By: Dr Zuhdi Jasser, Dr Waqas Khan, and Dr Shaaz Mahboob, in partnership with America Matters

The comparison between Female Genital Mutilation (FGM) and male circumcision on a medical basis is false and endangers women who are subjected to it.

Introduction

The April 2017 federal indictment of multiple Muslim physicians for the crime of female genital mutilation (FGM) in Michigan is spurring honest conversations in the United States about the nature, origins, and criminality of FGM. Dr Jumana Nagarwala, a former Henry Ford Medical Center physician, along with clinic owners, Dr Fakhruddin Attar and Farida Attar, will stand trial in 2018 for their crimes against at least two young girls, who were brought to the Attars’ Detroit-area clinic one evening, after the clinic was officially closed to patients. While many activists believe the case will be an easy win for those in favour of the minor girls due to the egregious nature of the harm, arguments to normalise the practice in the U.S. will make the legal battle more difficult than many human rights advocates realise.

To most women’s rights advocates, anti-FGM leaders, and even the World Health Organization (WHO), any non-medical procedure done to young girls’ genitals is a form of FGM.[1] This includes the most supposedly minimal procedures, such as pin pricks on the clitoral hood, which the American Medical Association (AMA)[2] agrees can leave lasting emotional and physical scars on survivors. Yet, some supporters of the defendants, including prominent attorney Alan Dershowitz, have sadly spoken in favour of this conveniently-called ‘compromise nicking procedure’. They do this by falsely equating FGM with male circumcision, often using a moral and religious freedom narrative.[3] But from a medical standpoint, the two procedures are not the same.

As Muslim doctors, we are invested in the landmark Detroit FGM trial, which has brought the medical community at an intersection with faith and culture. FGM has been performed for many centuries, across many cultures, and in many different regions of the globe. Some people use religious justification for the procedure, but the heart of it is based on gender-violence and inequality that anchors women to future burdens, including forced marriage and domestic violence. Since these procedures are ostensibly being performed under the sanction of physicians, we feel ethically obligated—as doctors, Muslims, and human rights advocates—to speak out and set the record straight about the realities of FGM, and how it is medically different any form of male circumcision. Through this knowledge, we aim to stop FGM. We are not advocating for or against male circumcision.

Understanding the Difference Between the Two Procedures

Male Circumcision

To fully understand the medical differences between male circumcision and FGM, we first need to compare the anatomy of the male and female genitalia. Both male and female sexual organs have an extensive supply of circulation and sensory nerve endings that make them one of the most sensitive biological systems within our bodies. But out of the entire genitalia, there is one specific area in males and females, which is the most sensitive—the female clitoris and the male glans penis, or the tip of the penis. The extreme sensitivity of the clitoris and glans penis plays a vital part in both sexual arousal and achieving orgasm.

Male circumcision is an elective surgical procedure that involves the full or partial removal of the foreskin (prepuce). It does not have anything to do with the glans penis, and the methods used in procedure make it almost impossible to injure it in the foreskin procedure.[4] Thus, when done properly, male circumcision does not affect a man’s sexual function and health[5], which is in contrast to FGM (see Female Genital Mutilation below).

The American Academy of Pediatrics (AAP) Male Circumcision Task Force concluded in 2012 that “the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it.”[6] The bio-ethical and medical sanction of male circumcision is predicated by a valid, long established and tested medical tradition. As noted by the AAP Task Force, male circumcision may have medical benefits,[7]including better and easier hygiene, decreased risk of urinary tract infections, sexually transmitted diseases and even penile cancer.[8] It is important to note that most of these benefits are more prevalent in developing countries, in areas with limited access to medical care, compared to Western populations.[9]

There is brief, albeit, severe pain involved in male circumcision when the foreskin is removed. Other short-term complications include bleeding, infection, and injury to the penis. The rates of these problems are incredibly low, occurring in 1.8 out of every 1,000 patients, or fewer.[10] Long-term health effects may involve incomplete circumcision, excessive skin removal, adhesions, narrowing of the urethra, phimosis, and cysts.[11] For these reasons, the AAP strongly recommends that male circumcision is performed with the use of pain relievers, and by a medical professional, as the instances of complication increase outside of these parameters.[12] The Centers for Disease Control (CDC), and World Health Organization (WHO) recommend male circumcision in certain regions of the world based on its purported health benefits, which includes reducing the transmission of some sexually transmitted diseases. This includes a possible 60 percent reduction in HIV transmission in some countries where the disease is prevalent.[13] [14]

Female Genital Mutilation

FGM comprises all procedures that involve partial or total removal of the clitoris—the most sensitive female sexual organ—and other parts of the external female genitalia.[15]

WHO categorizes FGM into four types:

Type I: Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).

