On Female Genital Cutting: Factors to be Considered When Confronted With a Request to Re-infibulate
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According to the World Health Organization, female genital cutting affects millions of girls and women worldwide, particularly on the African continent and in the Middle East. This paper presents a plausible, albeit hypothetical, clinical vignette and then explores the legal landscape as well as the ethical landscape physicians should use to evaluate the adult patient who requests re-infibulation. The principles of non-maleficence, beneficence, justice, and autonomy are considered for guidance, and physician conscientious objection to this procedure is discussed as well. Analyses of law and predominant principles of bioethics fail to yield a clear answer regarding performing female genital cutting or re-infibulation on an adult in the United States. Physicians should consider the patient’s physical, mental, and social health when thinking about female genital cutting and should understand the deep-rooted cultural significance of the practice.
KeywordsFemale genital cutting Female genital mutilation Re-infibulation Beneficence Autonomy
Jamilah is a twenty-year-old married Somali woman who immigrated to the United States two years ago with her Somali husband. She completed high school in Somalia and was married soon after. She is happy about being pregnant with her first child and comes into to an obstetrics clinic for her first visit. Jamilah’s obstetrician/gynecologist was educated and trained in the United States and engages in a positive doctor–patient relationship with Jamilah. Jamilah accepts her doctor’s prenatal advice on nutrition, vaccinations, and the various tests that will ensure the good health of both mother and baby. Throughout the conversation, Jamilah makes it clear that she believes that being a good wife and mother are her most important duties in life.
Upon examination, the physician notes that Jamilah has experienced Type III female genital cutting (FGC)—a type of female genital cutting wherein all external female genitalia are removed and the remaining defect is sutured closed except for a small area— and that her vaginal orifice is quite narrow. Jamilah informs her physician that she underwent FGC when she was seven years old in Somalia. She states that while the procedure was painful for her at the time, all the women in her community have undergone it. With more questioning, it is clear that Jamilah is not upset by the FGC and views it as a normal part of her life. Additionally, she states that in the eyes of her community and her husband, an “uncut” woman is not considered as mature or attractive as a woman who has been cut. At the end of the visit, Jamilah mentions that after the vaginal delivery, she would like the physician to sew her up again (re-infibulate) to restore her to current form. When the physician asks Jamilah why she would like to be re-infibulated, Jamilah states that since she has been infibulated for the majority of her life, she would like to be re-infibulated after the delivery.
The physician is at a loss for how to respond because she knows that there are various legal and ethical aspects to consider, and she has never re-infibulated a woman before. The physician informs Jamilah that they will discuss this point further at her next obstetrics visit since it is still early in the pregnancy, and the physician needs time to decide whether or not she will comply with the post-delivery request.
Female genital cutting (FGC) is defined as the partial or total removal of external female genitalia for non-medical reasons (World Health Organization 2008). Female genital cutting is considered by many entities, including the World Health Organization (WHO), UNICEF, and the United Nations to be a human rights violation that occurs over large swaths of Africa and the Middle East, though it does occur elsewhere to a lesser degree (WHO 2008). To date, the World Health Organization (WHO) estimates that 200 million girls and women have undergone FGC (WHO 2016). In the United States, 513,000 girls and women are estimated to be at risk of FGC (Goldberg et al. 2016). The United Nations Committee Against Torture considers FGC a form of torture, yet this practice remains commonplace in many countries (United Nations Committee Against Torture 2008). Throughout this paper, we use the term “female genital cutting (FGC)” as opposed to “female genital mutilation (FGM)” or “female circumcision.” We do this in order to avoid the suggestion that any woman who has undergone FGC has “mutilated” genitalia. This paper aims to maintain objectivity while discussing patient care in the face of this controversial practice.
Type I FGC involves removal of the clitoral hood (prepuce) and/or clitoris. Type II FGC involves removal of the clitoris, clitoral hood, and labia minora, with or without removal of the labia majora. Type III FGC (infibulation) involves removal of all external female genitalia and then the suturing of the remaining aperture, usually leaving a small opening for urine and products of menstruation to pass. Type IV FGC involves all other forms of alteration of female genitalia for non-medical purposes, including nicking, pricking, or stretching of the labia (Abdulcadir et al. 2016). In this case, Jamilah has experienced Type III FGC and is asking to have her vaginal orifice re-infibulated (re-sutured) after she delivers her baby.
