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Rapid Responses: Rapid Responses published:
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Female Genital Alterations: Mutilations or Modification
- Lois S Bibbings (15 July 2006)
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FGM - No excuse
- Surendra I Deo (15 July 2006)
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No excuse
- Leonard Peter (17 July 2006)
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Psychological damage from FGM
- Janet Menage (17 July 2006)
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Rational argument.
- Geraldine M Martin (18 July 2006)
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FGM: There is no justification
- Dr Emmanuel A Okpo, Dr Blessing U Okpo, GP Trainee (21 July 2006)
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What is genital mutilation?
- Umo I. Esen, Eric Archibong (23 July 2006)
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Advancing the cause against female genital mutilation
- Simon P Kay (24 July 2006)
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FGM major factor in HIV transmission in Africa
- Gillian A Braunold (25 July 2006)
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French law against female genital mutilation
- Cécile MAMANOUIL, Maxime Gignon, Sarah Traullé, Olivier Jardé (26 July 2006)
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What values are being supported?
- Joan McClusky (27 July 2006)
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Female Genital Mutilation: deeply rooted cultural problem
- Mayada A Abu Affan, MD, MRCOG,MSC (27 July 2006)
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Lois S Bibbings, Senior Lecturer in Law School of Law, University of Bristol, Wills Memorial Building, Queens Road, Bristol BS8 1RJ
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Conroy’s editorial, along with Elmusharaf and colleagues’ study,1 represent welcome contributions to a literature which has, indeed, often tended to be ‘long on polemic and short on data’. In particular, Conroy’s recognition that our conceptions of what constitutes female genital mutilation need further thought is long overdue. As I have argued, a coherent response requires both that female genital alterations are considered in terms of their socio-cultural significances and that the full range of practices from around the globe are examined together.2 This entails, inter alia, that responses to and definitions of mutilation recognise the increasing range of genital plastic surgeries and the use of body alterations, such as genital piercing. In addition, any attempt at reconceptualisation and reclassification should, I would argue, examine arguments from those claiming that in some instances male circumcision and intersex surgeries constitute genital mutilation. Such an endeavour would raise difficult ethical, legal and medical issues regarding, for example, the drawing of distinctions between modifications and mutilations and the relevance (or irrelevance) of fully informed consent on the part of the (adult or child) alteree. Also, the various cultural and religious defences of the practices would need to be re-examined and re-assessed along with human rights and established health concerns. In fact, some of these issues have already been explored.3 Beyond this, whilst it is important to raise concerns about the ‘burgeoning industry’ which sells the ‘cyborg porn babe’ body, it is crucial also to be aware that this perspective risks both undermining the autonomy of women who buy the ‘products’ and disregarding their perspectives.4 It would be wrong to simply cast such women or, indeed, (for want of a better term) ‘non-Western’ genital alterees as victims and/or cultural dopes. Lois S Bibbings Senior Lecturer School of Law University of Bristol 1 Elmusharaf S, Elhadi N, Almroth L. Reliability of self reported
form of female genital mutilation and WHO classification: cross sectional
study. BMJ 2006; 333: 124-7.
Competing interests: None declared |
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Surendra I Deo, General Practitioner St Ann's Hospital London N15
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Conroy's editorial uses the findings of Elmusharaf et al to argue that we should attend to 'cosmetic' genital surgery in rich countries before criticising traditional practices elsewhere. This is a seriously flawed argument. The findings show an underreporting of Female Genital Mutilation (FGM) done on women when they were children. Any justification using arguments of cultural relativism fails at the first stage because, however you paint it, this is a barbarous and callous practice that is rightly deplored and outlawed in civilised societies. Yes it is true that forms of FGM were practised in the west but then so was hanging and slavery - we have moved on and thank God for that - its called progress. We should not ignore the cruel practise of FGM at any price and there should be no argument to excuse it. Cosmetic surgery in all its forms is on the increase. This is surgery done with the informed consent and not on innocent children. It is done at the instigation of the patient. It is often seen as therapeutic for the patient and so in fact would not fit into the WHO definition. Competing interests: None declared |
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Leonard Peter, GP Harrow HA3 %HF
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I found Conroy's editorial difficult to understand. That genital mutilation was widely practised in the west in the nineteenth century is surely no recommendation for the procedure. Indeed, so was slavery but that does not undermine modern western criticisms of slavery today. I agree that we should not adopt a high moral tone on this issue, but then nor should we about many practices that undermine health including smoking, overeating and unsafe sexual behaviour. It is not our role as health practitioners to ignore dangers to the health of children in the third world just because some women in our society choose unwise cosmetic surgery on their genitalia or anywhere else. Dealing with one problem does not condone another. I really do expect a higher standard of debate in BMJ editorials. Competing interests: None declared |
