Intended for healthcare professionals

Rapid response to:

Views & Reviews Personal View

Circumcision in boys and girls: why the double standard?

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d978 (Published 16 February 2011) Cite this as: BMJ 2011;342:d978

Rapid Response:

Male circumcision is not comparable to female genital mutilation

In response to Ms MacDonald and Mr Dalton, I would like to urge both to reconsider their views of comparing male circumcision to female genital mutilation (FGM).

Male circumcision is although largely unconsented genital surgery that carries potential health risks, female genital mutilation (FGM) has such a long list of acute and long term complications that, as Dr Clarke clearly states, brings FGM to a completely different status where risks and ethical considerations are concerned.

FGM is not confined to clitoridectomy - Type III (infibulation) involves excision of part or all of the external genitalia (the clitoris, labia minora and labia majora) with stitching of the labia minora or majora to narrow of the vaginal opening. (1) Young women who have undergone this type of FGM commonly suffer from a number of complications, including difficulty urinating, dysmennorhhea and also haematocolpos (accumulation of blood in the vagina). (1) When it comes to labour, these women have to be defibulated (surgical re-opening of the scar) in order for the baby to be delivered safely. (2) Obstetric management of these women is extremely complicated, and not without risks. (2)

It has also been shown that women commonly avoid normal gynaecological screening such as smear tests and STI screening due to the difficulties associated with vaginal examinations. (3)

In most cultures the legs of the victims are bound together after the procedure, and there are cases where some girls have broken their limbs due to being restrained during the procedure. (1)

Children who have been brought back from 'holidays' having been mutilated don't feel able to communicate about their experiences, and often suffer from not only psychological complications but also recurrent urinary tract infections and dysmenorrhea, consequently often missing a number of days in education. The guardian has published a short documentary highlighting some of these problems: http://www.guardian.co.uk/uk/video/2010/jul/25/girls-facing-female- circumcision

Although FGM is illegal in the UK, there have not yet been any prosecutions, (4) and mutilation is still being performed, both through parents taking their children abroad, and through 'cutters' being flown over to perform FGM on a mass scale in communities. (3)

The reports online and on youtube claiming that FGM is healthier and cleaner are outrageous. If we analyse the article sited in these videos, (5) the authors suppose the link between reduced HIV prevalence and FGM is based on confounders such as age at circumcision, type of circumcision and ethnicity. In fact women who have undergone FGM are less likely to engage in intercourse - either they can't, or they take no pleasure in it. This would be much like publishing an article looking at congenital impotence and HIV prevalence, concluding that impotent men have a significantly lower HIV prevalence, and claiming impotence is a protective factor for STI transmission. I have no doubt such a paper would get rejected by any publisher. In comparison, Brewer et al published results from a cross-sectional study showing an increased rate of HIV in those who had undergone either FGM or male circumcision.(7)

When scientifically justifying the published studies claiming a reduced HIV transmission rate amongst circumcised males and speculating on the effect of FGM, HIV target cells, especially Langerhans cells that are present in the external genitalia may offer a link. Langerhans cells are present in the foreskin of males, and throughout the genitalia, but especially in the ectocervix of females. (8)

As Ms MacDonald mentions of male circumcision:

"In suggesting that forced male circumcision is justified where he may (possibly) reap some future reduction in cancer, HIV or even just smegma we open the door for these people to prove their case and demand a similar excision be promoted or pushed on women and girls."

Similarly, the online resources that are pro-FGM are open to misunderstanding and abuse.

Male circumcision is not comparable to female genital mutilation, although I agree that consideration should be given to banning male circumcision in childhood, and allowing for adults to make a fully informed decision as to whether they want the procedure or not.

References

1- RCOG. Female Genital Mutilation and Its Management. Green-top Guideline. No. 53. 2009

2- Rashid M, Rashid M. Obstetric management of women with female genital mutilation. The Obstetrician & Gynaecologist. 2007;9:95-101

3- FORWARD. Female Genital Mutilation: Information Pack. 2002

4- Carroll J. Metropolitan Police Authority. Female Genital Mutilation - MPS project Azure. Report 8. 2010 http://www.mpa.gov.uk/committees/cep/2010/101104/08/

5- Stallings, R.Y., Karugendo, E.. "Female circumcision and HIV infection in Tanzania: for better or for worse? (3rd IAS conference on HIV pathogenesis and treatment)". International AIDS Society. http://www.ias- 2005.org/planner/Presentations/ppt/3138.ppt.

6- Brewer D, Potterat J, Roberts J, Brody S. Male and Female Circumcision Associated With Prevalent HIV Infection in Virgins and Adolescents in Kenya, Lesotho, and Tanzania. Ann Epidemiol.2007;17:217- 226.

8- Decatur M. Could Female Genital Cutting decrease the risk of HIV infection in a similar manner as male circumcision and if so, what implications does this have for Female Genital Cutting eradication efforts? http://bit.ly/g2oB1I (accessed 22nd February 2011)

Competing interests: None declared

Competing interests: No competing interests

22 February 2011
Zimmermann
4th Year Medical Student
Peninsula Medical School