Loretta M Kopelman. Bioethics. Editor: Bruce Jennings, 4th Edition, Volume 2, Macmillan Reference USA, 2014.
While communities practicing female circumcisions may insist it is done to benefit and honor women, these procedures are increasingly seen globally as human rights violations, as public health hazards, and as oppression of and violence against women. In 1997 the World Health Organization (WHO) and other United Nations agencies began using the words female genital mutilation rather than the less judgmental language female circumcision or female genital cutting to describe these practices (UNICEF 2013). This was done to emphasize the gravity of harms these procedures cause and that they are viewed internationally as a violation of girls’ and women’s human rights (WHO 2010). WHO offers the following definition: “Female Genital Mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for nonmedical reasons” (WHO 2013). The United Nations Children’s Fund (UNICEF) uses the abbreviation “FGM/C” for female genital mutilation, circumcision, or cutting.
WHO (2013) estimates that 140 million girls and women have had some form of FGM/C and that another eight thousand girls per day or three million each year are at risk. They classify these practices into four groups: Type 1 is the removal of the prepuce with or without removal of all or some of the clitoris. Type 2 is the removal of the entire clitoris and all or most of the labia minora. Type 3, or pharaonic circumcision, is the removal of all of some or all of the clitoris and labia minora and parts of the labia majora as well as the practice of infibulation (the wound to the vulva from the cutting is stitched closely, leaving a tiny opening so that the woman can pass urine and menstrual flow). Type 4 includes “all other harmful procedures to the female genitalia for nonmedical purposes, e.g., pricking, piercing, incising, scraping and cauterizing the genital area.” Not surprisingly, the morbidity, disability, and mortality vary with the type of procedure. UNICEF (2013) reports countries with the highest prevalence include Somalia (98%), Egypt (91%), Mali (89%), and Sudan (88%). These rituals are usually done during infancy or childhood.
Growing Global Awareness of and Advocacy for the Elimination of FGM/C
The worldwide scrutiny and condemnation of FGM/C grew when important medical studies appeared in the 1980s documenting its harm. The investigators were both activists for the elimination of FGM/C and citizens of the countries where these surgeries were popular. Their studies showed the extent of the immediate and long-term pain, morbidity, disability, and mortality associated with FGM/C and revealed the nature and extent of the problem to the world. Those pioneering medical studies included the investigations in the Sudan by Asma El Dareer (1982), in Somalia by Raquiya Haji Dualeh Abdalla (1982), and in Sierra Leone by Olayinka Koso-Thomas (1987). The death, infection, and disabilities associated with FGM/C challenged local beliefs that these procedures promote health, cleanliness, and perinatal well-being. For example, as Koso-Thomas pointed out, stable medical evidence discredited the belief that “death could result if, during delivery, the baby’s head touches the clitoris” (10) and Abdalla pointed to the hazards of regional practices of putting “salt into the vagina after childbirth … [because this] induces the narrowing of the vagina—to restore the vagina to its former shape and size and make intercourse more pleasurable for the husbands” (16).
Later studies confirmed their findings. For example, Daphne Williams Ntiri (1993) found that in some African countries most young girls between infancy and ten years of age have received type 3 circumcision from traditional practitioners who often used sharpened or hot stones, razors, or knives, frequently without anesthesia or antibiotics. In 2006 WHO published a study of 28,393 women and found a significant increase of obstetrical risks and perinatal deaths, concluding, “FGM is estimated to lead to an extra one to two perinatal deaths per 100 deliveries Women with FGM are significantly more likely than those without FGM to have adverse obstetrical outcomes. Risks seem to be greater with more extensive FGM” (WHO 2006). A WHO fact sheet later summarized findings about the harms associated with FGM:
Immediate complications [from FGM] can include severe pain, shock, haemorrhage (bleeding), tetanus or sepsis (bacterial infection), urine retention, open sores in the genital region and injury to nearby genital tissue. Long-term consequences can include: recurrent bladder and urinary tract infections, cysts, infertility, an increased risk of childbirth complications and newborn deaths, [and] the need for later surgeries. For example, the FGM procedure that seals or narrows a vaginal opening (type 3 above) needs to be cut open later to allow for sexual intercourse and childbirth. Sometimes it is stitched again several times, including after childbirth, hence the woman goes through repeated opening and closing procedures, further increasing and repeated both immediate and long-term risks. (WHO 2013)
Confirmation of the harms associated with FGM/C are further documented in a comprehensive 2013 UNICEF report based on 74 surveys conducted over two decades from 29 countries in the Middle East and Africa where FGM/C is concentrated.
