Female genital cutting: distinguishing the rights from the health agenda.

Abstract

It is estimated that 100–130 million girls and women alive today have undergone some form of cutting of their external genitalia, or female genital cutting (FGC). Genital cutting among females is an old practice referred to in pharaonic writings, and evidence suggests that it continues to be widespread in Africa and parts of the Middle East. Rationales for FGC vary by ethnic group and region, but generally highlight reducing female sexual responsiveness (and hence, promiscuity), and easing childbirth. The practice varies with regard to the age of circumcision, the types of social and religious rituals associated with cutting, and the actual form of cutting. In an effort to streamline descriptions of the practice, The World Health Organization (WHO) has classified the predominant types of cutting as Type I: excision of the prepuce, with or without excision of part or all of the clitoris; Type II: excision of the clitoris with partial or total excision of the labia minora; Type III: excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation) ( World Health Organization 1997). While these categories are not necessarily mutually exclusive and ambiguous cuts are noted, the categories are a helpful effort to bring uniformity to research on FGC. Female genital cutting has received increasing attention from the public health field in the past decade, especially after the International Conference of Population and Development (ICPD) in 1994, with its emphasis on reproductive rights, rights of the female child, and harmful traditional practices. But the focus of public health attention has been more political than scientific. Obermeyer estimates that from 1966 to 1999, just over 10% of articles on FGC were from genuine scientific sources, while the rest were journalistic ( Obermeyer 2000). Advocacy has out-paced research, and reliable documentation about the regional prevalence by type, or the social or clinical consequences of the practice are available for only a few regions ( De Silva 1989; EFCS 1996; Adinma 1997; Mbackéet al. 1998 ; Jones et al. 1999 ). An advocacy approach is valid if FGC is regarded primarily as a rights violation. That advocacy should form the majority of public health attention to FGC is defensible, if one agrees that all such cutting is a violation of bodily integrity, and hence human rights, and should be eradicated regardless of clinical or social consequences. Such a stance is especially salient for FGC given that cutting frequently occurs among infants or young girls, and is so closely linked to social definitions of femininity that avoiding the practice may lead to estrangement or social rejection. The gender dimension of FGC adds intensity to the debate over its continuation, and to whether or not outsiders should lobby for eradication of the practice. Rationales for the practice frequently emphasize shaping female behaviour to match local ideals, such as enhancing female passivity, reducing sexual expression, or tempering assertiveness. Such rationales add a symbolic potency to FGC in the eyes of anyone struggling for gender equality or women’s rights, and galvanize a movement that may feel more diffused, or complex, elsewhere. This is especially the case given that FGC is carried out on minors, defying relativistic comparisons to self-induced beauty treatments (breast implants or other plastic surgeries) that are popular among adult women in the West. But regrettably, the advocacy literature against FGC is cluttered with generalizations and bad research, especially with respect to the health dimensions of the practice. This makes the rights position vulnerable to challenges of false claims and exaggerated dangers. A strengthening of research is sorely needed to clarify whether women with FGC need special clinical support, but also to provoke a distillation of the rights debate to its legitimate elements. Public health scientists like a challenge, and especially an opportunity to clarify the facts where others have exaggerated a point (or neglected a denominator). We are comforted by facts, and nowhere is such comfort more valuable than when confronting unfamiliar and apparently gruesome customs that appear customary to otherwise normal people who aren’t us. A few facts can be a vital tonic after reviewing photos of disfigured genitalia. But refuge in facts is arguably the most valuable contribution to the debate over FGC, by those living outside societies that practice FGC. The research problems with FGC begin with prevalence data. Until recently, the source of much prevalence data on FGC were the global mappings from Hosken (1978), and these data continue to be extensively cited. Making an effort to estimate the practice from weak data, Hosken used anecdotal accounts, and generalized from small studies. More rigorous were the estimates by Toubia (1994), as she cites the difficulties of population estimates, and provides confidence intervals for her estimations. More recently, the Demographic and Health Surveys (DHS) are providing representative estimates of prevalence, but also underscoring the variations between ethnic groups within the same country, and hence the dangers of generalizing from small