Female genital mutilation

Female genital mutilation is defined by the World Health Organization as any procedure that involves partial or total removal of the external genitalia or other injury to the female genital organs for non-medical reasons.1 Worldwide, 100-140 million girls and women are estimated to live with the consequences of such practices.

Although a graded classification of types exists,2 female genital mutilation is recognised internationally as a violation of human rights with no health benefits. Immediate risks include haemorrhage, infection, and death. Long term consequences include menstrual problems, infertility, psychosexual and psychological difficulties, and adverse obstetric outcomes including caesarean section, perineal trauma, haemorrhage, and perinatal death.3 So why did the American Academy of Paediatrics (AAP) amend an earlier policy to suggest that United States law could be changed to allow doctors to “nick” female genitalia, as a cultural compromise?4 Women’s rights organisations, the World Health Organisation, and the UK Royal Colleges of Obstetrics and Gynaecology and Paediatrics and Child Health all expressed dismay.5 6 The AAP released a statement on 27 May to say that they have withdrawn the policy,7 but at the time of going to press it remains available unchanged on their website.4

Migration has led to an increase in women with genital mutilation in developed countries. In 2001, 66 000 were estimated to live in England and Wales, with over 20 000 young girls at risk. An estimated 1.43% of all childbirths in 2004 occurred in women with genital mutilation (6.3% in inner London).8 The 1985 Prohibition of Female Circumcision Act made it an offence to carry out, aid, abet, or procure any form of female genital mutilation in the United Kingdom. The 2003 Female Mutilation Act closed the loophole that allowed families to circumnavigate the law by taking daughters abroad. Local authorities can intervene under the Children Act of 1989 if a girl has had or is likely to undergo such mutilation.9 Campaigning groups such as FORWARD have raised government awareness, as illustrated by the inclusion of female genital mutilation in the recent Taskforce on Health Aspects of Violence Against Women and Children.10

Worldwide much progress has been made, measured in terms of girls who successfully refuse genital mutilation, community leaders speaking against the practice, and organisations working to end it. Social change has been brought about through the media; health professionals; educators; religious, political, and traditional leaders; and people of all ages, depending on the setting. The means evolve according to local needs and might include development work (such as education, training, sanitation, and improving economic potential) while also making communities sensitive to the problem of female genital mutilation through education, radio programmes, arts and sporting activities, and children’s clubs; in this way, peer educators will be created. Alternative sources of income may need to be found for ex-circumcisers.

A documentary, Africa Rising,11 shows grassroots activists using local culture to change this harmful tradition. In May 2010, an interparliamentary conference in Dakar brought parliamentarians and activists together to ensure that ministries prioritise female genital mutilation and achieve a United Nations resolution for an explicit ban. Two thirds of the 28 countries in Africa where female genital mutilation is practised have laws against it, and other countries are likely to follow suit. Lack of political will means that laws are not often enforced—except in Burkina Faso—but changes have been seen, particularly if a girl has died.12 Many countries have ratified human rights instruments that expressly prohibit female genital mutilation and its medicalisation (including pricking and piercing).13 They caution against obscuring the absolute nature of human rights standards in this matter.

Which brings us back to the peculiar view of the AAP Bioethics Committee. The committee seemed naive or uncaring about the effect of its suggestion on the understanding of female genital mutilation as a form of sex discrimination and gender based violence. Presenting laceration as a minor medical procedure will confuse clinicians rather than improve their education.

Harm limitation is an established medical principle, but unjustified in the light of the campaign for harm elimination, the child’s best medical interests, and their inability to consent. A banal comparison with ear piercing reinforces the fact that a “nick” is not an indicated treatment or the proper business of paediatricians. Neither of these procedures is a medical treatment. Cultural rituals, fashion, rites of passage, adult female sexual pleasure, and marriageability are not within the scope of appropriate, expert paediatric practice. A girl without a problem is not a patient; the doctor becomes a stranger with no indication to expose, touch, or cut the genitalia. However minor, assaults on children should be named and requests met with a gentle but firm “no.” Indigenous grassroots groups, activists, and traditional leaders have encouraged local communities to abandon all types of female genital mutilation. The United States is seeking to make transportation of girls out of the country for female genital mutilation illegal, as it is in the UK. Even if withdrawn, the AAP episode undermined local, national, regional, and international initiatives against female genital mutilation.