Female genital mutilation (FGM) is a very difficult issue for me to consider and I suspect many of you will feel the same, because this involves respecting the autonomy of an individual’s right to make an informed decision about a medical procedure and the doctor’s duty to do good and to do no harm.
There are many medical procedures that have no clinical value and can lead to harm for the patient concerned. One such procedure is female genital mutilation.
As family doctors we see many people who suffer as a result of what appears to be a cultural practice. This can prevent people from discussing this topic because of the fear of being considered culturally insensitive. What we forget is that culture is not static; culture is dynamic and evolves over time.
So what is female genital mutilation?
Female genital mutilation is the partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.
According to the World Health Organization, more than 200 million women and girls alive today have been cut in this way, mainly in Africa, the Middle East and Asia. With globalisation, many more cases of females previously cut are being seen in general practice and obstetrics and gynaecology clinics in Europe and the USA.
Female genital mutilation is known to be associated with immediate and long term risks. The procedure itself can cause pain, fever, infections and, longer term, it is associated with an increased risk of caesarean section, increased bleeding following the delivery of a child, low birth weight babies and increased risk of babies dying during childbirth.
There are also psychological complications. It can lead to Post Traumatic Stress Disorder, anxiety, depression, low self-esteem and sexual problems.
Knowing about all these complications, why do people still choose to continue with this practice?
Often health care practitioners find it difficult to talk about female genital mutilation when they suspect it has happened, particularly as they do not want to offend those who have had the procedure and because they don’t know what to say, or how to say it.
Women who have had the procedure may not want to talk about it because they do not want to be seen as a victim or a rebel, especially as in many cultures it is practiced to ensure premarital virginity and marital fidelity. If these are the reasons for carrying out the procedure, it must be very difficult to speak out or say no.
Many parents in traditional societies are unwilling to stop the practice because they are worried that, once other people find out, their daughters will never find a husband. From my understanding there are no religious scripts that support this practice so surely we can assist such families to stand up for their daughters’ rights and abandon the practice of female genital mutilation. It is a matter of dignity.
Is this just an African, Middle Eastern and Asian phenomenon – what about female genital cosmetic surgery?
Just as female genital mutilation is common in some cultures, there are also some surgical procedures in the female genital region carried out for non-medical reasons. Female genital cosmetic surgery (FGCS) is on the rise in the developed world, is aimed at making the genital area more attractive and can include procedures such as vaginal rejuvenation, vulval liposculpture and re-virgination.
Although many people undergoing these procedures are autonomous adults, in some people there may be an element of coercion because some say they are doing it to satisfy their partner’s desires. Some studies have shown that this may be the case in approximately 30% of people undergoing this type of surgery. Others have unresolved emotional issues where ‘cutting’ seems a quicker fix than ‘talking’ only to find that this is not the right answer. So, for some people, cosmetic surgery may also become a form of female genital mutilation.
It is increasingly likely that family doctors, obstetricians, gynaecologists and sexologists will come across female genital cosmetic surgery as these procedures become more common in women in affluent societies who want to enhance their beauty. This is also a phenomenon rooted in culture, the culture of searching for physical perfection and the over-medicalisation of sex.
We shape our own culture. Education of professionals and the public has a role to play. Cutting may seem a quick fix to either satisfy your culture and the desires of others but, when done for a non-medical reasons, there is a high physical and psychological risk. Is this a risk worth taking, even for an autonomous individual?
We need an honest, open and respectful debate to find ways to move our thinking about genital cutting for non-medical reasons forward, wherever it is practiced in the world for whatever cultural reasons. It seems to me that society needs to work with those organisations that are actively engaged in supporting the abandonment of female genital mutilation in traditional cultures and society also needs to educate opinion leaders in cultures that practice female genital cosmetic surgery for non-medical reasons.
We know that female genital mutilation is happening. Being silent about it does not make it any less of a hazard. Cutting for non-medical reasons can lead to lasting psychological and physical damage – we must fight for the physical and psychological well-being of women worldwide.
- World Health Organization. Eliminating female genital mutilation. An interagency statement. OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCR, UNICEF, UNIFEM, WHO 2008 http://apps.who.int/iris/bitstream/10665/43839/1/9789241596442_eng.pdf
- Female genital mutilation/cutting. 2016 http://www.unicef.org/protection/57929_58002.html
- Inglesia CB. Cosmetic gynaecology and the elusive quest for the “perfect vagina.” Obstetrics and Gynaecology 2012; 119:1083-4
- Cain J, Inglesia CB, Dickens B, Montgomery O. Body enhancement through female genital cosmetic surgery creates ethical and rights dilemmas. International Journal of Gynacology and Obstetrics. 2013; 122: 169-72
- Barbara G, Facin F, Meschia M, Vercellini P. “The first cut is the deepest”: a psychological, sexological and gynaecological perspective on female genital cosmetic surgery. Acta Obstericia et Gynecologica. 2015. DOI: 10.1111/aogs.12660
Professor Gabriel Ivbijaro MBE, JP
MBBS, FRCGP, FWACPsych, MMedSci, MA, IDFAPA
President WFMH (World Federation for Mental Health)
Chair The World Dignity Project
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