When does FGM/C become defined as ‘medicalized FGM/C’ and is medicalized FGM/C an acceptable form of ‘harm reduction’?
Although not specifically addressed in the WHO definition, we argue that medicalization of FGM/C might also include performing less invasive forms of FGM/C, often promoted as ‘a harm reduction strategy’. This form of medicalization has been documented in African countries where FGM/C is prevalent, as well as in European countries and the USA. Indeed, in 2010 the American Academy of Pediatrics issued a position statement in which they suggested that ‘it might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick as a possible compromise to avoid greater harm”. Such a nick, or prick, would consist of pricking the prepuce of the clitoris, without removal of tissue. A study in Somaliland, for example, showed that there is a trend towards milder forms of FGM/C, with “pharaonic circumcision” (Type III or infibulation) being replaced by “sunna” cutting . Moreover, the study showed that girls are more likely to undergo the procedure in a medical facility where staff has received at least some medical training. A recent study from Nigeria demonstrated that the campaign and legislation against FGM/C and the training of nurses concerning the health implications of FGM/C made them more cautious and because they knew the complications, they were more likely to only nick the clitoris enough to cause bleeding and thus satisfy parents that the procedure had been done, without removing much tissue .
Another complication with defining medicalized FGM/C is whether the use of medical instruments (such as sterile razor blades or surgical blades, forceps), antibiotics and/or anesthetics to carry out FGM/C, especially when used by traditional practitioners, should be considered as a form of medicalized FGM/C. Data on this are notably lacking, and only anecdotal evidence is available. In Guinea, the use of razor blades instead of traditional instruments is attributed to the increasing medicalization of the procedure and sensitization campaigns  A qualitative study conducted in four communities in the Nigerian States of Delta, Ekiti, Imo and Kaduna, showed that health workers used a range of essential supplies when carrying out FGM/C: antiseptic, artery forceps, surgical scissors or blades, cotton wool, and antibiotics. They described the steps of the procedure as: “using an antiseptic to clean the area, clamping the tissue with forceps, cutting the tissue with scissors or a surgical blade, applying pressure with cotton wool to control bleeding, cleaning the area again with an antiseptic, and applying an oil or Vaseline”. Some ‘health workers’ mentioned also administering pain relief and prescribing antibiotics .
Finally, we want to highlight the issue of medicalized reinfibulation, and how a recent court case in the UK demonstrates the difficulties in defining what constitutes medicalized FGM/C, especially in the context of re-stitching following the birth of a child (reinfibulation). The UK case study (see Table 1) is a demonstration of an unsuccessful legal case brought against a doctor who allegedly performed a reinfibulation and illustrates the difficulty of proving to a court that FGM/C has taken place. However, the huge publicity that occurred during and following the court case made it very clear that medicalized, as well as traditional FGM/C, was against the law and prosecutions would be brought. Since this case in 2015, two further unsuccessful cases have been brought in the UK against two different fathers of girls who have allegedly been subjected to FGM/C. Again, these showed a weakness in the law concerning the testimony of the victims and expert evidence from health professionals who could not agree whether FGM/C had taken place on the girls. However, in February 2019 the first successful case was prosecuted in the UK of a mother who performed FGM/C using traditional techniques, FGM/C on her three-year-old daughter.
Medicalized FGM/C: harm reduction or human rights abuse?
One of the most important reasons given by health care professionals who perform FGM/C is their belief that when it is done by skilled professionals, it reduces the immediate health risks and pain, especially when antiseptic techniques, anesthetic and analgesic medication are used . Health professionals doing FGM/C might indeed be able to control the immediate physical consequences of cutting the genitals, such as the severe pain, bleeding and infections. However, many health professionals who perform FGM/C have limited knowledge of long-term health consequences of the procedure, in particular the mental health implications. Even if women do not report physical after-effects of FGM/C, research suggests that the majority of women subjected to FGM/C have reported mental health problems and emotional disorders with living with the effects of FGM/C . A study by Knipscheer indicated a high level of reporting of severe depression, anxiety and Post Traumatic Stress Disorder (PTSD) by FGM/C survivors . Eisold found that FGM/C can affect the emotional well-being of women throughout their lives .
