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msJAMA
September 4, 2002

Female Genital Mutilation

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JAMA. 2002;288(9):1130. doi:10.1001/jama.288.9.1130-JMS0904-2-1

The problem of female genital mutilation (FGM) inspired nearly 100 medical students from 3 continents to submit their work for the 2002 John Conley Ethics Essay Contest for Medical Students. Essayists discussed ethical issues that would arise if an 18-year-old woman requested that a surgeon in the United States perform FGM on her before she returned home to Africa, where FGM is most commonly practiced. Also known as "female genital cutting" and "female circumcision," FGM includes 4 types according to a classification scheme delineated by the World Health Organization in 1995. The classification is based on increasingly extensive excisions of the genitalia from types I to type III, with types I and II comprising the majority of procedures. Variations of FGM that do not meet the criteria for the first 3 types are classified as type IV.

The young woman in the scenario requested that the surgeon perform type III, or infibulation, which is the most surgically extensive form of FGM. Type III includes an excision of part or all of the external genitalia and stitching of the vaginal opening, and has been associated with the most serious health complications.

Ninety-five percent of FGM is performed on girls between one day to 16 years old, particularly between the ages of 4 and 10 years. However, some cultures perform FGM into adulthood, such as at the time of marriage. Thus, the patient in this scenario requested to have the procedure performed at a relatively old age.

According to the scenario, the woman wanted the surgery before returning to her homeland in order to decrease her risk of complications that may occur as a result of having it done under unsterile and relatively primitive conditions. The literature on the health risks associated with FGM has mostly focused on gynecologic problems such as hemorrhage, infection, and dysmenorrhea. Other health-related parameters such as overall mortality and morbidity have yet to be documented thoroughly, and the data on which advocates have argued against FGM have been criticized for not meeting rigorous scientific standards of evidence. Nevertheless, national and international health and government organizations have taken strong stands against the practice, arguing that the currently available data sufficiently document the dangers of FGM.

The winning essays in this year's contest explore ethical, moral, and professional dilemmas raised by considering whether or not to perform FGM. Peter Moschovis argues that FGM is wrong because it violates universal moral values and harms the patient-physician relationship overall. Also arguing against FGM, Kyle Brothers challenges physicians to consider relating to their patients as covenant partners whose voices deserve to be heard. Natalie Moniaga makes the case that a physician opposed to FGM can still perform the procedure without contradicting his or her values. And finally Sara Cichowski relates a fictional dialogue between a young woman requesting FGM and the surgeon whom she asks to perform the procedure. Cichowski based the dialogue on an actual encounter she had with a young woman who requested a similar procedure.

We thank this year's judges—Jeffrey Botkin, MD, MPH, Sally Sheldon, PhD, and Sidney Wolfe, MD.

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