Female Genital Mutilation – Confronting the Cultural Practice and implication for the work of the United Nations

Female Genital Mutilation – Confronting the Cultural Practice and implication for the work of the United Nations

The international community has spoken out against Female Genital Mutilation (FGM) since the 1970’s and the indigenous African campaign against the practice started in 1990 with a statement by the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children. For at least 30 years there have been consistent messages against the practice and yet, millions of women and young girls are still being mutilated with the UN estimating that about 3 million girls and women are at risk every year.

Eliminating Female Genital Mutilation: An Interagency Statement, written by UN, in 2008 is a statement made by several agencies within the UN including agencies involved in human rights, international development, women’s health and development, and children’s health and rights.  The paper describes female genital mutilation and argues for a strict zero tolerance rule.  Activists have proposed that the role of the international community is to take this zero tolerance role and to spearhead the movement for complete eradication. Some have called for Western countries to deny visas to those who participate in the practice or to have new immigrants sign a waiver denouncing the process. By raising awareness and taking a harsh stand it seems that the hope is to use the invasive power of Western culture to try to influence massive change. I believe these ideas are misguided and in some ways counterproductive to the point of reducing pain, suffering and death from the practice, and to the point of connecting with people and assisting them to get the tools they need to make up their own minds.

But what is there to learn when there are instances where anti-FGM campaigns have been associated with increases in the practice? Winterbottom et al (2009) describes how culturally insensitive, human rights based anti-FGM programs have been counterproductive in Masai communities and have resulted in more FGM at younger ages.  Somewhere along the way, however well- intentioned, the UN raised a banner that few stood behind. The problem as I see it, is a lack of realism and a lack of open mindedness. Dr. Ester Kawira, an African physician working with women who have been mutilated states that “It’s good to have an open mind about female circumcision, where the reaction of a Western person might be automatic horror and revulsion.”  This leads to an agency that supports neither, efforts to make the practice more safe (like medicalizing infibulation* for example as has been done in Egypt), nor, minor symbolic procedures that some communities are adopting as an alternative (like poking the clitoral hood with a needle as has been done in Kenya). If a practice is more safe, or even completely without long term side effects then why should it be banned? Why a zero tolerance stance? Why not regulate the practice and train practitioners of all types to use healthy techniques like in the case of male circumcision?

No organization should ignore the effects of culture on sexuality and definitions of womanhood, by first not engaging those with the most power in the system of FGM and second by allowing no dialog except that of complete eradication. Take male circumcision as an example. FGM and male circumcision are different, however the reasons that parents and individuals give for both practices are very similar. As a physician I have had the experience of discussing the decision of circumcision with parents. I do not recommend it as there is no evidence that there is medical benefit*. Since physicians stopped recommending circumcisions in the US, rates have dropped significantly. What types of interventions would help the (mostly) women who recommend FGM to stop recommending it, to instead recommend an alternative? What chances have they had to come together, to discuss the outcomes, the risks and benefits, and the cultural origins of the practice? The UN could provide an excellent forum for these enablers, facilitators, and practitioners of FGM to come together to discuss an alternative, even less desirable ones as discussed above,  in ways that are meaningful to each particular community.

“Programmes that have demonstrated success in promoting abandonment of Female Genital Mutilation on a large scale build on human rights and gender equality and are non-judgmental and non-coercive. They focus on encouraging a collective choice to abandon female genital mutilation”(UNAIDS et al 2008).

This statement itself emphasizes the importance of the involvement of the whole community, and yet the zero tolerance stance, does not leave room for the community to decide. I believe the UN could be very useful, if it provided resources for indigenous activists or those intimately familiar with practice to first listen to the most significant actors in the community. They can then use their great influence to slowly change the practice.

The international community can also help by specifically addressing the root of a women’s sense of powerlessness regarding the decision to participate in the practice. Women who are empowered, educated, or financially independent are often less likely to participate in the practice (Elnasher, 2007). Those are touted as the keys to eradication of the practice. Until those aspects can be truly addressed it is likely that the practice will continue. If different organizations stand by the zero tolerance stance they may alienate the very groups that they mean to assist in issues like women’s empowerment or education.

The intention of the zero tolerance stance, is to make sure that the procedure is completely eliminated without even the slightest manipulation of the female genitalia. Those writing the statement believe FGM is a way to control women, causes harm, and should be eradicated. If a group in Africa participating in the practice, decides to provide an alternative procedure such at a small cut in the clitoral hood, or a pin prick, the UN group would be adamantly against it, rendering itself useless in the fight against the harms of the practice. The practice is not free to evolve like other practices do in cultures because external forces are forcing one point of view.  As different groups attempt to find their own safer alternatives while maintaining the intent of the practice, the UN organizations are many other non-profits taking a similar stance, are not able to assist in areas such as providing expertise in sterile techniques, crediting practitioners and regulating the practice so that it is more safe, and people are more informed. The zero tolerance stance limits the UN organizations’ usefulness in reducing the harm of the procedure right now.

