Intended for healthcare professionals

Rapid response to:

Opinion

Medicalisation of female genital mutilation is a dangerous development

BMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p302 (Published 07 February 2023) Cite this as: BMJ 2023;380:p302

Rapid Response:

To make progress in settling debates over medicalisation of female genital mutilation/cutting (FGM/C), it is important to question assumptions and accurately assess evidence-based claims

Dear Editor,

Medicalisation of FGM/C has long been the subject of tenacious and vexing debates, and here I underscore the need to question assumptions and embrace evidence. An improved knowledge base makes it increasingly possible to empirically address key assertions, including those made by Kimani, Barrett and Muteshi-Strachan(1), namely that medicalisation hinders efforts to end the practice of FGM/C and is associated with more severe cutting. The opinion piece by Kimani et al.(1) diminishes clarity by committing three errors: 1) mis-stating the findings of some empirical research, 2) providing some inaccurate references, and 3) being selective in the presentation of evidence.

The authors correctly state that medicalised FGM/C is geographically concentrated, but they have conflated the national rate of medicalised cutting (the proportion of women with FGM/C cut by a health professional) with the geographic distribution of numbers of women who experienced medicalised FGM/C. An estimated 16 million women self-reported medicalised cutting.(2) Of these, more than 90% live in just 3 countries: Egypt, Sudan and Nigeria. These numbers are different than national rates of medicalisation. Countries with the highest rates of medicalisation are Sudan (67%), Egypt (38%), Kenya (15%), and Nigeria (13%), and mother-daughter comparisons show that medicalised cutting is increasing in each of these countries except of Nigeria (counter to the authors’ statement).(2, 3)

Kimani et al. state that over 60 million women in Indonesia have FGM/C, performed mainly by health professionals.(1) However, the cited references(3, 4) are incorrect. The only nationally-representative data on FGM/C that have been collected in Indonesia are for girls ages 11 and under(5). The authors also state that health professionals perform more severe forms of cutting than traditional cutters, but provide no reference for the figures. More importantly, the authors’ are selective in their use of evidence, ignoring research that does not support their claim. Several studies have documented that health professionals at times elect to perform less severe forms of cutting. For example, a study in Nigeria(6) reported that health professionals who performed FGM/C promoted nicking in lieu of clitoridectomy to reduce the risk of complications; the same phenomenon was reported in southwest Kenya.(7) A review of nationally representative survey data on type of FGM/C showed a positive association between medicalization and a shift to “cut, no flesh removed”.(2) Admittedly, this is a descriptive finding that needs to be explored with multivariate analyses. The fact remains that there are conflicting findings making it premature to conclude that medicalised FGM/C is associated with more extensive cutting.

Studies also challenge Kimani et al.’s claim that medicalisation perpetuates FGM/C and is responsible for the likely failure to achieve the UN sustainable development goal target of eliminating FGM/C by 2030.(1) Trends across consecutive surveys show increased rates of medicalisation have occurred alongside declines in the prevalence of FGM/C in Egypt, Kenya and Sudan.(2) Van Eekert and colleagues(8) improved upon this work with multivariate analyses across three waves of DHS data from Egypt, showing simultaneous increases in medicalisation and decreases in FGM/C prevalence, contradicting the assumption that medicalisation counteracts abandonment of FGM/C. A similar conclusion was reach in an analysis of qualitative data from western Kenya.(9) It was suggested that medicalisation may be an indicator of risk awareness that ultimately motivates abandonment of FGM/C.

I have in the past had the great pleasure of working with Drs. Kimani, Barrett and Muteshi-Strachan, and I share their goal of promoting gender equity and the well-being of girls and women. My aim is not to critique their moral objections to medicalisation of FGM/C, but instead emphasize the need to accurately report empirical evidence and point to gaps in knowledge that merit further research.

1. Kimani S, Barrett H, Muteshi-Strachan J. Medicalization of female genital mutilation is a dangerous development. BMJ. 2023;380:302.
2. Shell-Duncan B, Moore Z, Njue C. Trends in medicalization of female genital mutilation/cutting: what do the data reveal? Nairobi. http://www.popcouncil.org/uploads/pdfs/2017RH_MedicalizationFGMC.pdf: Population Council; 2017.
3. Kimani S, Shell-Duncan B. Medicalized Female Genital Mutilation/Cutting: Contentious Practices and Persistent Debates. Current Sexual Health Reports https://doiorg/101007/s11930-018-0140-y. 2018.
4. UNICEF. Female genital mutilation. https://datauniceforg/topic/child-protection/female-genital-mutilation/. 2022.
5. UNICEF. Indonesia. Statistical profile on female genital mutilation/cutting. 2019.
6. Orubuloye IO, Caldwell P, Caldwell J. Female "circumcision" among the Yoruba of Southwestern Nigeria: The beginning of change. In: Shell-Duncan B, Hernlund Y, editors. Female "Circumcision" in Africa: Culture, Controversy and Change. Boulder, CO: Lynne Rienner Publishers, Inc.; 2000. p. 73-94.
7. Njue C, Askew I. Medicalization of female genital cutting among the Abagusii in Nyanza Province, Kenya. Nairobi, Kenya: Frontiers in Reproductive Health Program, Population Council; 2004.
8. Van Eekert N, Biegel N, Gadeyne S, Van De Velde S. An examination of the medicalization trend in female genital cutting in Egypt: How does it relate to a girl's risk of being cut? Social Science and Medicine. 2020;258:113024.
9. Van Eekert N. To medicalise or not to medicalise: Is that the question? Afrika Focus. 2021;34:172-81.

Competing interests: No competing interests

05 March 2023
Bettina Shell-Duncan
Professor of Anthropology
University of Washington
Seattle, WA USA