The Facts About FGM
Here is the current four-part classification of FGM procedures that is used by WHO and other UN agencies:
Type I: 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 and appositioning the labia minora and/or the labia majora, with or without 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 [World Health Organization, 2008, p. 4, emphasis added].
These practices are usually performed on girls from birth to age fifteen, but are also performed on adults (World Health Organization, 2008). Some adult women who had been infibulated request to be reinfibulated after vaginal delivery. The severe physical and mental harms of FGM have been well documented and include extreme pain, bleeding, chronic pelvic and urinary tract infections, dermoid cysts, keloids, and problems in childbirth (Toubia, 1994). No medical benefits are known to exist (World Health Organization, 2008, p. 1). Thus, FGM is not comparable to male circumcision, which provides some health benefits, has few risks or complications, and does not interfere with normal sexual functioning.
The practice of FGM has been most common in certain parts of Africa, such as Burkina Faso, Djibouti, Egypt, Eritrea, Ethiopia, Gambia, Guinea, Mali, Mauritania, Sierra Leone, Somalia, and Sudan. It has also been practiced in some areas of the Middle East, such as Yemen (World Health Organization, 2008, p. 29). In recent years many people have migrated from those regions to Europe, North America, Australia, New Zealand, and other countries. This widespread migration has forced health care providers in industrialized countries to face ethical issues they had never expected to face.
It is important to recognize and to try to understand the cultural significance of FGM, as well as the consequences within certain cultures of rejecting FGM. As stated by Turillazzi and Fineschi (2007), “it is through the mutilation of her own genitals that every woman recognises herself and is recognised as a member of her community. Not undergoing these practices means condemning herself to exclusion and rejection and thus to a loss of the sense of belonging to a community” (p. 100). In addition, as Nahid Toubia (1994) has explained, for societies in which marriage may be the only realistic option for women, “Female circumcision is the physical marking of the marriageability of women, because it symbolizes social control of their sexual pleasure (clitoridectomy) and their reproduction (infibulation)” (p. 714). However, Fadwa El Guindi has argued that FGM increases female sexuality and female sexual enjoyment (El Guindi, 2006, pp. 27, 31–32).
Meanwhile, significant ambiguity exists as to whether FGM is a religious requirement. Some of the opponents of FGM insist that it is not required as a matter of religious belief but is only a matter of cultural practice (Center for Reproductive Rights, 2004, p. 1). The 2003 Cairo Declaration for the Elimination of FGM emphasized statements by supreme religious authorities in Egypt that no religious principle of Islam or Christianity justifies FGM (Egyptian National Council for Childhood and Motherhood, 2003). Similarly, WHO’s Regional Office for the Eastern Mediterranean, in Alexandria, Egypt, published a treatise in 1996 by an Islamic scholar to demonstrate that Islam does not require the performance of FGM (World Health Organization, 1996). However, clerics still disagree about the relationship between FGM and Islam (Gibeau, 1998, pp. 87–88). For example, Sheikh Mohammed Sayed Tantawy, the Grand Sheikh of Al-Azhar, has stated that Islam does not justify FGM, but another Islamic cleric in Egypt, Yusuf El-Badry, has argued that FGM is indeed part of Islam (Fam, 2007).
In fact, when Egypt’s Ministry of Health issued a decree making FGM unlawful, Yusuf El-Badry filed a lawsuit against the health minister in an attempt to overturn the prohibition. The practice of FGM had been prohibited for a long time in Egypt, but there had been loopholes in the prohibition. After a fourteen-year-old girl died during an FGM procedure, the Egyptian government strengthened the law by closing the loopholes. Then El-Badry filed a lawsuit against the government. According to El-Badry, the government was trying to criminalize a part of Islam. Eventually, the Parliament of Egypt enacted a new law, in June of 2008, to criminalize FGM (Egyptian National Council for Childhood and Motherhood, 2008).