In most countries, a traditional practitioner without any medical training usually performs FGC, and while it can be performed at any age, the procedure is usually performed on children (UNICEF 2013). In some countries, such as Egypt, FGC has become a highly medicalized practice, often performed by physicians in an office or operating room and utilizing anesthesia (UNICEF 2005). There are potential acute medical complications associated with FGC, including infection, hemorrhage, or even death (WHO 2016). Girls and women who have experienced FGC face the risk of chronic conditions such as sexual dysfunction, urinary dysfunction, and/or dyspareunia (pain during sexual intercourse) (WHO 2016). While FGC is a normalized experience for some women who are from cultures that sanction the practice, there are others who develop significant psychological trauma as a result (WHO 2008).
Due to the deep-rooted traditional and social significance of FGC in various communities, it is often thought to be a religious practice, specifically in reference to Islam. Yet the practice pre-dates any of the major Abrahamic religions and has historically been practiced by members of various faiths (al-Sabbagh 1996). It is not officially endorsed by any major religion, and multiple Islamic scholars have stated that there is no mention of FGC in the Qur’an nor in widely respected, verified, and authenticated hadith (sayings of the Prophet Muhammad) (al-Sabbagh 1996).
Female genital cutting is illegal for minors in the United States under a code that states it is illegal for any person to perform circumcision, excision, or infibulation of any part of the labia majora, minora, or clitoris of a person who has not yet attained eighteen years of age.1 This particular part of the law is irrelevant for the patient in this scenario since she is a fully competent and consenting adult. However, this act goes on to say that “a surgical operation is not a violation of this section if the operation is (1) necessary to the health of the person on whom it is performed.” Finally, the law then proclaims, “no account shall be taken of the effect on the person on whom the operation is to be performed of any belief on the part of that person, or any person, that the operation is required as a matter of custom or ritual.” The WHO defines health as “a state of physical, mental and social well being” (World Health Organization 2006). While this is not a definition that is without controversy (Nobile 2014), it will be utilized throughout this paper because it is broad and flexible enough to easily apply to the clinical vignette. While this definition of health highlights the importance of mental and social well-being, in addition to physical well-being, it conflicts with the law described above in that the law appears to present a false dichotomy between one’s well-being and the culture one exists within. Specifically, if being denied re-infibulation would harm a woman mentally or socially as a result of the importance of custom or ritual, it appears that clinicians are both required to and required not to re-infibulate. Due to this lack of legal clarity (especially because the law does not indicate which definition of health is being utilized), the provision of re-infibulation in this case on American soil exists in a legal grey area where it appears that it may be legal or illegal, depending on the interpretation of the law and on the interpretation of the word “health.” Further, the law is clear when it comes to FGC being illegal in minors, but there is room for interpretation in reference to consenting adults who request FGC.
Current Ethical Standing
Female genital cutting remains a controversial issue and has been written about extensively by various authors. Some, such as Loretta Kopelman, cite the United Nations Universal Draft Declaration on Bioethics and Human Rights and assert that there is a set of universal human rights that all people should be granted and that freedom from female genital cutting is one of them, regardless of the importance of this practice in any particular culture (2005). Kopelman argues against conventionalist ethical relativism as it relates to female genital cutting, which is an argument often utilized to deflect criticism of the practice given that it is an accepted part of the cultures which practice it. Others, such as Nancy Scheper-Hughes, advocate for Westerners to remain neutral on this topic, proclaiming, “Let Egyptian and Sudanese women argue this one out for themselves” (1991, 26). Scheper-Hughes believes that if female genital cutting is an important and accepted part of a certain culture, it should be allowed to advance unhindered by Western interference.