A Human Rights Issue
One reason to view FGM/C as a human rights violation then, despite local protests, is because these practices cause many immediate and long term health problems. As we have seen, repeated studies show FGM/C causes significant morbidity, disabilities, and mortality among many girls and women. The increased risks of infections, pain, bleeding, infertility, sexual dysfunction, and other harms associated with FGM/C affect the quality of their lives.
Another reason these procedures are viewed globally as human rights violations is because practitioners do not typically obtain informed consent. FGM/C is usually done between infancy and the early teen years, when girls cannot give their informed, competent, and unpressured consent for this loss of bodily integrity. In half of the countries with available data, most girls were cut before the age of five (UNESCO 2013, 5). The communities practicing FGM/C might argue that these procedures are in the girl’s best interest and thus parental permission is sufficient. Moreover, they point out that some women in their communities willingly give consent. In part, the global dispute is about whether those who give permission or consent are adequately informed about the hazards of FMG/C. It is also about whether the consent is unpressured since these procedures are often necessary for community membership or marriage. Whether or not the self-determination of these girls or women is valued in these communities, agreement, assent, or consent to surgical procedures limiting future options has become an important standard of international human rights, considered more important globally than respect for cultural diversity by many nations of the world (Kopelman 2005; UNICEF 2005, 2013).
Moreover, support for FGM/C is eroding. Even in locations where FGM/C is deeply entrenched and most women have FGM/C, large percentages of men and women in these communities wish it would end. Support for FGM/C varies but UNICEF concludes, “the majority of girls and women think it should end” (UNICEF 2013, 52). In addition, “in most countries the majority of boys and men think FGM/C should end” (UNICEF 2013, 58). Those who are young, more affluent, educated and urban dwellers are among those most ready to abandon these practices.
UNICEF (2013) surveyed countries where FGM/C is concentrated and found that between 25–55 percent of women see no benefits: the most commonly reported benefit of FGM/C by girls and women “is gaining social acceptance” (UNICEF 2013, 67). Men and boys are even more inclined to see no benefit and would like to see it end, but women often do not know this because they do not speak openly about these matters. The lack of open discussions about FGM/C results in people not really knowing each others’ views. In most, but not all countries some once-popular reasons are less frequently given (e.g., that it is a religious requirement, that it offers men more sexual pleasure, or that it promotes cleanliness). The UNICEF (2013) report concludes that FGM/C continues in part due to misunderstandings that most people want it done and from the social pressure this misunderstandings generates.
A further reason to view FGM/C as a human rights violation arises by comparison with harms to other groups that are unequivocally considered to be human rights violations. Despite insistence by people within these cultures about their good intentions, FGM/C is condemned by those outside the culture as a brutal form of oppression of women, comparable to making men eunuchs (removal of the testes or external genitals). FGM/C is illegal in most countries and many international organizations denounced these practices, including WHO, UNICEF, the American Academy of Pediatrics, the International Federation of Gynecologists and Obstetricians, and the American Medical Association. They deny that this is just a cultural issue, arguing that FGM/C should be opposed with the same vigor as are other violations of human rights (Schroder 1994; Toubia 1994). Pressure from human rights groups has been successful in forcing some governments to make FGM/C illegal, in banning all registered health professionals from performing female cutting or infibulation and in helping women find political asylum in other countries to avoid FGM/C.
Some countries are more willing to pass laws prohibiting FGM/C than they are willing to enforce those laws. UNICEF (2003) and WHO (2012) have been critical of governments’ lack of will to confront these practices where they are popular, to enforce existing laws that prohibit them, or to offer education about their risk. UNICEF and WHO promote education as being crucial to dispel the beliefs, attitudes, and customs that support FGM/C and discrimination against uncircumcised women. Even in the United States, the United Kingdom, France, Canada, and other countries where FGM/C is illegal and viewed as child abuse, it is hard to prosecute because it is often practiced in people’s homes. Moreover, it is hard for child protective agencies to know what to do for the child when the parents are typically well-meaning and loving (Davis 2001).
