Female circumcision: using facts to moderate the message

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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