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Female circumcision

Are health professionals complicit in female genital mutilation (FGM)?

19 Nov, 15 | by Leslie Goode, Blogmaster

The practice of female genital mutilation (FGM) has been a topic of concern to contributors to this journal (Herieka & Dhar (STIs); Dominguez & Jones (STIs); Leighton & Kingston (STIs).  The problem of avoiding extremist or ethnocentric responses to this important and emotive issue is discussed in an earlier blog (Using facts to moderate the message (STI/blog)) – as well as the question of its religious basis in Islam (Sexual health this week (STIs/blog).  The introduction in the UK of mandatory reporting (September 2014) has raised the profile of this issue in this country, as well as raising the question of how professionals – in a sexual health setting as much as elsewhere – should respond (Leighton & Kingston (STIs)).

Of general relevance to this response, therefore, is a recently published review paper (Reig-Alcaraz & Solano-Ruiz) examining the role of health professionals in general, both positive and negative, in relation to FGM.  The study develops a thematic synthesis of relevant studies, descriptive, quantitative and qualitative, and seeks to cover both African countries where these practices are traditional, and American and European countries where migration has brought populations still attached to them.

Underlying the whole study is an idea which the authors argue to be well-supported by the literature: that health professionals – and midwives and nurses especially – are particularly well placed to play a decisive role in relation to FGM.  Sadly, there is little in the way of research to guide ‘holistic interventions for risk-identification, prevention and child safeguarding’.  At least, however, health professionals should be on the side of ‘no harm’.  Yet, sadly, the authors claim, some degree of complicity with FGM often seems widespread among health professionals (and not only in countries of origin) – as is proved, if nowhere else, in the support of health workers for medicalization of the practice.   Medicalization, our authors argue, may be inconsistent with the legal status of FGM (where laws against FGM exist) – and it is certainly incompatible with the ethical principles of human rights which might be supposed to be at the basis of such laws.

This ambivalence in regard to FGM seems consistent with certain weaknesses in the training and culture of health professionals which the authors find to have been identified by their sources.  These include: ignorance of protocols and guidelines where these exist (e.g. Spain); ignorance of national legislation regarding FGM (e.g. in countries of origin that outlaw FGM, as well as in countries of residence); a tendency to categorize the practice of FGM as ‘religious’ (e.g. in Spain); support for medlcalization, both in countries of origin and residence; a general lack of access to information or training on FGM.

The study seems to focus particularly on Spain.  The UK comes out little better than other countries of residence where FGM is illegal, but has not been successfully eliminated.  On a more positive note, the UK intervention described by Dominguez & Jones (STIs)) offers a example of action on the part of sexual health professionals that is ethnically sensitive without compromise on ethical principal, and seems to have had a beneficial impact.

Female circumcision: using facts to moderate the message

3 Jan, 13 | by Leslie Goode, Blogmaster

In a contemporary Western context female circumcision is hardly an issue that divides opinion.  A  WHO study, published in The Lancet (2006), and receiving considerable media coverage, appeared to corroborate widespread concerns as to its implications for the health of “cut” women and their babies   (http://www.thelancet.com/search/results?searchTerm=WHO+Study+Group+on+Female+Genital+Mutilation&fieldName=AllFields&journalFromWhichSearchStarted=lancet).

However, a paper in the latest Hastings Center Report (HCR) – by the Public Policy Advisory Network on Female Genital Surgery in Africa (PPAN) – takes issue with recent coverage of the issue for being sensationalist, and excessively influenced by advocacy literature; it calls for a less partisan discussion based on evidence and informed by a full range of bio-ethical and anthropological debate (http://onlinelibrary.wiley.com/doi/10.1002/hast.81/full#hast81-bib-0015).  An added interest is the inclusion in this issue of responses to the PPAN paper; that of Nawal M. Nour, in particular, is sympathetic, yet critical (http://www.thehastingscenter.org/Publications/HCR/Detail.aspx?id=6062).  Overall, this discussion offers a fascinating insight into a complex ethical issue.

The PPAN are anxious to dispel a certain idea of circumcision (or “genital surgery”) as imposed on women by repressive and patriarchal attitudes.   They point out that the practice is generally managed by women for women, and tends to be regarded as an aesthetic enhancement – like a breast implant.  On the sensationalist claims of the campaigning literature – and the unfortunate tendency of the medical literature to echo such claims – there seems to be a measure of agreement among contributors to the Report.

Disagreement arises in relation to the evaluation of the medical consequences of female circumcision.  The PPAN are content to contest the claim that circumcision causes increased maternal mortality (as was suggested by media coverage of the 2006 WHO report); Nour, who agrees on this point, nevertheless also draws attention to significantly increased levels established by the WHO report for caesarean section.  Risks include  post-partum haemorrhage, extended hospital stay, and infants needing resuscitation in circumcised women (RR for cases of circumcision involving excision of external clitoris and labia minora, but not infibulation, respectively: 1.29; 1.21; 1.51; 1.32).  As for reduced sexual responsiveness, this is evidently difficult to assess; but, in response to the PPAN who dismiss the idea, Nour cites the evidence of a recent systematic review (Berg & Denison: http://link.springer.com.libproxy.ucl.ac.uk/article/10.1007/s13178-011-0048-z/fulltext.html) for increased levels of dyspareunia  and failure to experience sexual desire (respectively: 1.15; 2.15 in the case of circumcision without infibulation).

In the stand-off between the PPAN and the advocates of anti-circumcision, we have an object lesson in the way that advocacy positions on one side or another can bias the presentation of data – as becomes admirably clear from Nour’s response to the PPAN position.  Claims, on one side, that “female genital cutting raises by 50% the likelihood that mothers or their newborns will die” are met by assertions that may be less extreme but would be hard to substantiate by data – such as that “a high percentage of women who have had genital surgery have rich sexual lives”, or “medical complications associated with female genital surgeries in Africa are infrequent events and represent the exception rather than the rule”.  Nour, on the other hand, points us to data, such as those cited above, that are not sensationalist but suggest some level of negative consequences.  On the whole, there seems much to recommend her policy of “using facts to moderate the message”.

 

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