samples. More systemic problems which the DHS cannot easily address are variations in type or severity of FGC, and the fact that most surveys rely on self-reporting. The difficulties in attributing prevalence values to type of FGC are of concern to rights advocacy, because ‘severity’ is an important criterion for all discussions of physical violation, and would set priority areas for intervention. More relevant to health concerns, emerging data on the health consequences of FGC need to be stratified by type, so that clinical response can be tailored accordingly. Toubia (1994) estimates that less than 15% of all FGC practice is Type III, and that this occurs in north-eastern Africa, particularly the Sudan and Ethiopia. Types I and II are the predominant forms, practised in a wide range of countries from Egypt to Indonesia, West Africa to Tanzania. Self-reports of FGC will remain the source for most studies, but generalizations about the validity of self-reporting should be undertaken cautiously. In Egypt, an impressive 93% of women accurately reported their status, as verified by physical exam. But in a study from south-east Nigeria, self-reporting was only accurate in 57% of women ( Adinma 1997). As the validity of self-reporting may differ by custom, or the severity of cutting, self-reporting may need to be re-evaluated wherever significant research efforts are planned. Recent studies also underscore the difficulty of generalizing social determinants of the practice: the impact of religion is frequently eclipsed by other regional or ethnic customs, and neither Islam, nor any other religion, appears to have a uniform impact on the custom. In southern Nigeria, Islamic women are less likely to be circumcised than Christians ( Slanger 2000), and in Ghana FGC was equally prevalent among Muslims and Christians ( Mbackéet al. 1998 ). Urban development is equally unpredictable in its impact on the practice, without clear changes from rural to urban areas. The one social determinant that appears to have a consistent impact on the practice is female education ( Mbackéet al. 1998 ; Slanger 2000), with lower rates of FGC among those with higher education. Most problematic is our current understanding of the negative health consequences of FGC. While advocacy claims have included long-term infections, cysts, infertility, psycho-social problems, loss of sexual response, severe complications with childbirth and even death, the data on which such claims are based are largely confined to case reports, without comparison groups. They are also drawn predominately from regions where the worst type of FGC is practiced. The few case-control studies show no evidence of increased infertility ( Larsen 2000), or reproductive infections, while the sexual response data are too weak to allow conclusions. There is better evidence that FGC may lead to more episiotomies, tears or bleeding with delivery ( Berardi et al. 1985 ; De Silva 1989; Adinma 1997; Jones 1999), but several of these papers suffer from small samples, or from a failure to control for potential confounders, such as where delivery took place. Whether the prevalence of FGC is 100 or 130 million, these women deserve appropriate reproductive health services tailored to their needs. Most women with genital cutting will give birth, and clinicians need to be informed about any added risks to birth outcomes. A few clinical manuals address the safe and appropriate delivery of infibulated women, but we need more rigorous assessment of good practice, and whether other forms of cutting result in measurable reproductive health consequences. These efforts are badly needed, but most importantly, they can be conducted without detracting resources from the overall efforts to improve reproductive health data, and guide health interventions accordingly. But while improving health data is a manageable undertaking and warrants support, one must confront the disparity between advocacy and the evidence that many women support FGC as an important social custom and intend to circumcise their daughters. As recently as 1995, 82% of Egyptian women stated that they support the continuation of the practice. Obermeyer writes eloquently that FGC may be accepted, even if it causes suffering and long-term health problems, because the accrued social value is high ( Obermeyer 2000). Equally plausible is that women in these settings have more urgent health concerns: the morbidity and mortality risks to their children, unassisted childbirth, malnutrition, HIV/AIDs, and the general lack of health services. They may rightfully wonder at outsiders’ concerns over FGC, if such concerns are not integrated into an overall effort to improve reproductive health and health services. Research is a comfortable domain for the public health community, but that doesn’t undermine its value. For the rights debates and the struggles over FGC, efforts to improve the documentation may seem peripheral at best, and noncommital at worst. But the rights debate over FGC will ultimately be strengthened by information, whether about where, why, or what follows. In struggles over the customs and needs of others information is a legitimate contribution, and sometimes the most respectful. The thoughtful input of Tracy Slanger is gratefully acknowleged.