Whether or not the intent of these procedures is to benefit or honor women, UNICEF and others regard them as “culturally sanctioned forms of women’s oppression, male domination, and control of women’s sexuality” (UNICEF 2003). The US State Department (2012) takes the position that FGM/C is “not only a public health concern, but also a human rights issue that violates a women’s right to bodily integrity” and a form of “gender-based violence.” The UN General Assembly formally accepted a resolution in December 2012 which seeks the elimination of female genital mutilation (WHO 2013).
Ongoing Disputes About Zero Tolerance
Prominent African activists, including Olayinka Koso-Thomas, Nahid Toubia, and Raquiya Abdalla, have long advocated for stopping all forms of FGM/C while retaining the cultural and religious rituals that educate and welcome girls into adulthood and the community. They favor rituals that do not cause bleeding and which promote education to men and women that includes telling about the health hazards to women and asking young males to make a vow not to require circumcision as a condition of marriage. These advocates argue these changes can accommodate important religious, cultural, economic, community, and family considerations without harming girls. They also stress the importance of education about religious considerations. For example, many but not all of those practicing FGM/C are Muslim, yet it is not a requirement of Islam nor practiced in Saudi Arabia, Islam’s’ spiritual home.
In 1997 WHO, the United Nations Children’s Fund (UNICEF), and the United Nations Population Fund (UNFPA) issued a joint statement advocating zero tolerance of all forms of FGM/C (WHO 1997). The World Health Assembly in 2008 passed resolution WHA61.16 favoring zero tolerance of FGM while stressing the importance of cooperation among different nations and professional communities to coordinate their responses to the intertwined issues of public health, women’s affairs, financial opportunities, laws, and justice. In 2010 a WHO publication titled “Global Strategy to Stop Heath Care Providers from Performing Female Genital Mutilation” offered ways to eliminate FGM/C and clarified that these procedures are not legitimate medical procedures.
Since 1997, when WHO, UNICEF, and the UNFPA released their joint statement advocating for zero tolerance of all forms of FGM, WHO has worked with communities practicing FGM/C to offer good training for medical providers, to find alternative ways to welcome girls into their communities, and to teach about how cultural values such as modesty and cleanliness can be achieved without the need for FGM/C.
Besides WHO, many other health care professional organizations have adopted policies against having health care providers perform FGM/C, including the American Academy of Pediatrics, the International Federation of Gynecologists and Obstetricians and the American Academy of Medicine. Yet not all health care professionals follow these directives. As more parents have learned about the morbidity, disability, and mortality caused by FGM/C when done by traditional healers, more have sought the services of licensed doctors and nurses. In Egypt this has led to an increase in the percentage done by health care professionals from about half in 1995 to 75 percent in 2013 (UNICEF 2013). WHO (2013) is alarmed at the growing trend for medically trained personnel to perform FGM/C and estimates that health care providers now perform over 18 percent of these surgeries. In some areas, however, professional policy is more effective such as in Kenya which has seen a dramatic decline (now 27%).
Asma El Dareer (1982) and Dena Davis (2001), among others, however, argue that a more effective approach than zero tolerance would be to replace the more mutilating forms of FGM/C with removal of the foreskin around the clitoris or with tiny nicks in the labia. This, they maintain, might “wean” people away from the more extreme forms of genital mutilation and be less likely to cause morbidity, mortality, or sexual dysfunction. The chance of success with this tactic is more promising and realistic, they hold, than would be the case with an outright ban; people could maintain many of their traditions and rituals of welcome without causing as much harm, especially if the operations were done by doctors and nurses under sterile conditions. Davis expresses the concern that something other than zero tolerance could send the wrong message to immigrants:
Because FGA [female genital alteration] in its most common forms around the world is mutilating and life threatening, it is reasonable to adopt a “zero tolerance” policy to make it absolutely clear to immigrants that this practice is never acceptable … further, an argument could be made that, once a “nick” is allowed, it would be difficult if not impossible for the state to make sure this did not become a loophole through which the worst elements of FGA would slide. As MGA [male genital alteration] is not anywhere close to as mutilating and threatening to life and health as are many forms of FGA, this argument would serve as a constitutionally valid distinction between the two practices. (561)
In the end, however, Davis tries to justify a compromise for the sake of cultural sensitivity, legal consistency, and medical safety, arguing that procedures might be permitted that allow roughly the same harm done to girls as is done to boys in male circumcision: no more than a minor nick in a girl’s labia or clitoral hood. This reasoning, however, has been challenged.