In addition to these theoretical perspectives, a special clinical commentary on FGC was released in 2010 in the International Journal of Gynecology & Obstetrics (Cook and Dickens 2010). The commentary holds that an obstetrician/gynecologist would not be acting in violation of ethical or most legal requirements in performing re-infibulation, but the authors conclude that physicians should decline to perform this procedure on the basis that agreeing to re-infibulate would give the appearance of the medical profession condoning FGC. In doing so, the authors equate re-infibulation and initial infibulation from an ethical standpoint. While we are sympathetic to Cook and Dickens’ argument, we hope to illustrate, through an ethical analysis of Jamilah’s case, that the complex ethical terrain surrounding requests for re-infibulation is incompatible with such general claims. Female genital cutting occurs, in large part, due to patriarchal forces that take away power from women, both individually and as a population. By presenting an individual vignette and applying broad bioethical principles to this specific patient, this paper advances the idea that all women are individuals in their own right and deserve a thoughtful analysis of their situation.
Non-Maleficence and Beneficence
The bioethical principle of non-maleficence “asserts an obligation not to inflict harm on others,” while beneficence is defined as engaging in actions that contribute to the welfare of one’s patient (Beauchamp and Childress 2001). It is difficult to fully separate non-maleficence from beneficence since “no sharp breaks exist on the continuum from not inflicting harm to providing benefit” (Beauchamp and Childress 2001, 165). For this reason, the two principles will be addressed jointly. If health is defined as the well-being of the physical-emotional-social trifecta described by the WHO, then harm could be defined as the violation of any piece of it, while benefit could be defined as a positive impact on any piece of it. Therefore, non-maleficence could be interpreted to mean that the physician should inflict no physical, no mental, and no social harm, and beneficence could be interpreted to mean that physical, mental, and social benefits should be sought out. The question here is: would an obstetrician/gynecologist be violating these principles if she agreed to re-infibulate Jamilah?
Jamilah’s body may be harmed by re-infibulation. If the aperture left behind after re-infibulation is too small, then passage of blood and urine in the immediate post-partum period may become difficult. Re-infibulation would cause Jamilah even more scarring, which could make subsequent vaginal deliveries difficult or impossible. Because of previous scarring, the underlying anatomy may be modified, and suturing the area could risk involving the clitoris, leading to subsequent chronic pain or dysfunction. There are no clinical guidelines on how to perform re-infibulation, so the obstetrician/gynecologist in this scenario would be performing the re-infibulation without any experience. Thus, refusing to perform the re-infibulation post-delivery would mean that the physician would not engage in doing any physical harm to the patient, which is consistent with the principle of non-maleficence.
If Jamilah cannot find a physician to re-infibulate her in the United States, she may seek re-infibulation in Somalia or with an inexperienced or unlicensed practitioner in the United States, and it may be in an environment where one cannot guarantee sterility or hygienic technique. Further, Jamilah has disclosed that being infibulated makes her an accepted member among the women in her community. If she is not re-infibulated, this may harm her social well-being and standing within her community, which may be emotionally distressing for her. Further, if Jamilah’s husband leaves her if she is not re-infibulated (he did express that he prefers her infibulated appearance), this may lead to poverty and more social stigma against Jamilah. All of these constitute indirect harms that could result from this doctor’s refusal to re-infibulate and ought to be taken into account in considering how to provide care that is beneficent and non-maleficent (Cook and Dickens 2010).
With these considerations in mind, one may argue that the physician violates the code of non-maleficence if she does not perform the procedure. Performing the re-infibulation will likely minimize disruption to Jamilah’s life; it would be done in a hygienic environment using sterile technique, she is likely to be satisfied with her post-partum appearance, and her appearance would be satisfactory to both her husband and her community, all of which would fulfill the principle of beneficence. However, re-infibulation could mean physical harm to Jamilah’s body as well as difficulty with future vaginal deliveries, which would make it a violation of both non-maleficence and beneficence. Thus, it is crucial to explore the anticipated effects of either accepting or refusing a request for re-infibulation with each patient, in order to understand how non-maleficence and beneficence could be honoured or violated in their particular case.