Whilst medicalized FGM/C might minimize – but not avoid - some of the long-term physical consequences of FGM/C, the fact remains that there are no perceived health benefits of the practice itself. It is therefore considered to be against good medical practice and a violation of the medical code of ethics, as even “do less harm” is contradictory to the Oath of Hippocrates ‘do no harm’.
Still, the harm reduction approach dominates the discourse, as is demonstrated by the high numbers and increasing rates of health professionals that engage in performing FGM/C. Health professionals performing FGM/C in order to provide a safer setting for the procedure are ignoring the human rights issues associated with FGM/C, including the right to freedom from violence and discrimination, amongst others. The trend to medicalize FGM/C is worrying, given that its impact on the global campaign and efforts to end FGM/C is still not clear. How the promotion of medicalized ‘safe’ or ‘light’ versions of cutting girls’ and women’s genitals influences these efforts is difficult to assess, but it is commonly believed that promoting medicalized forms of FGM/C communicates the message to practicing communities that FGM/C is acceptable when done by health professionals, and thus is a legitimation of the practice . This harm-reduction approach contrasts with the human rights approach, which states that health professionals performing FGM/C in order to provide a safer setting for the procedure, are ignoring the human rights aspects associated with FGM/C.
Furthermore, the assumption that medicalization reduces harm is not empirically proven. Moreover, in the Indonesian case described in Table 2 there is anecdotal evidence to the contrary, namely that midwives perform more severe forms of FGM/C than traditional practitioners. The case of Indonesia also shows that the government has been oscillating between the human rights approach and the harm reduction strategy. Government policy has played a crucial key role in medicalizing FGM/C in Indonesia, together with strong religious/social norms that underpinned this medicalization.
Medicalized FGM/C: reflecting the social norm or used to justify financial gain?
One aspect that plays a key role in health care professionals deciding to do FGM/C is that they commonly share the same social norms regarding cutting the genitals of girls and women, hence resisting the pressure or the demand to do FGM/C from the community is challenging. A study from Nigeria for example, demonstrated that most health workers that engage in FGM/C do so because they share the same FGM/C beliefs as the community they serve, and this was evidenced by the fact that four out of five health workers with daughters had also cut their own daughters . Another study, from Sudan, concluded that medicalization is primarily driven by the demand motivated by social norms .
The patriarchal nature of FGM/C underpins many of the arguments to continue FGM/C, whether it is medicalized or not, and parallels between FGM/C, patriarchy and female genital surgeries have been discussed elsewhere by various scholars (see for example Pedwell C , Ogbe E et al. ).
However, the financial gains to perform FGM/C for both health professionals and parents should not be underestimated, as FGM/C can bring in additional income to health professionals and for parents it can mean a higher bride price/dowry can be expected when their daughter is married. Health professionals’ motivation to perform FGM/C is reinforced by the fact that many health systems in countries where FGM/C is prevalent are weak, and so extra financial income is attractive. Serour suggests that medicalization of FGM/C is a major source of income for those who perform it. Fees are high, especially in countries where FGM/C is illegal [9, 34].
This is demonstrated by the case study that looks at Egypt, where medical doctors have taken the lead in the medicalization of FGM/C, often arguing that as FGM/C is a strong social norm and will happen whatever, that it is better that it is performed by a medical doctor than a traditional practitioner (Table 3). It has also been argued that many of these doctors support the practice for cultural and religious reasons and in addition make a good livelihood from performing the procedure. Despite cases where girls have died following medicalized FGM/C, few successful prosecutions have taken place against a medical professional in Egypt ; a country where medicalized FGM/C is highly prevalent and numbers rising. The Egyptian case study shows us the importance of the context in which FGM/C arises.
FGM/C: cultural rights versus human rights?
Both the Egyptian case discussed above and the Kenyan case discussed hereafter (Table 4) demonstrate how the law has limited influence in contradiction with culture and tradition. It shows how FGM/C is embedded in cultural and traditional norms and rights that are considered by proponents to prevail over the law of the country.
As alluded to in the Kenyan case of a medical doctor supporting the medicalization of FGM/C, there may be gaps in the law that proponents of FGM/C might use to push their agenda. This case indicates that some medical practitioners themselves do not only medicalize, or support it, but do so by exploiting gaps in the judicial system hence derailing progress made towards abandonment of FGM/C.