Type II: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).

Type III: Narrowing of the vaginal oriﬁce with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (inﬁbulation).

Type IV: All other harmful procedures to the female genitalia for non-medical purposes, for example pricking, piercing, incising, scraping and cauterisation.”[16]

Male circumcision has never needed to be medically divided into “types” to understand the extent of foreskin removal, let alone genital destruction, involved. All FGM types involve some type of female genital destruction with the risks being far higher than any falsely claimed benefits.

Male circumcision does not destroy sexual function or sensory satisfaction, but FGM does, in fact, impair girls and women in these ways. Therefore, the physical/medical comparison between male circumcision and FGM falls apart at every level.

In contrast to circumcision in males, medical authorities, like the National Health Service in Britain, have stated that women derive no medical benefit from the procedure. Instead, women and girls experience profound physical and psychological harm from FGM, regardless of how minor or extensive the procedure[17]. The nicking of the clitoral hood (Type IV FGM) is often equated with male circumcision by proponents of FGM, and both the proponents and opponents of male circumcision.

But even this procedure, which is only millimetres away from the clitoris, can easily cause scarring or injuries with unacceptably high complication rates.[18] This includes extensive bleeding, infection, permanent scarring, disfigurement, dyspareunia (pain associated with sexual intercourse), and the inability to experience orgasm. Survivors experience other long-term problems, including increased risk of childbirth complications, menstrual problems, and, most significantly, psychological trauma that can impact every aspect of their lives. Indeed, a study comparing Senegalese women who had experienced FGM found “the high rate of PTSD of more than 30% in this group [FGM survivors] is comparable to the rate of PTSD of early childhood abuse.”[19] Those who lobby to end FGM, such as ourselves, do so based on these horrific physical and mental traumas the practice inflicts on young girls and women.

Some supporters of FGM claim there are benefits to Type IV FGM, such as heightened sexual arousal[20] [21], but we can find no medical evidence that adult women require reduction procedures of their clitoral hoods to optimise their sexual experience. Such a claim is absurd and an insult to survivor’s humanity given the harm of the procedure.

Our Oath To Do No Harm

Physicians’ central professional ethics and teaching is to promote good (beneficence) and do no harm (nonmaleficence). Ethical analyses of any medical procedure are predicated and assessed by the actual intent and necessity of any procedure itself, and then framing the risks and harm within that initial construct. No doctor can become a vehicle for any ritual that is medically unsound, and whose intent is morally questionable.

Physicians are trained not to impose their moral standards upon patients; however, autonomous practitioners must find the reasoning to be ethically sound and, at a minimum, not abhorrent when asked to impose a procedure upon another human being by parents. It is unquestionable that physicians should not be complicit in this practice. FGM inflicts severe physical harm and psychological trauma and has no benefits for young girls and women. The analysis makes it clear that FGM is a form of gender violence. No religious reasoning, or otherwise, can justify its practice in the medical community.

Conclusion

The stated equivalency of male circumcision and FGM by some people is medically false and is a dangerous attempt to normalise obvious gender violence toward women. As Muslim physicians, we often hear advocates of FGM cite theological arguments, as well as the defence of religious freedom to push their agenda in the United States. Although not mandated by the Quran, some communities such as the Bohra Muslim sect in Islam firmly believe FGM is a religious obligation,[22] while others defend the procedure as a legitimate way to tame a woman’s ‘hypersexuality’.[23] The FGM procedure, therefore, can also facilitate a tribal culture of subjugation and inferiority for young girls. It is done ‘to’ them by a patriarchal family, tribe, and culture to keep their ‘inferior’ psyche in check lest they ever seek sexual, and in essence human, equality or autonomy. Thus, even the moral intent of the practice requires questioning.

Physicians must lead the way for reforms against all of the underpinnings of FGM. As doctors, we can advocate for education within our profession, such that medical practitioners know the physical and emotional signs survivors may exhibit; and, have the proper cultural sensitivity training to have honest and caring conversations with survivors and the community. As Muslim physicians, we can have a significant impact within the populations that practice FGM. When we speak to families about FGM we can educate them on the negative physical and emotional effects the procedure has on young girls and help them separate (what they view as) a theological mandate for purification from the procedure.

It is incumbent upon Muslim physicians, and community leaders of conscience from all backgrounds, to make clear the physical and emotional damage FGM causes young girls, and to call for an end of this horrific practice once and for all.