Does the distinction between religion and culture really matter? As a practical matter, it could be more difficult to stop a practice that is required or authorized by an organized religion. As an ethical matter, however, it should not matter whether FGM is supposedly justified by religion or only by culture. If it is concluded that FGM is ethically wrong, then FGM would be wrong even if it were required or authorized by the explicit rules of an organized religion.
Some progress has been made in stopping the practice of FGM, but it is still a significant problem of public health and human rights. Agencies and organizations around the world have opposed FGM in the strongest possible terms, and have recognized February 6 of each year as the International Day of Zero Tolerance to FGM. Specifically, WHO and nine other UN agencies have declared that FGM “violates the rights to health, security and physical integrity of the person, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death” (World Health Organization, 2008, p. 1). Those international agencies also have recognized that FGM is a severe type of discrimination on the basis of gender, violates the rights of children, and is analogous to the former practice of binding women’s feet in China as a method of societal control of women (World Health Organization, 2008, pp. 1, 5). Professional organizations also consider FGM to violate the principles of medical ethics. For example, the World Medical Association (2005) has stated that it “condemns the practice of genital mutilation including the circumcision of women and girls and condemns the participation of physicians in such practices.”
Many countries have enacted laws to prohibit the practice of FGM. As of February 2009, eighteen African countries had passed laws making FGM a crime, as had twelve industrialized countries to which people from Africa and the Middle East have immigrated (Center for Reproductive Rights, 2009). In addition to making the practice of FGM a crime, it is also possible to treat the practice of FGM on a minor as child abuse.
In discussing the ethical implications of a 2006 Italian law against FGM, Turillazzi and Fineschi (2007) noted that the law applies even to citizens or residents of Italy who perform FGM outside Italy (p. 100). Similarly, the 2003 law prohibiting FGM in the United Kingdom applies as well to certain actions performed outside that country by a U.K. national or by a permanent U.K. resident, and also prohibits assisting or procuring a foreign person to perform FGM outside the United Kingdom (Female Genital Mutilation Act, 2003, sections 3–4). Such extraterritorial provisions are extremely important because, as experts recognize, children may be subjected to FGM during holiday trips to their family’s country of origin (Turillazzi and Fineschi, 2007, p. 99; Kaplan-Marcusan and others, 2009).
In the United States, under a 1996 federal law, it is a crime to perform FGM on a person under the age of eighteen (Criminalization of Female Genital Mutilation Act of 1996, 2006). However, FGM is permitted if the surgical procedure is necessary for the health of the patient and is performed by a licensed medical practitioner. In addition, a surgical procedure is permitted by an appropriate practitioner for medical purposes in connection with labor or delivery. It is important to note that the U.S. federal law does not prohibit the performance of FGM on a person over the age of eighteen. Meanwhile, at least seventeen U.S. states have enacted their own laws against FGM (Center for Reproductive Rights, 2009). Three U.S. states (Minnesota, Rhode Island, and Tennessee) have prohibited FGM for adults as well as for minors, which means that FGM may be performed lawfully on adult women in most of the fifty U.S. states (Center for Reproductive Rights, 2004, p. 5). Where laws prohibit FGM only for minors, we need to face the important ethical questions of whether health care professionals should perform FGM for adult women who request it, and whether health care organizations should allow FGM to be performed in their facilities. These ethical issues are discussed later in this chapter.
Legal prohibitions are important both because they can reduce the incidence of FGM and because laws have a normative function of expressing a society’s strong rejection of a practice. However, laws alone are not sufficient. The elimination of FGM will require a comprehensive strategy that combines legislation with education, social change, and greater economic opportunities for women. In addition, health care professionals and facilities need to be prepared to help their patients by preventing FGM and by treating patients who already have been subjected to those procedures.
The reading that follows comes from an article that describes the perceptions and experiences with FGM among health care providers in Spain and that also reviews previous research in two other European countries. As discussed in this excerpt, FGM poses complex ethical issues for health care professionals and organizations. For example, when health care professionals think that a child is at risk of being subjected to FGM, should they notify the police or other governmental authorities? Health care providers have an ethical obligation to notify the proper authorities about any type of child abuse, and notification might even be required by law. However, notification could also result in legal proceedings that would destabilize the family by sending a parent to prison. There are no easy answers to these dilemmas.