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Janet Menage, GP Bulkington Surgery CV23 9HF
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Whilst I can understand Ronan Conroy’s concerns regarding cosmetic surgery in the West, he appears to have missed the fundamental differences between that and the genital mutilation of children. When a child is mutilated by adults the procedure constitutes a sexual assault in that the child does not understand what is happening, has no control over it and does not consent to it. On the other hand, if an adult chooses, however misguidedly, to reconstruct their genitalia it is with knowledge and agreement. The effect on the psyche of the two processes is quite different. In my published research,’Post traumatic stress disorder in women who have undergone obstetric and/or gynaecological procedures’ (1), psychological trauma was correlated with several factors: feeling powerless to influence the event, lack of information given to the patient, the experience of physical pain, a perceived unsympathetic attitude on the part of the examiner, and a lack of clearly-understood consent for the procedure. Other forms of attack on women, such as rape, childhood sexual abuse and sexual torture, are also known to cause PTSD (2). Mr Conroy suggests that the, “high social value”, of FGM somehow means that it is not, “forced on unwilling young girls”. However, ‘social value’ is an adult concept whereas the child only understands the experience subjectively. Indeed, a WHO report states, “For many girls genital mutilation is a major experience of fear, submission, inhibition, and suppression of feelings and thinking. This experience becomes a vivid landmark in their mental development, the memory of which persists throughout life….for some, nothing they have subsequently gone through, including pain and stress in pregnancy….has come close to the painful experience of genital mutilation…their tension and tears reflect the magnitude of emotional pain they silently endure at all times…the resulting loss of confidence and trust in family and friends can affect the child/parent relationship and has implications for future intimate relationships between the adult and their own children.”(3) Victims of childhood abuse may idealise the trauma and become perpetrators as a means of overcoming their anxieties, thus ensuring transgenerational continuation of the practice (4). It must be remembered that some medical commentators will themselves have been circumcised and, unwilling to acknowledge their victim status, may unwittingly introduce bias into their analyses. References: (1) Menage, J.(1993) Post traumatic stress disorder in women who have undergone obstetric and/or gynaecological procedures, Journal of Reproductive and Infant Psychology, Vol.11, pp221-228 (2) Duddle,M. (1991) Emotional Sequelae of Sexual Assault, Journal of the Royal Society of Medicine, 84: 26-28 (3) WHO Female Genital Mutilation, Report of a WHO Technical Working Group. Geneva, 1996: 10 (4) Denniston et al (1999) Male and Female Circumcison, Kluwer Academic/Plenum Publishers, New York Competing interests: None declared |
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Geraldine M Martin, retired GP Penarth CF64 3UU
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I could not believe my eyes when I read your editorial about female genital mutilation (FGM). I have never read such puerile illogical argument - except possibly on the letters page. Just because something is socially acceptable in a society doesn't mean we cannot say it is wrong. As the article later on makes clear, women don't know exactly what has been done to them. How could they? They don't know what normal is. And to illustrate this with a picture of a girl who will never know normal sex is disturbing. If Ronan Conroy cannot see the difference between FGM and plastic surgery with all its psychological connotations in this country then I question how he was educated to argue rationally. Competing interests: None declared |
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Dr Emmanuel A Okpo, SpR Public Health Medicine Aberdeen AB11 6QD, Dr Blessing U Okpo, GP Trainee
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We have read with great interest the debate triggered by Ronan Conroy’s editorial on female genital mutilation (FGM)(1). Certainly Conroy can see the difference between “cosmetic” genital surgery which follows an informed consent and female genital mutilation which basically is done against the will of the victim. The basic fact here is that FGM is a crime against innocent and helpless young people who have no rights, no bargaining power. To pay no attention to this because of similar practice in Europe and America in the 19th century or because more recently a few ill-advised adults are paying for “designer laser vaginoplasty” and “laser vaginal rejuvenation” would be selfish to say the least because FGM is no longer being practiced in the western world (because of its associated health complications) and "cosmetic" genital surgery follows informed consent and ability to pay and therefore cannot be equated to FGM which more often than not is not consented to. Although data on FGM and its attendant complications obstetric and otherwise may be scare, Banks and colleagues (2) have found a significantly higher risk of adverse obstetric outcomes in women who have undergone extensive FGM compared to those who have not. From previous experience working in obstetrics and gynaecology in Nigeria, we have experienced first hand the emotional and obstetric issues associated with FGM. Therefore the real issue for this debate should not be to turn deaf ears to this problem, or as Conroy puts it…. to tackle “cosmetic” surgery in rich countries first before criticising traditional practices elsewhere but a)To see the need to re-examine the current WHO definition of FGM to allow a reliable classification which would correspond to the degree of mutilation because as Elmusharaf and colleagues have found the WHO classification fails to relate the defined forms of FGM to severity of the operation (3). b)As health care practitioners to advise and raise awareness against cultural/traditional practices that are a health hazard. There is no justification whatsoever to act otherwise. 1.Ronán M Conroy Female genital mutilation: whose problem, whose solution? BMJ 2006; 333: 106-107 2.Banks E, Meirik O, Farley T, Akande O, Bathija H, Ali M. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 2006;367: 1835-41. 3.Elmusharaf S, Elhadi N, Almroth L. Reliability of self reported form of female genital mutilation and WHO classification: cross sectional study. BMJ 2006; 333: 124-7. Competing interests: None declared |
