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Revista Latinoamericana de Bioética

versão impressa ISSN 1657-4702
versão On-line ISSN 2462-859X

rev.latinoam.bioet. v.8 n.1 Bogotá jan./jun. 2008

 

Some Ethical Considerations Regarding Medicalization of Female Genital Mutilation/cutting (Female Circumcision)

ALGUNAS CONSIDERACIONES ÉTICAS ACERCA DE LA MEDICALIZACIÓN DE LA MUTILACIÓN/CORTE GENITAL FEMENINA (CIRCUNCISIÓN FEMENINA)

Ahmed R. A. Ragab*

* Médico Gineco-Obstetra con Maestría en Bioética. Profesor de investigación de la salud reproductiva aplicada de la Universidad de Al-zhar (El Cairo, Egipto). Email: arragab@yahoo.com

Fecha Recepción: Julio 8 de 2007
Fecha Aceptación: Noviembre 10 de 2007


ABSTRACT

According to each society's condition the ethical attitude of the individual may be colored by the attitude of the society. It is therefore not surprising to find what is ethical in one society might not be ethical in another. Female Genital Cutting, as an example, is seen in some societies as a must and something good for the whole community in general and for girls in particular, while in others, it is seen as mutilation and violation of human rights. The practice of female genital cutting is a complex issue that ties the traditional gender roles, superstition, local concepts on health and sexuality, as well as several other social relations. Worldwide, an estimated 130 million girls and women have undergone FGC.

The current paper examines medicalization of female genital cutting from ethical point of view. The paper discusses the issue in the following themes: definition of the practice, the justifications of the practice, the complications and lastly the ethical reflections. The paper argues that laws that prohibit the practice would not work, without wide socio-cultural change; any effort to eradicate the practice would not succeed.

Key Words: Female Genital Mutilation, Ethics, ethical principles, Muslims.


RESUMEN

De acuerdo a las condiciones sociales la actitud ética del individuo puede ser matizada por la actitud de la sociedad. Por lo tanto no es sorprendente encontrar, que algo que es ético en una sociedad no lo sea para otra sociedad. La mutilación genital femenina, es un ejemplo de esto, ésta mutilación es vista en algunas sociedades como lo debido y algo bueno para toda la comunidad en general y para las niñas en particular; mientras que en otras sociedades, esto es visto como mutilación y violación de los derechos humanos. Esta práctica, es un aspecto complejo que ata los roles tradicionales de género, la superstición, los conceptos locales en cuanto a sexualidad, salud, así como otras relaciones sociales. En el mundo se tiene un estimado de 130 millones de niñas y mujeres que han sido sometidas a la mutilación genital femenina (FGC)

El presente artículo examina la medicalización de ésta práctica, desde un punto de vista ético. Este documento discute el tópico en los siguientes temas : definición de la práctica, justificación de la misma, sus complicaciones y finalmente las reflexiones éticas. Este artículo argumenta que las leyes que prohiben esta práctica no funcionarían sin un amplio cambio sociocultural; cualquier esfuerzo para erradicar dicha práctica no será exitoso.

Palabras Clave: Mutilación genital femenina, ética, principios éticos, Musulmanes.


INTRODUCTION

In all cultures, from inception of humanity, medical practice was regulated by codes of ethics. According to each society's condition the ethical attitude of the individual may be colored by the attitude of the society, which reflects the interest of the theologians, legislators, sociologists, economists, physicians, ethicists, demographers and policy makers (Serour, 1994). It is mandatory for ethicists to be aware of such background before they make their judgment on different ethical problems. It is therefore not surprising to find what is ethical in one society might not be ethical in another (Serour, 1994).

FGC is seen in some societies as a must and something good for the whole community in general and for girls in particular. Girls and women take it as a part of being females in this society. Worldwide, an estimated 130 million girls and women have undergone FGC (UNFPA, 1997, WHO, 1991).

At least two million girls a year are at risk of undergoing some form of the procedure amounting to almost 5500 each day (Cook, et al, 2002).

Female genital cutting is carried out in approximately 40 countries, primarily in East and West Africa, countries in the Arabian Peninsula, and in Asia. An increasing number among immigrant communities in Australia, Canada, Europe and the United States of America also practise this custom. The frequency and extent of the mutilation varies from country to country (Toubia, 1993).