Excerpt from “Perception of Primary Health Professionals about Female Genital Mutilation: From Healthcare to Intercultural Competence”
By Adriana Kaplan-Marcusan and Others
Background…
The substantial migratory flow of the Sub-Saharan population towards Europe in recent years is leading to increasingly more complex and diverse societies. The approach to the healthcare problems affecting this population represents a challenge to healthcare systems and the professionals working therein, who must develop their own competence to achieve transcultural care.
It is not continents or colours that emigrate but rather people and their cultures, in recent years a visible distortion has been produced in the phenomena associated with gender and immigration, especially in the case of Sub-Saharan women, their daughters and the harmful traditional practices of initiation involving mutilation of female genitals. International organisations and professional associations have made statements against FGM. Indeed, many countries have promulgated legislation against these practices. In Spain the law punishes this crime with prison sentences of 6 to 12 years for the parents, and the girls are taken into care by Social Services.
In addition to adequate laws, a preventive stand is essential which, from a perspective of knowledge and sensitization, allows healthcare professionals to approach the question of FGM and thereby avoid the conflicts produced by legal action against aspects such as those linked to the intimacy and identity of these people.
The first cases of FGM in Spain were detected and reported by healthcare professionals in 1993. Since then, new mutilations have not been reported in Spain, although it is known that some families take advantage of vacation trips to their countries of origin to carry out FGM.…[W]e have estimated that in our country around 9,545 women have undergone some type of FGM and approximately 3,824 girls are at an age of risk of having this done within the next few years
This emerging sociodemographic reality has led to new challenges for which healthcare professionals should be prepared to intervene from a preventive point of view. The FGM…[is] a problem which affects us, as healthcare professionals, in a double sense, as a violation of human rights, which we have the moral obligation to impede, and as an aggression against the health of the persons to which we have the professional obligation to attempt to prevent, to thereby avoid the consequences to the physical, psychic, sexual and reproductive well being of the women.
The cultural pressure and social structure which these practices maintain are strong since they are rooted and nourished by the tradition and the previous experience of their elders, their mothers and confusing religious messages in their communities of origin.
We believe that the receptor countries should approach the question of the FGM from any of the possible points of contact of the migrant families with Primary Health Care, advancing in the double line of:
- Training the professionals in detection and recognition and preventive intervention in the families and girls in a situation of risk of undergoing FGM.
- Identify[ing] the women and girls at risk in the population assigned to each healthcare centre.
Because of its proximity to the families and the longitudinal approach to the problems throughout the whole vital cycle, primary healthcare is one entry point for implementing a preventive intervention towards FGM.
The objectives of this study were to analyse the perceptions, degree of knowledge and attitudes of primary care professionals related to FGM, as well as explore possible trends towards a change in these perceptions and attitudes in two periods of time, 2001 and 2004.
Methods
A cross-sectional study was conducted with a self-administered questionnaire to primary healthcare professionals. In the Catalonian Healthcare System, primary healthcare professionals work in teams who attend the healthcare needs of the population assigned in a determined territory. These teams are made up of family physicians/general medicine, paediatricians, nurses and social workers. Support programs are available within the setting of sexual and reproductive health and these are mainly constituted by gynaecologists and midwives. We considered three large groups of professionals according to the characteristics of the population they attend: General Medicine (physicians and nurses) attending a population over the age of 15 years; Paediatrics (physicians and nurses) attending a population under the age of 15 years and Gynaecology (gynaecologists, nurses and midwives) attending the program of sexual and reproductive health.
Two time points were used: April-May 2001 and October-November 2004. Between the two time points the results of the first questionnaire were made public, and some educational activities were carried out (seminars, sessions and courses) in the healthcare centres, although these activities were not part of a structured training programme related to FGM. In June 2002 a “Protocol of action to prevent FGM” was edited on behalf of the autonomous Government of Catalonia and in January 2004 guidelines for professionals were presented within the framework of a European project against sexual violence.