Raquiya Abdalla (1982) and others object to equating female circumcision with male circumcision, arguing their purposes and degree of harm differ drastically. Attempts to remove the clitoral hood frequently damage the clitoris since, given the female anatomy, additional tissue is almost always taken (Toubia 1994; Bishop 2004). Removal of the clitoris is comparable to amputation of the penis rather than removal of the foreskin in men. For some people the best reason for drawing parallels between male and female genital cutting is to help abolish both practices. Even if the timetables do not coincide exactly, they hold, comparisons should not be used to allow some female circumcision in countries that permit male circumcision. Still others maintain that there are demonstrated health benefits to male circumcision that justify distinguishing the two.
WHO has argued it is important for health care providers to refuse to do any form of FGM/C or reinfibulation. Repudiating them in a health care setting shows health care professionals advocate for their elimination and do not view them as legitimate medical procedures but causes of morbidity, disability, and mortality. UNICEF also took the same stand:
the benefits of a marginal decrease in harm resulting from less severe forms of FGM/C need to be weighed against the opportunity costs of promoting the end of FGM/C as one of many harmful practices that jeopardizes the well-being of girls and infringes upon their human rights. (UNICEF 2013, Executive Summary, 6)
Finally, although legal consistency may be an important goal, so many differences exist between female and male circumcisions they do not seem comparable. Moreover, legal consistency is difficult to justify if it increases the pain and suffering of children and negatively affects their quality of life.
Debates Over Cultural Diversity
After 1980 increasing numbers of immigrants from North Africa and southern Arabia brought these non-medically indicated female genital surgeries with them, further raising awareness of FGM/C worldwide. Those immigrants came from regions where most women undergo FGM/C and moved to areas of the world where these procedures are generally viewed as horrific, oppressive, and illegal practices that put girls and young women at terrible risk of morbidity, disability, and mortality. Consequently, families that sought FGM/C often return to their country of origin to have the procedures done.
The cultural clashes that have resulted from criticisms of FGM/C often center on whether there is any justification for interfering with the deeply held practices of other cultures. The position of extreme ethical relativism holds there is no moral or epistemological basis for interfering with popular customs in other countries and that meddling constitutes cultural imperialism (Shweder 1990; Ginsberg 1991; Scheper-Hughes 1994; Bishop 2004). Extreme ethical relativism, however, has been challenged on many sides (Schroeder 1994; Kopel-man 1994, 1997; Macklin 1999; Putnam 2008).
A first point in this challenge is that cultures are not monolithic but rather they are fluid and contain passionate disagreements even among family and neighbors. As noted above, studies document that even where FGM/C is firmly entrenched many people would prefer it end. In some places criticism of FGM/C is growing and change is occurring rapidly (Moschovis 2002; UNICEF 2013; WFIO 2013). In such places, the cultural commitment to FGM/C is eroding and people, often the affluent, educated and urban dwellers, abandon these rites. As the investigators who originally touched off the contemporary debate over FGM/C illustrate, some disagreements about FGM/C have existed for decades in these cultures.
A second point is that cultures overlap and are hard to count as separate entities in our world of jet travel, Internet communication, mass migrations, and international news reports. Few people live in only one culture but cross easily from one culture to another in their businesses, professions, religions, and ethnic groups. People who brought the practice of FGM/C with them when they immigrated, for example, live in more than one culture. Cultural, religious, professional, ethnic, and other groups overlap and have many variations within nation-states. To say that people belong to overlapping cultures or that people cannot distinguish precisely between cultures, however, undercuts extreme ethical relativism and its tenet that the only way to determine whether something is right or wrong, good or bad is to see if it has cultural approval (Kopelman 1994, 1997, 2005; Macklin 1999).