Ultimately, I believe the first step in the UN organizations role as players in the fight against the HARMS of FGM is to loosen its’ zero tolerance’ stance, so that the UN will be more consistent in its role to be both culturally sensitive and to provide the safest alternatives to undesirable practices.

 

*Definition of infibulation click here

* More information about medicalization available here

* Health benefits of circumcision with HIV? See this article and this one.

References

  1. Elnashar AM, et al (2007).Female sexual dysfunction in Lower Egypt. BJOG. Feb;114(2):201-6.
  2. UNAIDS et al. (2008), Eliminating Female genital mutilation: an interagency statement. http://web.unfpa.org/upload/lib_pub_file/756_filename_fgm.pdf Accessed 23 September 2009
  3. Winterbottom, Anna et al. 2009. Female Genital Cutting: Cultural Rights and Rites of Defiance in Northern Tanzania. African Studies Review; 52(1): 47-71

Merrian Brooks

Merrian is a medical resident studying the specialty of pediatrics in the USA. She was born and raised a Black American and feels proud to be the descendant of a group as a resilient and strong as those known as African slaves. She hopes to one day be a part of a movement to make medical systems work better for people of color in the US, and children and adolescents in sub-Saharan Africa.

4 Responses to Female Genital Mutilation – Confronting the Cultural Practice and implication for the work of the United Nations

  1. Hi,
    Whilst I may not agree with your opinion on FGM, I do respect it. Yes – organizations such as the UN need to take into account cultural moeurs when implementing or atleast trying to implement global programs such as these. Based on my knowledge (and perhaps biased opinion), I will absolutely continue to agree with the current zero tolerance program until sound scientific proof that these “alternative methods” actually will not result in any harm.
    Yes – alot of the time it comes across as though these organizations are forcing people to comply with their rules. However, before advising governments to implement these programs, years of scientific research has been undertaken to get to these conclusions. An example of this is the eradication of polio. According to the latest WHO data, only 4 polio endemic countries remain. The main reason for this setback (and in the case of Nigeria where there is an increase in polio cases), is that governments/organizations have been unsuccessful in explaining to people the advantage of vaccination – in my opinion, because they did not understand their customs and cultures. Understanding of these would have aided in making these populations understand and accept the importance of injecting their children.
    It saddens and frightens me that as a physician, you do not recommend circumcision “as there is no evidence that there is medical benefit”. You cite the history of circumcision website as a “evidence” for this.May I recommend that you take the time to read this article cited in a peer reviewed scientific journal that has critically evaluated the state of the current evidence for male circumcision in reducing HIV infection in Sub-saharan Africa? The website is: http://www.ncbi.nlm.nih.gov/pubmed/22014096

    It clearly demonstrates using well established studies the need to accelerate the implementation of medical male circumcision. If we had to rely on heresay and what governments believe rather than actual scientific evidence, in South Africa for example implementation of Highly Active Antiretroviral therapy against HIV would never have occurred (or atleast not on the current scale – which sadly is still not sufficient to reduce this pandemic) since the former president Thabo Mbeki had for many years said that HIV does not cause AIDS.

    As people who have the power to make a difference in even one person’s life, and especially for those of us who practice medicine and have insight into our cultures, please let us take the time to research current scientific data before leading our people astray with false information that could ultimately result in their deaths. Rather, lets use these current scientifically proven data in addition to our insight into our cultures to ensure better qualities of life as well as increase the life expectancy of our people.

    • thanks for your well articulated response.

      1. regarding fgm. i wrote this article so that people reading this will reconsider merely repeating a sentiment because its the loudest one mentioned and the one those with resources have decided is ‘correct’. you will find it interesting to read articles by Shell Duncan such as this one:
      The medicalization of female “circumcision”: harm reduction or promotion of a dangerous practice? Shell-Duncan B.Soc Sci Med. 2001 Apr;52(7):1013-28. Review.

      There are others that you can find in here citation as well as extensive other papers/books from physicians and other researchers in AFrica who offer an ALTERNATE view to the zero tolerance stance. when i first started researching this topic I was shocked to find so many other ways of looking at it. Again, if you can stop and think about REDUCING HARM which again is my view then you have to consider alternatives to the zero tolerance rule until there is eradication of HARMFUL practices.

      2. I am a pediatrician in the US and I DO NOT recommend circumcision. http://pediatrics.aappublications.org/content/103/3/686.full?sid=26336fb1-07d7-46d2-97f0-8805a534ccf1.
      Again. I am not trying to pretend that things don’t work, but I never blindly accept a stance. I like to research all views and decide how I feel. Yes there is evidence to support male circumcision as having some benefits, but do those benefits outweight the risks in a harm reduction view. If you reduce HIV but increase poor outcomes based on poor procedures and lack of training then what have you gained? an article I should have posted for your perusal that you should view is this one: http://jme.bmj.com/content/33/6/357.full#ref-25 A quote from that paper illustrates the not so strait forward nature of the recommendation.