The study was undertaken in the Maresme, a county on the Mediterranean coast north of Barcelona with a population of 412,840 inhabitants. This area was one of the first areas to receive large groups of Sub-Saharan immigrants, mainly from Gambia and Senegal during the migratory wave produced at the beginning of the 1980s. According to the census of 2005, 11.28% of the population of the county was foreigners, 30.24% of whom were from North Africa and 13.44% from Sub-Saharan Africa
Results
…Nurses identified the different types of FGM better than the physicians in all the professional groups in both years, except for gynaecology in 2001
…The professionals who had attended some educative activity on FGM or were familiar with any protocol or guideline of action had up to a 5.0-fold greater probability to correctly identify the typology.
The detection of cases was mainly undertaken by female professionals…of less than 40 years in age. Females identified the FGM better than males…, developed educational attitudes from the approach to the FGM…, and declared greater interest in the subject of FGM
The gynaecologists demonstrated better knowledge of the FGM…and a greater probability of case detection…
Discussion
This study demonstrates that the problems related to FGM are not infrequent in primary care consultations since up to 16% of the participants surveyed in 2004 declared having detected cases. Eighteen percent of the professionals declared no interest in knowing more about the subject. Less than 40% correctly identified the typology and less than 30% knew the countries in which this practice was common. There seemed to be greater sensitivity towards the subject by female nurses and midwives within the professional areas of paediatrics and gynaecology. A trend towards education and sensitisation versus the problem was observed accompanied by reporting to the authorities when these preventive approaches failed.
The percentage of professionals who declared having detected a case practically tripled from 2001 to 2004, although these values are far from the 60% declared in a questionnaire to professionals from four Swedish cities.
It should be taken into account that our questionnaire only allowed exploration of whether [they] had diagnosed or had knowledge of any child in their office that had undergone FGM. We could not determine the number of cases diagnosed. We only considered the number of professionals who, in their practice and based on their clinical practice, had diagnosed or known of any child with FGM.
In the Swedish study a very low rate of response was obtained (28%) and it cannot be ruled out that the professionals who responded had been in contact with cases of FGM and were especially motivated or sensitised with the subject. In our study the rate of response was much higher, which we believe better represents the opinion of most of the professional groups. Moreover, our study population included a lower proportion of gynaecologists and midwives than the Swedish study, which may explain the lower percent of professionals in contact with cases. Knowledge of FGM seemed to be similar in the two populations. In the Swedish survey 35% of the gynaecologists and 29% of the midwives declared having “sufficient knowledge” of the subject. In our study 45% of the participants correctly identified the typology and 24% the countries of origin. The difference…[lies] in that in our study the data was obtained from the emission of correct responses, similar to an examination, to two questions related to this subject, while the Swedish questionnaire concerned the perception of “sufficient knowledge” on behalf of the professionals.
In a study carried out in Switzerland only 8% of the 37 professionals interviewed referred [to] having developed any preventive intervention in their consultations. In our questionnaire in 2004, 31% of the professionals expressed the need to develop educational and sensitisation attitudes to avoid FGM. We believe that these differences may be due to the limited sample size, being mainly of professionals specialised in gynaecology in the Swiss study, while in our study the collective analysed included primary care professionals with a more general view of healthcare problems, being theoretically closer to preventive and educational healthcare activities.
The discrepancy between the perception of having correct knowledge (knowing in which countries FGM is performed and for what reasons) and the correct identification of the typology, the countries and the reasons for its performance, should be pointed out. This indicates that, in fact, the professionals in our environment have a significant lack of knowledge with regard to FGM. If we add the fact that 80% of those surveyed stated that they attended a population of Sub-Saharan origin and that the detection of cases tripled from 2001 to 2004, it may be deduced that we are faced with an emerging healthcare problem which we are treating with a great lack of knowledge on its social and cultural background.