References:

[1] Female Genital Mutilation. WHO Fact Sheet. February 2017. (http://www.who.int/mediacentre/factsheets/fs241/en/ accessed 01 Oct. 2017)

[2] American Medical Association, Board of Trustees. Annual Meeting Minutes. 2017. Pages 43-46

[3] Jasser, M. Zuhdi. Female Genital Mutilation: American Muslim Physician Says Stop Defending the Abuse of Girls and Women. Gatestone Institute. June 26, 2017. (https://www.gatestoneinstitute.org/10585/female-genital-mutilation-american-muslim accessed 01 Oct 2017)

[4] Mayo Clinic Staff. Male Circumcision: Why it’s done. 15 February 2015. (https://www.mayoclinic.org/tests-procedures/circumcision/basics/why-its-done/prc-20013585 accessed 22 October 2017).

[5] Technical Report: Male Circumcision. Pediatrics. Vol. 130: No. 3, September 2012. (http://pediatrics.aappublications.org/content/pediatrics/130/3/e756.full.pdf accessed 1 Oct. 2017)

[6] Technical Report: Male Circumcision. Pediatrics. Vol. 130: No. 3, September 2012. (http://pediatrics.aappublications.org/content/pediatrics/130/3/e756.full.pdf accessed 1 Oct. 2017)

[7] Mayo Clinic Staff. Male Circumcision: Why it’s done. 15 February 2015. (https://www.mayoclinic.org/tests-procedures/circumcision/basics/why-its-done/prc-20013585 accessed 22 October 2017).

[8] Technical Report: Male Circumcision. Pediatrics. Vol. 130: No. 3, September 2012. (http://pediatrics.aappublications.org/content/pediatrics/130/3/e756.full.pdf accessed 1 Oct. 2017)

[9] Voluntary Male Circumcision for HIV Prevention. WHO Fact Sheet. July 2012. (http://www.who.int/hiv/topics/malecircumcision/fact_sheet/en/ accessed 01 Oct 2017).

[10] Neonatal Circumcision. American Academy of Family Physicians. 2013. (http://www.aafp.org/about/policies/all/neonatal-circumcision.html accessed 09 Nov 2017)

[11] Neonatal Circumcision. American Academy of Family Physicians. 2013. (http://www.aafp.org/about/policies/all/neonatal-circumcision.html accessed 09 Nov 2017)

[12] Technical Report: Male Circumcision. Pediatrics. Vol. 130: No. 3, September 2012. (http://pediatrics.aappublications.org/content/pediatrics/130/3/e756.full.pdf accessed 1 Oct. 2017)

[13] Voluntary Male Circumcision for HIV Prevention. WHO Fact Sheet. July 2012. (http://www.who.int/hiv/topics/malecircumcision/fact_sheet/en/ accessed 01 Oct 2017).

[14] HIV and Male Circumcision. CDC. 2011. (https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/hivcircumcision.html accessed 09 Nov 2017)

[15] Female Genital Mutilation. WHO Fact Sheet. February 2017. (http://www.who.int/mediacentre/factsheets/fs241/en/ accessed 01 Oct 2017)

[16] Eliminating Female Genital Mutilation. An Interagency Statement (OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCR, UNICEF, UNIFEM, WHO). 2008. http://apps.who.int/iris/bitstream/10665/43839/1/9789241596442_eng.pdf accessed 01 October 2017).

[17] Female Genital Mutilation: The Facts. June 16, 2016. (http://www.nhs.uk/Conditions/female-genital-mutilation/Pages/Introduction.aspx Accessed 01 Oct 2017).

[18] Female Genital Mutilation. WHO Fact Sheet. February 2017. (http://www.who.int/mediacentre/factsheets/fs241/en/ accessed 01 Oct 2017)

[19] Behrendt, A. et al. The American Journal of Psychiatry. 2005; 162: 1000-1002.

[20] Female Circumcision in Islam. Muslims in Calgary. 2017. (http://muslimsincalgary.ca/female-circumcision-in-islam/ accessed 09 Nov 2017)

[21] (http://torontosun.com/2017/09/05/female-genital-mutilation-defended-in-article-on-muslims-in-calgary-website/wcm/e9b82a54-21dc-43b8-b2a6-ad52bcc6fad7 accessed 13 Nov 2017)

[22] Johari, A. What can Bohras learn from a new report on the global status of female genital cutting? Sahiyo. October 2016. (https://sahiyo.com/2016/10/16/what-can-bohras-learn-from-a-new-report-on-the-global-status-of-female-genital-cutting/ accessed 13 Nov 2017)

[23] MEMRI “Virginia Imam Shaker Elsayed Endorses Female Circumcision (FGM): It Prevents Girls from Becoming Hypersexually Active”. Clip No. 6043. https://memri.org/tv/dar-al-hijrah-mosque-fairfax-virginia-fgm-prevents-hypersexuality/transcript (accessed 01 October 2017)