Female genital cutting results from patriarchal power structures that legitimize the need to control women's lives. Cook, (1992) Suggested that he practice arises from the stereotypical perception that women are the principal guardians of a community's sexual morality.

Female genital cutting curtails women's sexual expression in order to ensure women's chastity. In some cultures, FGC is considered necessary for the best interest of the girl, in that it prepares the girl for the pain of childbirth. The symbolic significance marks the girl's rite of passage into womanhood and the acceptance of her responsibilities towards her future husband and her community, thus improving her "marriageability" (Cook, 1992, Ragab, 2002).

The ritual significance of the practice often masks the devastating physical and psychological effects it has on the woman. Traditionally performed by birth attendants who use crude and unhygienic instruments, the "operation" creates a serious risk of local and systemic infections, abscesses, ulcers, delayed healing, septicaemia, tetanus and gangrene. Short-term complications can include severe pain and haemorrhage that can lead to shock or even death, while long-term complications can include urine retention, resulting in repeated urinary infections; obstruction of menstrual flow, leading to frequent reproductive tract infections and infertility; and prolonged and obstructed labour. (Center for Reproductive Law and Policy 1997). Furthermore, FGC can result in psychological problems such as chronic anxiety and depression. The cycle of pain continues when cutting and restitching is carried out to accommodate sexual intimacy and childbirth.

Because the procedure can render sexual intercourse extremely painful, FGC fulfils the social goal of suppressing women's sexual desire. Girls are taught to inhibit their sexuality in preparation for marriage because of the social value that requires "respectable" women to not appear "lustful". (Ragab, 1999 and 2002).

The practice of female genital cutting has been condemned as a violation of the rights of women and girls. Female genital cutting affects women's enjoyment of their lives and reproductive health in a manner that denies liberty and security to women, and subjects them, usually at a young age, to physical violence and serious health problems. In an effort to prevent such violations, the ICPD Programme of Action urges Governments to prohibit FGM where it is practised and to give "vigorous support to efforts among non-governmental and community organizations and religious organizations to eliminate such practices" (paras. 4.22, 5.5 and 7.40).

Numerous African countries, including Ghana, Burkina Faso, Egypt and the Gambia, as well as some countries with significant African immigrant populations, such as the United Kingdom, Sweden, France, Australia and the United States, have criminalized the practice. However, these laws are ineffective in decreasing the prevalence of FGC.

Mainly traditional birth attendants and barbers carried out the procedure in the past (Ragab, 1999). However, there is an increasing trend of medicalization of FGC. In many urban areas of Africa and the Egypt, trained health personnel increasingly practice FGC. The procedure is done by personnel working at hospitals and health centers and include those trained by international non-governmental organizations. Within this complexity of the issue, ethics has a role to play in the debate.

RELIGION OF ISLAM AND FEMALE GENITAL CUTTING:

FGC predates Islam and is not practiced by the majority of Muslims, but has acquired a religious dimension. Where Muslims practice it, religion is frequently cited as a reason. The main problem is that Islamic Leaders are not unanimous on the subject. The Quran does not contain any call for FGC, but a few Hadith (sayings attributed to the Prophet Muhammed) refer to it. Most of these sayings are categorised by the Hadith's specialists as weak (Ragab, 1999 and 2002).

ETHICS AND FGC

The discussion of FGC is not complete without an ethical review. The debate on FGC has evoked several questions that have yet to be resolved. Some of these questions, for example, concern the right of an individual or a group to preserve their cultural beliefs and practices. Do people -parents or other members of a group- have the right to later the body of a child in the name of a tradition? Should an adult have the right to choose and consent on non-therapeutic medical or ritualistic altering of their bodies?

The four ethical principles involve the traditional principles of justice, autonomy (respect for persons) beneficence and nonmaleficence. When we look into the practice of FGC from the principalism approach we can argue safely that this practice violates the principle of Beneficence, it is by all means a maleficent practice. In addition it violates the principle of justice. It is not just to have women enjoying their marital and sexual lives and others suffer from theirs.

