Female genital mutilation: whose problem, whose solution?

In this week's BMJ, Elmusharaf and colleagues present a study of the agreement between self reports of female genital mutilation and the findings of clinical examination in a cohort of girls and another of women.¹ They report that girls and women were inaccurate in describing what had been done to them, and that the actual mutilations did not readily fit into the World Health Organization's classification system. These findings have implications for research and, more broadly, for tackling the problem of female genital mutilation worldwide. They suggest that we need to re-examine our current conceptualisation of female genital mutilation with a view to defining a valid and reliable definition and classification system.

Figure 1.

In Pokot society as in many others, genital mutilation marks entry into adulthood

The literature on female genital mutilation is long on polemic and short on data. Some writers make unsupported claims of physical and psychological adverse effects, something that hardly makes their case more credible among the very people who need to be convinced in the cultures which practise genital mutilation. Recent evidence from a large, well conducted study by WHO confirms the association between female genital mutilation and obstetric outcome.² However, the associations are of modest strength: for women with WHO type III mutilations (the most severe) there was a relative risk of 1.3 for both caesarean section and infant resuscitation, and 1.6 for stillbirth or early neonatal death, and there was no increased risk for the 32% of women who had WHO type I mutilation. These findings place female genital mutilation somewhere behind maternal smoking as a risk factor in pregnancy.

But to attack female genital mutilation on the grounds of the associated risks implies that it is an unacceptable practice because it is medically dangerous. There is a risky corollary to this: if all female genital mutilation could be made as safe as WHO type I, would it then be all right?

European and American writers often assume that female genital mutilation is forced on unwilling young girls. This is at odds with the high social value placed on it in societies that practise it.³ As a symbol of entry into adulthood and acceptance into society as a woman or man, genital mutilation in both sexes may have pivotal cultural significance. The young Pokot woman in the photograph was pictured on the occasion of her proud ceremonial walk around the village, marking the end of her period of convalescence after the ceremony and her first appearance as an adult. It reminds us that, if we are to change the practice of genital mutilation, we may be unwise to attack the underlying cultural significance and should concentrate on the form of the initiation ritual. There are encouraging signs that the cultures which practise female genital mutilation are responding to the concerns about the health consequences while trying to maintain their cultural values.⁴,⁵

The high moral tone with which those in richer countries criticise female genital mutilation would be more credible if we in the rich North had not practised it and did not continue to practise it. We have conveniently forgotten that female “circumcision” was practised by the European and American medical professions in the 19th century as a cure for a wide variety of conditions including insomnia, sterility, unhappy marriage, and psychological disorders.⁶ It was advocated by no less a figure than the father of gynaecology, J Marion Sima.⁷ Jonathan Hutchinson, then president of the Royal College of Surgeons, enthusiastically advocated circumcision and “other measures more radical than circumcision” to prevent the adverse mental effects of masturbation as “a true kindness to many patients of both sexes.”⁸ The last known medical female circumcision in the richer world took place in Kentucky in 1953, on a girl aged 12.⁹ Our own sexually repressive use of female genital mutilation may be at the root of our misunderstanding of its role in other cultures.

The practice of female genital mutilation is on the increase nowhere in the world except in our so called developed societies. “Designer laser vaginoplasty” and “laser vaginal rejuvenation” are growth areas in plastic surgery, representing the latest chapter in the surgical victimisation of women in our culture. The procedures offered include vaginal tightening and vulval remodelling to make the vulva appear more childlike. In the words of one of the many clinics offering these services on the internet: “Many people have asked us for an example of the aesthetically pleasing vulva. We went to our patients for the answer and they said the playmates of Playboy.”¹⁰ In other words, women are being mutilated to fit male masturbation fantasies, in what Faith Wilding calls “the full-scale consumer spectacle of the cyborg porn babe.”¹¹ This burgeoning industry is able to operate without the slightest attention being paid to it by medical researchers. There is not a single reference to laser vaginoplasty on PubMed.

The WHO definition of female genital mutilation is “all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious, or other non-therapeutic reasons.” It is Western medicine which, by a process of disease mongering,¹² is driving the advance of female genital mutilation by promoting the fear in women that what is natural biological variation is a defect, a problem requiring the knife.