A third challenge to the extreme ethical relativist argument is that cross-cultural criticism seems to be important and even obligatory when one considers that some cultures engage in terrorism, war, torture, exploitation, racism, rape, human trafficking, pirating, infanticide, or slavery. Because extreme ethical relativism holds that any act is right if it has cultural approval (however members of the culture define themselves) then it follows that culturally endorsed act involving such activities are right. This leads to the highly implausible conclusion that the disapproval of people in cultures being ravaged or attacked is irrelevant in determining whether acts of aggressors are right or wrong. The credibility of this version of extreme ethical relativism is therefore eroded by its conclusion that the disapproval of people in other cultures, even victims of war, oppression, enslavement, aggression, exploitation, rape, racism, or torture, lacks any moral authority and is irrelevant in deciding that anything is good or bad, right or wrong, in the aggressor culture. Because this conclusion lacks credibility, the burden of proof should be on those claiming people cannot meaningfully discuss moral issues or praise or criticize practices across cultures in a way that has moral authority. They need to show why we are wrong in thinking we can sometimes meaningfully criticize other cultures and they us. This will be difficult, since to say people cannot meaningfully criticize other cultures requires some authoritative trans-cultural basis; yet this is what they say is impossible.
Finally, it also seems highly implausible that culturally distinct groups do not share any goals and methods. For example, while there are differences among professional nursing and medical practices in different regions, there are also many similarities. It was doctors and nurses in cultures practicing FGM/C who conducted the initial studies showing that FGM/C caused pain, emotional trauma, painful intercourse, obstetrical dangers to mother and child, infection, sexual dysfunction, chronic disease, disability, and death. Their studies were confirmed by larger studies conducted by WHO, UNICEF, and others in later years. Health care professionals share many goals and methods, belong to many of the same international societies, read many of the same journals, visit each other’s clinics and hospitals, and learn from each other. They cooperate in global research projects to address such things as pandemics and environmental hazards. These shared goals and methods have been used to show that the means used in some cultures to promote health, such as FGM/C, are destructive practices. People in different cultures want to promote the health of their children, although we may disagree about how to do it. This goal may be normative but the means to attain that goal is informed by factual assessment about what causes harms and benefits.
Consistency
The beliefs and attitudes associated with FGM/C in some regions carry several apparent contradictions. For example, on the one hand some people from those regions claim that nothing is given up because women cannot enjoy sex, but on the other hand they say that the procedures are needed to control women who might be sexually out of control without the surgeries. This fear that girls will be sexually promiscuous is a frequently given reason for doing the surgery in the West, where girls and young women have considerable freedom compared with the situation in their parents’ original homelands.
Another apparent inconsistency concerns insistence that respect for cultural mores requires that deeply embedded cultural views about FGM/C must be respected in people’s adopted countries even if this means violating the deeply embedded views of the dominant culture. It is inconsistent to insist that all groups’ deeply embedded views must be respected—but not those of some cultures.
Finally, extreme cultural relativism entails that there is no trans-cultural way to determine what is right or wrong, or good or bad, outside of specific cultures. For holders of this position to then advocate in favor of trans-cultural universal normative principles such as “maintain respect for other cultures,” “every culture counts for one,” “preserve ancient cultures,” and “when in Rome do as the Romans do” is logically inconsistent (Kopelman 1994, 1997).
Extreme ethical relativism is often intended to promote tolerance and respect toward other cultures. Yet it seems neither respectful nor plausible to argue that because we are so different we cannot have any meaningful conversations about what is right or wrong, or good or bad, or about what is reliable evidence or good findings.
The Future of FGM/C
Global concern about FGM/C since the last decade of the twentieth century has made those procedures the center of controversy about human rights, public health, ethical relativism, and the limits of tolerance of cultural diversity. Medical studies document that FGM/C increases the likelihood of pain, infections, morbidity, mortality, disabilities, perinatal risks, and lack of sexual sensitivity and satisfaction for millions of women. Global scrutiny has resulted in international and national organizations, nation-states, and professional organizations supporting activists who work to stop FGM/C in those regions where it occurs. Respectful cooperation with these communities is essential to address the issues of public health, women’s rights, and social change that are related to FGM/C (Abdalla 1982; El Daree 1982; Koso-Thomas 1987; Dirie and Lindmark 1992; Toubia 1994; WHO 2012; UNICEF 2013).
Laws making these procedures illegal have been widely adopted but their effectiveness is limited if local communities do not enforce them. UNICEF (2013) reports that support for FGM/C is abating and large percentages of men and women believe it should be stopped, even in regions where FGM/C is widely practiced. WHO (2013) and UNICEF (2013) recommend that the most effective way to stop these practices includes education about its harms, respectful and open discussions to address misconceptions that many people want these practices to continue when they do not, zero tolerance or having health care providers refuse to do them, and improved status and opportunities for women and girls.