The Belmont report initially defines justice using its counterpart and states, “An injustice occurs when some benefit to which a person is entitled is denied without good reason or when some burden is imposed unduly” (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research 1978). Physicians are responsible for meting out medical treatments and advice justly. While an American-trained clinician may immediately shrink away from the thought of performing re-infibulation, even on a wilful, consenting, and competent woman, there are other procedures performed routinely in the United States that do not cause the same type of ethical turmoil. Consider, for instance, how physicians perform vulvoplasty. J.D. Cantor argues, “Plastic surgeons operate on competent adults who voluntarily choose to alter their bodies to meet a personal or cultural ideal ... it is inconsistent to wall off a type of genital surgery as unethical because it originates in a non-Western culture” (Cantor 2006, 1161). In terms of cosmetic procedures, which are by definition medically unnecessary, this argument becomes difficult to ignore in the case of Jamilah. She is choosing a procedure that meets her personal and cultural ideal of physical attractiveness, and she would potentially be distressed if she was not re-infibulated. It may be a violation of the bioethical principle of justice for American physicians to perform other types of bodily alteration to meet standards of American culture but then refuse to perform re-infibulation to meet the personal and cultural standards of a non-Western individual. On the other hand, one may also argue that it is unjust for this obstetrician/gynecologist to spend time performing an unnecessary re-infibulation (or any other type of cosmetic procedure) because it may be unfair to other patients who require this physician’s skill and time for procedures that are medically necessary.
Autonomy is defined as the right to chart one’s own course in life: to self-govern (Beauchamp and Childress 2001). Physicians are taught that a patient’s autonomy should be respected, and indeed, it is autonomy that is at the core of informed consent: physicians often present patients with evidence and their personal expertise and a patient may then choose, for instance, to initiate a course of chemotherapy or not (Blasimme and Vayena 2016). Even if the choice goes against what the physician personally or professionally believes to be best, there is a duty to respect the right of the patient to control her own life. Patients consider many factors in making medical decisions, which a physician may not fully understand, particularly if there is some cultural dissonance between the two parties. The issue of patient autonomy is often applied to the right of a patient refusing medically recommended treatment, which concerns a negative right, that of an individual to refuse bodily interference. The case of Jamilah is different in that she is requesting an intervention that is generally considered to be medically unnecessary in this country, which concerns a positive right, that of accessing a surgical intervention.
It is arguable that as an adult, consenting woman who already understands what it means to be infibulated, Jamilah should at least have the right to initiate discussion regarding re-infibulation being performed in a safe, hygienic manner by a medical professional who—while not trained in this specific procedure—understands the basic principles of operating in this anatomical space. In terms of autonomy, the physician in this situation needs to ensure that this procedure is truly what Jamilah desires and that she is not requesting re-infibulation out of fear of becoming a pariah in her community. Female genital cutting is often an outgrowth of misogynistic viewpoints that delineate women as hypersexual and untrustworthy. While female genital cutting is indeed a practice that is performed on women and typically by other women, it is the result of patriarchal standards and rules. Thus, there is a complex and often non-dissectible relationship between what a woman in a society personally desires versus what society desires for her. Often, what society desires for a woman is manifested through the woman’s stated wishes. One’s own purported desires are the result of many factors, including fear and desire for acceptance by society. The same individual may not make a certain request if she is in a different situation.
Even if Jamilah is deemed completely competent to make this decision and if it is clearly necessary for her mental and emotional well-being, this situation raises the question of how active a physician must be in ensuring that the patient receives a medically unnecessary procedure she has autonomously requested if the physician is not in agreement with the procedure.
Societal Ramifications of Individual Patient Care Decisions
While most patient care decisions are made in the privacy of the physician’s office, with only the patient and doctor in attendance, the decisions that a physician makes often have broader societal implications. This point is highlighted in a special commentary on FGC by Cook and Dickens mentioned above: they emphasize that although re-infibulation may seem like the correct course of action in the case of a specific patient, the decision to re-infibulate may be misinterpreted as the medical field generally agreeing with re-infibulation (and by extension, FGC), applied broadly (Cook and Dickens 2010). If a physician defines herself as an advocate for women’s and girls’ rights, it may be difficult for her to be an active participant in what her Western culture has taught her to consider as female genital mutilation. She may identify that this procedure is a product of a type of misogyny in which she does not wish to take an active role. In her mind, she may justify similar procedures that occur routinely in the United States, such as vulvoplasty or labial reconstruction, but she may be unable to justify re-infibulation. It is also quite possible that the physician disagrees with all types of female genital alteration, among them infibulation as well as vulvoplasty or labial reconstruction. In that case, her refusal to re-infibulate is indeed consistent with her overarching views about not altering female genitalia. If the physician feels that she would be violating her code of conduct if she were to perform re-infibulation—even if she feels that Jamilah would indeed be mentally, emotionally, and socially better off—she reserves the right to refuse to perform the procedure.