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Umo I. Esen, Consultant Obstetrician & Gynaecologist South Tyneside NHS Foundation Trust, South Shields, NE34 OPL, Eric Archibong
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The editorial on female genital mutilation1 makes the point that this term means many things to many people and that some of the “experts” on this topic have a poor understanding of the socio-cultural background against which some of these practices occur. We are against all forms of “genital treatment” wherever it occurs, especially those which may be potentially harmful, including excision of the clitoris, labia, vaginoplasty and genital piercing. Genital piercing as a form of genital mutilation, especially with multiple piercings has remained largely unaddressed, despite the significant health problems2 For too long also, the emphasis has been on female genital mutilation with a near total lack of attention regarding male genital mutilation. Male genital mutilation takes the form of circumcision, penile and scrotal piercings which commonly involve multiple sites with the insertion of a variety of “jewellery.” The latter practice is enjoying an upsurge among young and middle aged males; despite significant health concerns. The time is ripe for an all inclusive assault on genital mutilation wherever it occurs be it on males or females. References: 1. Conroy R M. Female genital mutilation: whose problem, whose solution? BMJ 2006; 333:106-7. 2. Esen U I. Body piercing- a growing problem for clinicians. Hospital Medicine 2004; 65(2) : 86-7. Competing interests: None declared |
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Simon P Kay, Consultant Plastic Surgeon, Editor St James University Hospital, Leeds, LS97TF
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Editor, Ronan Conroy, in an editorial[1] that grabbed the media’s attention, tells us that female genital mutilation (FGM) is “on the increase nowhere in the world except in our so called developed societies.” How he knows this is not stated, but he then quotes from the advertising literature of a commercial clinic in order to synthesise a claim that “women are being mutilated to fit male masturbation fantasies”, before concluding that western medicine “is driving the advance of female genital mutilation”. This is emotive, sensationalist, and inaccurate and I take issue with respect. There are two big differences between the labial reductions that have become sought after by some western women, and FGM in developing countries. The former are matters of adult choice, usually treating unusually pendulous labia, whilst the latter are imposed upon juveniles. The former do not damage the clitoris, the latter often (intentionally or otherwise ) do. By conflating these two very different situations Conroy creates a very easy windmill to tilt at. FGM is a very complex subject: he illustrates his editorial with a picture of a Pokot woman (who presumably, but who knows how, gave informed consent for her picture to be published in this context) on the occasion of her proud ceremonial emergence after FGM, and rightly concludes that there is a cultural hill to climb if we are to stop this practice. In addition the very use of the word mutilation is tendentious: that the WHO classification would label women who wear a piercing in their labia as mutilated (WHO type IV)[2] somewhat devalues the concept. Finally, of interest is that Mr Conroy avoids comparison with ritual or religious circumcision of male infants (who also are obviously unable to exercise choice) in two of the major Abrahamic religions, in both the developed and developing worlds. This is a deeply complex subject both ethically and politically, but surely raises many of the same issues. In choosing a simple target, conflating such different examples, arguing from the ridiculous specific to the serious general, and ignoring the wider comparisons with “legitimate” genital mutilation, Conroy risks harming the cause of those who wish to halt FGM. Professor Simon Kay Editor Journal of Plastic Reconstructive and Aesthetic Surgery 1. Conroy R M Female Genital Mutilation: whose problem, whose solution? BMJ 2006;333:106 – 107 2. Elmusharaf S, Elhadi N, Almroth L reliability of self reported form of female genital mutilation and WHO classification:cross sectional study. BMJ 2006 124 - 127 Competing interests: Editor of Journal of Plastic, Aesthetic and Reconstructive Surgery |
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Gillian A Braunold, GP Kilburn Park Medical Centre 12 Cambridge Gardens London NW6 5AY
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Sir I have seldom seen referenced the trauma that is evident in heterosexual sex in couples following FGM type 2 just as much as type 3. This trauma must play an important part in the explosive spread of HIV on the African continent. Addressing FGM should be part of HIV prevention just as ensuring condom provision. Competing interests: None declared |
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Cécile MAMANOUIL, MCUPH forensic medicine and health law 80000, Maxime Gignon, Sarah Traullé, Olivier Jardé
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Maxime Gignon, Cécile Manaouil, Sarah Traullé, Olivier Jardé Forensic and legal medicine unit, Teaching Hospital, Place Victor
Pauchet 80054 Amiens cedex 1 – France.
