy and management – to encourage small businesses (‘Half the Sky’, Kristof and WuDunn, 2010). Men participate alongside women and this reflects that in order for a community to abandon FGM the decision must be supported by all involved.

Personally I first found out about FGM in rural Kenya in 2009; I was disgusted and appalled and initially it coloured my attitudes toward the Maasai people as a whole. Looking more at the practice and attempting to understand its place in contemporary African culture has changed the way I would hope to approach it if I had the opportunity. Condemnation and the pushing forward of Western values in a foreign culture does not have a good history of success, whereas education and discussion of the issues involved by men and women in the community may be better received. The ending of FGM will need to come from the locally owned ‘grassroots’ and lead by women from the community desirous of change.

If FGM is a manifestation of gender inequality, then ending the practice, rather than undermining cultural integrity may go hand in hand with the empowerment of women in the local community. In communities where FGM is rife a woman’s role is often that of marriage, childbearing and submission to men. In 2006 the then UN Secretary-General Kofi Annan said that ‘study after study has taught us, there is no tool for development more effective than the empowerment of women’. ‘Half the Sky’ describes global gender inequality to be the most ‘widespread human-rights violation of our age’. If women who have previously not contributed to their country’s economy are educated and employed, not only is the labour force dramatically increased but they may marry late, bear fewer children and will in turn be able to finance their children’s education. Lawrence Summers when he was chief economist of the World Bank wrote that ‘Investment in girls’ education may well be the highest return investment available in the developing world’. Educating women and empowering their own decision making on the issue of FGM may then have far-reaching effects on their communities.

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