Our results demonstrate that the primary care professionals surveyed declare a high interest (more than 70% answered “yes” to the question as to whether they are interested in knowing more on this subject), a low grade of knowledge (less than half correctly identified the types of FGM and less than 25% correctly identified the countries in which it is practiced) and some efficacy in the formation received (those stating that [they] had received formation had a greater probability of better identifying the typology and origin…). This leads to the need to prioritize strategies of sensitization and formation of professionals in relation to the identification of the population at risk and capacitation for a preventive and culturally respectful approach, to thereby avoid the families being exposed to the criminal and legal procedures linked to their socio-cultural roots and the consequent risk of familial destruction and separation.
In addition, in our country it so happens that the fertility of African women of Gambian origin doubles or triples that of women from other areas. To develop effective interventions in the immediate future it will be necessary to promote in depth knowledge of the social and cultural reality of these migrant communities which will allow these subjects to be approached with greater professional competence and thus, greater possibilities of success.
One interesting fact is the difference observed in the perception, attitudes and detection of the problem according to the gender of the professionals. The women showed greater interest, had more attitudes oriented towards education and detected most of the cases.…
The different perspective according to the gender of the professionals should be taken into account to avoid an increase in certain disparities in healthcare based on the professionals attending the migrant women population. The challenge…[lies] in avoiding the creation of another barrier in the approach to problems related to FGM due to this difference in gender in the perception of the professionals in relation to FGM. The results of our study indicate that to avoid these inequities men must be sensitized, cultural stereotypes should be opposed and we must be respectful as to the preferences of the migrant women with regard to the gender of the professional they wish to be attended by, similar to what has been observed in other types of problems
Catalonia has been a receptor of Sub-Saharan immigration since the 1980s and at the end of this decade the first phenomena of family regrouping took place with the arrival of the wives and children. Legislation against FGM in Spain was promulgated in 2003 and a law allowing extraterritorial persecution of this crime came into effect in 2005. We are, therefore, before a recent and culturally alien phenomenon for which practicing physicians have not received training.
The results of this study demonstrate that the way the primary care professionals in our area confront FGM is similar to that of their colleagues in five European countries studied by Leye. It also describes important gaps in knowledge and cultural contextualisation and scarce educational measures and support for decision making, with important ethical dilemmas which make not only a clinically adequate professional approach but also [a] culturally respectful approach towards the beliefs and needs of the women.
With regard to the limitations of this study it should be indicated that the anonymity of the questionnaire does not allow paired analysis between the professionals participating in 2001 and those of 2004. It should also be mentioned that the questionnaire in 2004 did not collect exactly the same information on the knowledge, reasons and countries in which this practice is common, and therefore we could not compare this information between the two years. We believe that the lack of statistical significance in some of the trends observed on multivariate analysis was due to a lack of study power to detect these differences.
Conclusion
This study demonstrates that the problem of FGM is present in the primary care centres in our country, with the percentage of professionals detecting some case having tripled in three years. The collectives most in contact with the problem are those in paediatrics and gynaecology, with women showing greater professional sensitivity towards the subject. The professionals over-evaluated their degree of knowledge of FGM and less than half could correctly identify the typology and countries in which FGM is practiced. It is therefore necessary to promote anthropologic knowledge of the problem to develop activities of prevention and detection of family risk to avoid legal actions against these subjects. The development of positive models of intervention, with respectful transcultural attention to values and beliefs in subjects as culturally deep-rooted and sensitive as FGM, will also allow other cultural aspects linked to health and disease among immigrants to be approached more successfully. This problem has only recently appeared in Spain and should be analysed and monitored with new studies to observe in depth the attitudes of the professionals towards this situation, and to also explore the beliefs and needs of the immigrant families in our countries
Source: Excerpted from “Perception of Primary Health Professionals About Female Genital Mutilation: From Healthcare to Intercultural Competence,” by A. Kaplan-Marcusan and others, 2009. BMC Health Services Research, 9(11), doi:10.1186/1472-6963-9-11 [http://www.biomedcentral.com/1472-6963/9/11] (citations, references, tables, and some text omitted). Copyright 2009 Kaplan-Marcusan et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited
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