In France, Henrion described what is female genital mutilation and complications 1. In order to fight against violence, the French law of April 4, 2006 modifies article 226-14 of the penal code concerning exemptions in professional secrecy. So, professional secrecy does not apply to the one that informs the judicial, medical or administrative authorities of hardships or ill-treatment, including when it is about effects or sexual mutilations, which come to his attention and that were imposed on a minor or one person who is not able to protect himself because of his age or his physical or psychic incapacity. Also, the physician who learns in the exercise of his profession, about ill-treatment or hardships, overestimating physical, sexual or psychic violence, can, with agreement of the victim, inform the Public prosecutor of it. If the victim is minor (in France, under 18 years old), her agreement is not necessary. Description to proper authorities made in these conditions cannot be the object of any disciplinary sanction in the profession. In France, since 1979, there were more than twenty lawsuits against parents from which the children died on the French territory following excisions, but also against women doing excision. The Court of Cassation established in 1983 that ablation of the clitoris was indeed a mutilation in the sense of the French penal code. The sentences provided for the author of a mutilation are defined by the penal code: 10 years in prison and a 150 000 euro fine (article 222-9 penal code) and 20 years of imprisonment with labour if the mutilation is committed on a minor of less than fifteen years by a lawful, natural or adoptive ascendant or by any other person having authority on the minor (article 222.10 pénal code). 1 Female genital mutilations, forced marriages, and early pregnancies. Henrion R. Bull Acad Natl Med. 2003;187(6):1051-66. Competing interests: None declared |
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Joan McClusky, Medical writer New York, NY 10003
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The fact that there may be some cultural value to something does not- -or should not--prevent us from examining it. Footbinding in China had a lot of value--crippling a girl in infancy was indicative of a social status that did not require her to walk easily. As to the "pride" of those who have undergone mutilation--a child who started to earn a living by digging in mines in the 19th century might also have felt pride. Does that mean we should reinstigate this practice? As to the cosmetics of genitalia--many women in New York get a "brazilian" wax--extremely painful, but setting a new standard on what is considered good grooming. But that is a choice made by a grown woman, not a child. And as to those who consider the choices equivalent, I would urge them to consider how they would feel if forced to undergo genital mutilation--at childhood or any other point. Competing interests: None declared |
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Mayada A Abu Affan, MD, MRCOG,MSC, Senior SpR, Public Health Medicine Grampian NHS Board, 2 Eady Road, Aberdeen AB15 6RE
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I think the author over simplified the Female genital mutilation problem by comparing it to genital cosmetic surgery in the west. FGM is a multidimensional and deeply rooted cultural problem. In some cultures FGM is the accepted norm and people with opposed views run the risk of being isolated within their own culture. One of the myths of the problem is the belief that uncircumcised females have slim chance of getting married due to male preference of circumcised females. In my numerous years working as an obstetrician in developing countries, I came to belief, FGM is a complex and deeply rooted cultural problem, this is why the effort put by many statutory and voluntary organisation to combat the problem is unsuccessful and the custom is still widely practised in many parts of the world. Such views are damaging to million of women in the developing world, a world that is dominated by men and governed by cultural myths and wrong beliefs. Competing interests: none |
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