Female Genital Mutilation: Why Are Doctors Silent?

A federal judge in Michigan recently ruled that a federal ban on female genital mutilation/cutting (FGM/C) was unconstitutional.[1] Charges against two local doctors accused of performing the procedure on young girls were dismissed. Other charges are still pending against one of the doctors and a few of their accomplices, but this case has shone a light on a practice that's becoming all too common around the world: medicalized FGM/C.[2]



FGM/C is a procedure in which parts of the female genitalia are cut to varying degrees,[3] usually before a girl turns 15. According to UNICEF, at least 200 million women and girls worldwide are affected.[4] The practice is considered a human rights violation and may have lifelong health and psychological consequences.

The Medicalization of FGM/C

Most commonly, FGM/C is carried out by traditional practitioners. In recent years, however, we have seen a trend moving it away from villages and homes, where it has usually been done, and into hospitals, clinics, and private offices. The location change has ushered in a vocational change. Health professionals—doctors and nurses—are now frequently the ones performing this procedure on young girls.[5]


Medicalization is rapidly increasing around the world. For example, in Egypt and Sudan, where FGM/C is nearly universal, almost 80%[5] of procedures are performed by members of the health sector. Medicalization is also significant in the Middle East and parts of Asia. Reports about clinics performing it pop up every now and then in other parts of the world, most recently in Russia.[6]

Do No Harm

Why are health professionals, who have sworn to do no harm, participating in a practice that is considered a human rights violation? A recent review[7] of 14 studies conducted in countries where FGM/C is common documented several ways that health professionals rationalize their participation.

Harm reduction. Some believe in the "harm reduction" theory—essentially that doctors can do it more safely and under better hygiene conditions than having it performed by traditional cutters.

Cultural concerns. Some clinicians were convinced of the benefits of the tradition. Other were influenced by their cultural beliefs.

Financial considerations. For some, it is a financial boon, like any other surgical procedure.

Community requests. Some healthcare providers indicated that their participation was the result of pressure from their community to perform FGM.

It is not surprising, then, that individuals who believe in FGM/C would seek out doctors right here in the United States to carry out these procedures.

How Do We End Medicalization of FGM/C?

In the absence of federal and state laws to ban this procedure (only 27 states currently have laws against FGM/C), whose responsibility is it to tell US physicians that they cannot engage in this practice?



A United Nations interagency statement on ending medicalization recommended that ministries of health "and professional regulatory bodies and syndicates

should issue policy statement against the medicalization of FGM."[5] The document further states that "professional organizations should adopt and disseminate clear standards condemning the practice."

Indeed, health-profession organizations often serve as thought leaders through the creation of practice guidelines, policies, and position statements. Often, such documents set the tone and direction for the organization and describe desired methods, behaviors, and actions applicable to the entire organization and its members.

Have US health professional organizations taken on FGM/C? Two Georgetown University colleagues, Isha Choudhary, MD, and Soyun Kim, PhD, and I sought to answer this question.[8]

We selected specialties and organizations whose members, by nature of their training, may be tasked with caring for female patients with, or at risk for, FGM/C. These organizations represented healthcare professionals in women's health, family medicine, pediatrics, dermatology, urology, internal medicine, plastic surgery, and emergency medicine.

Initially, we found that only four (26%) of 15 US-based, physician-focused organizations had any statements about FGM/C. Kudos to the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), the American Medical Association (AMA),[10] and the American College of Obstetricians and Gynecologists (ACOG). [9] That was a year ago. At the moment, a search on ACOG's site for any policy or position statements on FGM/C turns up nothing at all. And this is an organization whose main mission is women's health.

The American College of Nurse-Midwives (ACNM) also has one. Overall, this is pretty poor considering that, according to some estimates, more than 500,000 women and girls in the United States are at risk for FGM/C or its consequences.[11]

Only three out of these five organizations had explicit statements about clinician involvement in FGM/C.

