The traditional custom of female circumcision, also known as female genital mutilation (FGM) persists primarily in Africa but has occurrences in at least 28 countries (Morris, 1996, pg. 43). FGM is a collective term that describes several different traditional, not religious, rituals. It has been estimated that between 100 million and 140 million infants, toddlers, children and adolescent females have undergone a FGM procedure and that between 4-5 million of these procedures are performed yearly (Althaus, 1997, pg.1).
FGM is most often performed between the ages of 4-10 years and is performed by the village physician (Althaus, 1997, pg. 2). Typically the procedure uses a variety of instruments, such as knives, broken glass, and fruit thorns (Morris, 1996, pg. 45). According to Rita Morris, PhD, the procedures are classified according to the severity of structural disfigurement. Type I, often known as clitorectomy, involves removal of the skin surrounding the clitoris, and may or may not include removal of the clitoris. Type II, or excision, is the removal of the clitoris and part of all of the labia minora. The excisions are sutured with catgut or fruit thorns. Type III, infibulation, is the most severe form of FGM. In infibulation, the entire clitoris and labia minora are removed and the labia majora are sewn together, leaving only a large enough opening in the vagina for urination and menstruation. There are many physical and psychosocial ramifications associated with all types of FGM.
FGM has been performed on individuals from many cultures; however, the procedure is not indoctrinated or required by any specific faith or religion (JAMA, 1995, pg. 1714). It has been estimated that approximately 98% of all Somalian women, 94% of Mali women, and 82% of Sudanese women have undergone FGM (JAMA, 1995, pg. 1714). The cultures that uphold these customs do so to: uphold group identity, maintain cleanliness and health, preserve virginity and family honor, and to further marriage goals (Morris, 1996, pg. 47). If a woman is not circumcised, she is considered to be “unmarriable”. In some societies, uncircumcised women are regarded as unclean and are not allowed to handle food or water (Morris, 1996, pg. 47). Others believe that the clitoris is dangerous and that if during childbirth, the baby’s head touches the clitoris, the baby will die (Morris, 1996, pg. 47). Those women that have not undergone the procedure are shunned by the culture and are considered to be dangerous (Morris, 1996, pg.47).
The debate over medicalization of FGM is relatively recent. In 1996, the Congress of the United States enacted legislation to criminalize the performance of FGM by practitioners on females younger than 18 years of age and to develop educational programs about the harmful consequences of FGM (Althaus, 1997, pg. 2). The World Health Organization (WHO) considers that “the medicalization of the procedure does not eliminate harm and is inappropriate for two major reasons: genital mutilation runs against basic ethics of health care whereby unnecessary bodily mutilation cannot be condoned: and, it’s medicalization seems to legitimize the harmful practice” (JAMA, 1995. pg. 1715). In1997, the WHO, the United Nations Children’s Fund, and the United Nations Population Fund issued a statement noting that FGM is a deeply rooted cultural practice; culture is a dynamic state and is capable of change (Althaus, 1997, pg. 4).
Much work is being done in the area of education and cultural sensitivity. Although the Western medical community believes that refusal to perform FGM may reflect an ethnocentric viewpoint, protection of physical and mental health should be of utmost concern (Althaus, 1997. pg. 48). Various approaches to education can be implemented: community education, alternative rituals, and support groups should be available.
Upon reviewing the literature cited above, this researcher believes that this will be a very prevalent issue in her practice. Since Minnesota has quite a number of Somalian families, these issues will need to be addressed and in various settings and environments. This controversy may exist on an OB/GYN floor, a women’s unit, in labor and delivery, in an OR setting; in rural settings or in big cities. Since western medicine laws have been enacted, our practice of this procedure is very limited for those of varying cultures. It is a crime to perform these procedures on females under the age of 18 years and legislation does not regulate which types of FGM are available. It has been criminalized because the procedures have been viewed as a human rights violation and because the procedures are barbaric (Morris, 1996. pg. 46), however, the United States has a growing number of elective cosmetic surgeries each year, including labial reductions and genital reconstructions. Although these elective surgeries are legal, certain laws could be written to lessen the severity of FGM, yet still allow the culture to express itself. It is this researcher’s view that Western medicine allows our people to make a choice, but in the African culture, this procedure is not a choice. The procedures are severe in surgical nature and are performed in unsterile environments, using unclean techniques (Althaus, 1997, pg. 3). Our culture is aware of the sensitivity needed to ensure good quality and proper health care. This researcher believes that to guarantee the best health care experience, the client must be able to make their own decisions, thus adults should be allowed to make decisions for themselves, based on proper teaching, knowledge base, medical practice, and counseling.