Female genital mutilation

Editor,

Female genital mutilation-Bewley's et al's arguments are irresistible so
why are they not applied to the male equivalent, circumcision?

Bewley et al's arguments against medical involvement in even
'nicking' the female genitalia are compelling on logical grounds (BMJ 19
to June 2010, page 1317), but there is still the important issue of the
public's and parental/patient's preferences. Bewley et al's arguments
hold, without any exception that I can see, for the male equivalent i.e.
circumcision. For a detailed and incisive account of male circumcision in
its many varieties including some that can only be described as brutal, in
relation to the female equivalent, readers should examine the recent
article by Matthew Johnson, where he calls for a consistent approach to
tackling 'harmful cultural practices'.(1)

I have been impressed by how strongly the public feels that male
circumcision on religious grounds should be offered by doctors (2), and
such views have prevailed in Scotland where circumcision is available in
the NHS.

If the services are available for cultural reasons for males, surely,
similar requests, held equally strongly, deserve some consideration in
relation to females. Alternatively, let us apply the same stringent
arguments to both sexes. The debate is currently incomplete, for whether
decisions are to be made solely on clinical grounds, or to include
public/patient preferences, males and females are not being treated
equally. It is hard to argue that public/patient preferences have no
place, whatsoever, in publicly funded services, and such an argument
contravenes NHS policy.

Raj Bhopal DSc(hon)

Bruce and John Usher Professor of Public Health
Public Health Sciences Section,
Centre for Population Health Sciences,
University of Edinburgh, Teviot Place, Edinburgh EH89AG

http://www.chs.med.ed.ac.uk

Reference List

(1) Johnson M. Male genital mutilation: Beyond the tolerable?
Ethnicities 2010; 10(2):181-207.

(2) Bhopal R, Madhok R, Hameed A. Religious circumcision on the NHS:
opinions of Pakistani people in Middlesbrough, England. Journal of
Epidemiology & Community Health 1998; 52(11):758-759.

Competing interests:
None declared

Dear editor

I found it very interesting to read about female genital mutilation
as a form of violation of human rights [1]. It is important that we
understand that Female genital mutilation is not condoned or part of the
teachings of the religion of Islam. There has been some practice in some
areas of Africa & some Arabic countries that could be attributed to
cultural and traditional practices. Some of these practices may go back
to the Pharos & carry the name that labels it as the “circumcision of
Pharos”. Therefore it is important in our attempts to stop these inhumane
practices that we acknowledge it is not based on the teachings of any
religion particularly “Islam” and to use education and media as the best
way to help cultural change.

It is important we do not mix culture with
religion. In the last American Psychiatric Association “APA” Meeting in
New Orleans [1] and in a workshop on transcultural issues in Mental
Health: The speakers used the Term “Islamic Cultue”. I explained that
religion can affect the culture but it is not the same as culture.

Religion among Muslims is the same worldwide but culture may vary from one
Muslim country to the other e.g. culture in Bosnia, Algeria is different
from Yemen or Pakistan & all these countries are Muslim countries. We
do not say Christian Culture in Europe but we deal with Europe as
different cultures. So why do we say Islamic Culture while we agree that
Islam is a religion not a culture.

References:

1. Bewley, Creighton S, and Momoh c (2010) Female genital mutilation,
BMJB; 340: c2728

2. APA, new Orleans, Transcultural issues in Mental Health, 21 – 26 May
2010

Competing interests:
None declared

Dear Editor,

I found your June 1st article on Female Genital Mutilation
interesting and informative. The suggestions by the UK Royal College of
Obstetricians and Gynecologists and the Royal College of Pediatrics and
Child Health about the guidance that doctors could offer families "a
ritual nick as a possible compromise to avoid greater harm" as an option;
and the American Academy of Pediatrics retracting its 2010 policy
statement on female genital cutting after criticism without recalling
their commitment document highlight critical ethical debates.

Indeed it is difficult to deal with culture based practices without
offering alternative options. However, when it comes to female genital
cutting (FGC) or mutilation (FGM) there is not an easy option. The option
of performing “a ritual nick” sounds less harmful however in context, it
may not satisfactorily fulfill the objective for which, FGM or FGC is
performed. Therefore rather than performing it as an alternative, more
rigorous reach-out to the decision makers on FGM in the community
structures would be an option to consider alongside any others. The
elders in these communities must be convinced to change their attitudes
towards the practice.

Using the facts on the impact on the health of the females, and the
legal aspects of human rights through organized structures like religious
leaders, and provincial administration can be very useful. This approach
has been tried in parts of Africa for example in parts of Rift Valley and
the highlands of Nyanza provinces of Kenya with some success.

From a midwife's perspective, FGC is life-threatening with severe
consequences including sterility, infection and psychological trauma to
vulnerable girls who narrowly escape death due to, physical trauma at
birth and related complications like extensive perineal and vestibular
tears, and severe hemorrhage commonly reported during home deliveries.

I concur with Dr. Judith Palfrey, President of the American Academy
of Pediatrics (AAP) for reminding the world of the federal law that
forbids any minimal pinprick to the female genitals. It is high time other
nations follow this leading example and accelerate momentum on eradicating
Female Genital Mutilation or Cutting globally.

Relevant ref:

1."Partial Translation of Sunan Abu-Dawud, Book 41: General Behavior (Kitab
Al-Adab)," at: http://www.usc.edu/

2."Muslim scholars rule female circumcision un-Islamic," The Age, 2006-NOV-24.

Competing interests:
None declared

Community based programmes aiming at ending female genital Mutilation
(FGM) should be involved since they are involved in community approaches
that raise awareness about the harmful effects of FGM and promote a
positive image of uncircumcised girls. These groups understand the role
that FGM plays in the culture, and maintaining the healthy aspects of that
role through other practices, the community’s fear that change will lead
to social disintegration will be minimized. An example of this approach is
the Alternative Rites of Passage (ARP) ceremony developed and implemented
in Kenya.

It is also important to understand the various socio-cultural
dimensions and pressures that can affect the ability of individuals to
change. Community leaders are essential facilitators of change. They can
help give legitimacy and support to individuals who choose to alter
traditional norms and practices, neutralizing accusations that they are
undermining cultural identity. If this is done it will raise the girls’
self-esteem and confidence to resist community pressure and these are
further supported by the local leadership. The ARP in Kenya acted as a
culture compromise and it worked well.

http://www.path.org/files/RHR-Article-8.pdf

Competing interests:
None declared