In its statement, the AMA noted that it is "in opposition to the practice of FGM by any physician or licensed practitioner In the US." The AAP "counsels its members not to perform such procedures." ACNM states that midwives must "decline to perform FGM/C."

Silent on the matter were ACOG and the AAFP (who had general statements about FGM/C) and all of the other organizations serving as the collective voices of hundreds of thousands of physicians. (Full disclosure: I wrote the AAFP policy statement, so it is totally on me. Why didn't I include it? Naiveté and shortsightedness.)

In comparison, all of the seven Canadian physicians' organization we assessed had statements on medicalized FGM/C. Some organizations used stronger language than others, but overall the message was clear: This is not something doctors should do.

Words Matter

Professional organizations' policies and statements are important. Often, they take the lead and set the agenda for their members. More effectively than individual members, organizations can affect broader regulations, policies, and laws, and participate in multisectoral work. Our representative organizations have a responsibility to us and to our patients to develop, strengthen, and support specific and concrete actions directed towards helping our members appropriately address FGM/C in clinical practice.

Global trends in the medicalization of FGM/C should worry us here in the United States, regardless of the ultimate outcome of the Michigan case.[1]Individual physicians, along with our representative organizations and societies, must take a position on this issue and make explicit statements about our role in performing genital alteration on patients under the age of 18. We cannot wait for the current legal confusion to be resolved. We cannot wait until state legislators draft and vote on new FGM/C laws, or until Congress enacts a new federal law.

Our societies and member organizations have a responsibility to set the tone for an evidence-based national conversation and make their stand—our stand—clear to all stakeholders, including our patients and their family members. FGM/C is a human rights violation, and doctors—or any other health professional—should not perform it (in any form) or assist others in performing it.

Words matter. Against the silence, they are the only boundaries we have right now. Let's use them.

References

1. Belluck P. Federal ban on female genital mutilation ruled unconstitutional by judge. The New York Times. November 21, 2018. Source Accessed December 11, 2018.
   
   
2. Kimani S, Shell-Duncan B. Medicalized female genital mutilation/cutting: contentious practices and persistent debates. Curr Sex Health Rep. 2018; 10: 25–34. Source Accessed December 11, 2018.
   
   
3. World Health Organization. Classification of female genital mutilation. Source Accessed December 11, 2018.
   
   
4. UNICEF. Female genital mutilation. February 2018. Source Accessed December 11, 2018.
   
   
5. UNICEF. Calling for the End of the Medicalization of Female Genital Mutilation. June 2018. Source Accessed December 11, 2018.
   
   
6. Litvinova D. Female circumcision in Moscow clinic sparks 'complete shock'. Reuters. November 27, 2018. Source Accessed December 11, 2018.
   
   
7. Doucet MH, Pallitto C, Groleau D. Understanding the motivations of health-care providers in performing female genital mutilation: an integrative review of the literature. Reprod Health. 2017;14:46. Source Accessed December 12, 2018.
   
   
8. Choudhary I, Mishori R, Kim S. Words matter: charting the landscape of US and international health profession organizations' public statements about FGM/C. J Immigr Minor Health. 2018 Sep 1. doi: 10.1007/s10903-018-0818-2. [Epub ahead of print]
   
   
9. American College of Obstetricians and Gynecologists. Committee on Gynecologic Practice [and] Committee on International Affairs. Female genital mutilation. ACOG Committee Opinion No. 151. ACOG Comm Opin. 1995;151:1.
   
   
10. Female genital mutilation. Council on Scientific Affairs, American Medical Association. JAMA. 1995;274:1714-1716. Abstract
    
    
11. Goldberg H, Stupp P, Okoroh E, Besera G, Goodman D, Danel I. Female genital mutilation/cutting in the United States: updated estimates of women and girls at risk, 2012. Public Health Rep. 2016;131:340-347. Source Accessed December 12, 2018.
    

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