While the doctor here does not have to perform the re-infibulation, it is her responsibility to counsel the patient regarding the risks and benefits of being re-infibulated and what the medical implications are of being re-infibulated versus not. Another option in this situation is for the obstetrician/gynecologist to refer Jamilah to a plastic surgeon to perform the re-infibulation after the post-partum period has ended. Some plastic surgeons perform cosmetic genital surgeries in this country and are familiar with the concept of performing elective procedures for the purpose of enhancing cosmesis and self-esteem. A referral to a plastic surgeon is not ethically required, however, since this procedure is outside of the scope of standard medical practice.
This is a complex case that highlights the difficulty of interpreting non-Western cultural practices within the framework of Western ethical principles. While the principles of non-maleficence, beneficence, justice, and autonomy are often upheld as a framework to doctors in a variety of clinical situations, they do not cover all situations. Indeed, several of these principles are in conflict with one another in this particular situation. For example, if the physician refuses to re-infibulate on the basis of non-maleficence, this could be a violation of the autonomy of a competent and consenting adult patient. Similarly, while a consideration of the principle of justice might indicate that a request for re-infibulation should be refused, the principle of beneficence—if it takes into account the patient’s overall mental and physical well-being—may suggest that re-infibulation is ethically required. For this reason, both re-infibulation and refusal to perform the re-infibulation on this adult could be argued as being ethically sound given the appropriate reasoning.
In this scenario, the obstetrician/gynecologist reviews her personal moral code, which includes opposition to all alteration of female genitalia and decides against performing the re-infibulation. She also expresses concern over the formation of even more scar tissue if Jamilah were re-infibulated, which could lead to worse obstetric outcomes for Jamilah in the future. She does, however, understand the reasons why Jamilah would desire this procedure so strongly and thus refers Jamilah to a plastic surgeon familiar with female genital surgery to consider performing an interval re-infibulation (after the postpartum period is over).
Despite the lack of ethical clarity, clinical requests for re-infibulation should be approached with the idea that each case is unique. While re-infibulation may be the right choice for one patient, it may be the wrong choice for another patient, and the physician should have the clinical prowess to detect the difference. The discussion of potential harms and benefits of refusing or performing the procedure discussed above highlights some of the considerations that ought to be taken into account in a given case. Additionally, there are some minimal requirements that should be present in any case of re-infibulation. If, for instance, there is a U.S.-based obstetrician/gynecologist who practices in an area with a dense Somali population, she may perform re-infibulation routinely and have no moral objection to the procedure. She would still be responsible, however, for ensuring that a patient requesting re-infibulation is competent and is expressing a personal desire to be re-infibulated, not one that is arising solely out of fear of consequences from her partner or her community.
In the case of Jamilah, the determination of whether or not to perform re-infibulation ought to be informed by in-depth discussions throughout the course of her prenatal care, the development and nurturing of patient–physician trust. Throughout this process, it is also important that both Jamilah and her physician understand the broad implications of her either receiving or being refused re-infibulation, whether these concern how Jamilah is likely to be treated by her husband and community if she does not undergo re-infibulation and how an increase in scar tissue as a result of re-infibulation may complicate any future pregnancies she will have. The fact that this procedure lays in an ethically grey area does not excuse physicians from the responsibility of working with the patient to identify if this is an appropriate procedure in any given case and may even obligate them to work in partnership with each patient to understand what the procedure means to them.
Illegal Immigration Reform and Immigrant Responsibility Act of 1996, 8 USC §116 (1996).
The authors thank the Rudin Fellowship in Medical Ethics and Humanities of NYU School of Medicine for its funding support. The Rudin Fellowship required submission of this manuscript for publication although the fellowship committee was not involved in the writing of this manuscript.
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