The principle of 'autonomy' is influenced by values and experiences that vary widely, even within one region or country. Jacobson (1994:26) defined autonomy as 'an individual's ability to think and act independently of others to achieve her\his interests'. In the case of FGC, whose autonomy should be taken into considerations, the autonomy of the parents or the autonomy of the victim? The victim is a vulnerable person aged between 4 and 10 in most of the cases. According to the principle of autonomy parents have the liberty to decide when and how to have their daughter/s circumcised. Parents know best their own circumstances, and ultimately it is parents who must live with and make sacrifices for their children. However, is it the best interest of the girl, or the parents to have FGC done to the girl? Could the belief that the girl would be secure in her marriage or would keep her chastity justify carrying out this terrible procedure? It is a well-documented fact that the center for sex desire is in the brain not the clitoris. Consequently, if we need to control the sexuality of a girl we stop functioning her brain and not to cut her clitoris.

Informed consent refers to ensuring each individual has the information about the procedure that he/she is going to have. Does the individual who carry out this procedure do an effort to inform the parents about the following?

• The basic facts regarding the physiology of sexuality and that its center is in the brain not the clitoris,

• The procedure itself and how it is carried out and the functions of the parts which would be removed, and

• The complications of the procedure, especially the long terms.

Did the child, the victim, who might be 10 year or more gave her consent for this procedure, which would affect her entire life?

What type of information is given to the victim? In Ragab' study, 1999, the message which were given to the girls in order to convince them were:

If you are not circumcised:

• "Your prayer and fasting will not be accepted"

• "You will not be able to marry"

• "You will grow weak"

• "Your clitoris is unclean and should be removed"

• "Your clitoris will grew to be like a penis of a man, it will dingle between your legs, your vulva will be ugly and it will obstruct the childbirth".

• "When you would marry you will not be able to get pregnant".

• "Uncircumcised girls will run after men, they cannot control their sexual desires".

One can argue that ensuring virginity and consequently better marriage prospects for a girl can justify the procedure in a society which considers virginity as a must in order to marry and marriage is the only way to ensure security in life for a girl. Ragab et all (1999) affirmed that many of the respondents of their studies gave evidences that some brides had been returned to their families' homes once their husbands realized that they are not circumcised. Consequently, FGC might be seen as a way to raise the position of women in a society. This argument is rather weak. Education the society and in particular men, would change this attitude.

IN CONCLUSION

Female Genital Cutting at any degree is an unethical procedure. Doctors and other health providers who carry this procedure violate all the ethical principles.

REFERENCES

• Center for Reproductive Law and Policy, "Reproductive Freedom in Focus - Legislation on Female Genital Mutilation in the United States", October 1997, p. 2.        [ Links ]

• COOK, R. "International Protection of Women's Reproductive Rights", New York University Journal of International Law and Politics, vol. 24, Winter 1992, No. 2, p. 682.        [ Links ]

• COOK, R; Dickens, B; Fathalla, M: (2002): "Female Genital Cutting (Mutilation/Circumcision): ethical and legal dimensions". In International Journal of OB/GYN 79 (2002) 281-287.        [ Links ]

• JACOBSON, J. (1994): Family, Gender, and Population Policy: Views from the Middle East. Population Council (New York).        [ Links ]

• RAGAB, A. R. (1999) "Towards Total Eradication of Female Circumcision". A paper presented at the CDC Annual Conference, 1999.        [ Links ]

• RAGAB, A. R. (2002): "Towards Total Eradication of Female Genital Cutting in Somalia" UNICEF 2002, Unpublished Report.        [ Links ]

• SEROUR G; RAGAB A.; Mahmoud; M. (2002): The role of Husbands in Decision Making Regarding Some Reproductive Health Issues: A case Study from Egypt, National Population Council (2002).        [ Links ]

• SEROUR, G. I. (1994): "Islam and the Four Principles" In Gillon, R. and Lloyd, A. (eds) Principles of Health Care Ethics. John Wiley and Sons, New York, pp. 75-9        [ Links ]

• SHANDAL, A. A. (1967): "Circumcision And Infibulation of Females" Sudan Medical Journal 5: Pp 153-78.        [ Links ]

• TOUBIA, N (1993): Female Genital Mutilation: A Call for Global Action.        [ Links ]

• UNFPA (1997): The State of World Population.        [ Links ]

• WHO, (1991): Reproductive Health: a key to brighter future.        [ Links ]

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