      “The results of the trials in South Africa, Kenya and Uganda, all suggest that male circumcision could offer important clinical and public health benefits for individuals and populations in the high-HIV prevalence settings with heterosexually driven epidemics. Disagreements persist about the justification of promoting male circumcision as a part of the HIV prevention policy, on the basis of current scientific evidence. These disagreements hinge on whether a similarly high degree of protective effect can be replicated, over the long term, outside the context of a carefully controlled clinical trial. Some argue that health policies always involve risk, and HIV/AIDS is an urgent public health emergency, warranting and even demanding bold measures.25 ”

      you are right. there are medical benefits, but it is NOT staight forward and to a degree, I stated it that way so that people who consider an alterate view.

      The other article mentioned in the lancet also illustrates the point that it is a bit hyperbole to say that not having a male be circumcised will result in their death. many hetero and homosexual men in the all over the world get HIV DESPITE being cirucmcised which means that it cannot and should not be considered a “life saving treatment”. It is a practice that makes it MORE difficult for you to get HIV but does not eliminate risk and should be OFFERED as an option under a balanced view of risks and benefits as per any procedure. I would not recommend someone be circumcised in a group with other males for example which often happens in some context, or by someone who doesn’t know what their doing for example.

      Yes scientific evidence is important. my point is that the science that is on the bullhorn is not the only science out there, and the viewpoints of the powerful are not the only ones to consider especially for entrenched practices that are not being eliminated with the current strategy like in FGM.

  2. Thanks for writing this piece Merrian. I think I understand what you are trying to say, and indeed we should always be cautious against international institutions interventions in what is largely cultural practices.

    But I tend to agree with the comment above,and I don’t want to repeat it all. But I was also a little taken aback by the article, while I haven’t read up on the issue. I think its a bit unfair to compare female genital mutilation to male circumcision. From what I have read FGM deprives women of sexual pleasure, whereas male circumcision actually enhances male sexual pleasure. And like the comment above has mentioned, male circumcision actually has the added benefit of reducing risk of HIV transmission for men, while increasing the chances for infection for women.

    I agree we need to respect people’s cultural practices, but we should also always be cautious of endorsing cultural practices like FGM where often, especially in patriarchal settings like Africa, women have very little agency in their own destiny. Thus far I am not convinced of the added benefits of FGM, hence I tend to support the UN’s zero-tolerance stance against it, as there is no evidence that its done in a dignified manner with the women’s express authority.

  3. Again. I think you all should read much more about this topic. there are studies on the topic that show, documentary films etc that show that many women do “decide” that they want to be cirucmcised, and that WOMEN in the community are the predominant agents of the pratice.

    And there is no direct comparison to male cirucmcision anatomically or as a technical practice HOWEVER, people give VERY similar REASONS for having FGM done which is the point is what we need to focus on the WHY. WHYYYYY are mostly women having this practice done on their girls and teens. why are some women choosing it? I think it is unfair to assume that these women are powerlessly being overpowered by men in the hundreds of thousands. To presume it is all about poor African women who can’t say no to thier men if is a superficial understanding of a complex practice.

    I do not ENDORSE FGM that causes harm. I do believe in HARM REDUCTION. in other words, if they are GOING TO DO IT ANYWAY, how do we make it safe. If a community as a collective decides to poke the clitoral hood with a needle and call that their ritual practice then great! thats less than a tattoo or some of the scarring that people get for fraternities or cultural markings such as those that I’ve seen some people get in West Africa. I will absolutely condone a practice like that, especially as a replacement for a more harmful one. And whats wrong with that? if you can condone male circumcision why not condone a nick in the clitoral hood again as above.

    and as a fun fact side note, there are thousands of nerve cells in the male foreskin. An erect man naturally retracts his forskin so if anything the presence of foreskin should at least result in no difference in sexual pleasure for men. there were times in hx when male circumcision was recommended to CURB mens sexual appetite in much the same way it is recommended for women.

    one more thought. my mom taught me to protect myself sexually to not let just anyone go there to stay a virgin as long as possible etc. she would joke about putting on a chasity belt and me not going out there with many men. These families likely want the same thing for their daughters that most people in the world want, for them to not have babies before they are ready, for them to not be taken advantage of, and also just like in most societies including the Western one a version of fear of a womans sexuality. yes there are power dynamics at play, but no more so than anywere else. until the UN bans plastic surgery which is NOT comfortable, can result in health problems, and is done to PLEASE MEN, it is hypocritical to say all bets are off with any and every type of FGM out there.

    I love that people are taking a stance I am just taking a different one and as I said above, I put this article out there so people can think that it IS OK to find nuanced solutions to this very big problem and that we as the international community should be more supportive.

    It is not an either or situation. We don’t have to support cultural pratices or not when we find them repulsive, we can work with people to help them help themselves which is what people who consider themselves equals do.

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