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September 4, 2002

When Cultures Are Wrong

Author Affiliations

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JAMA. 2002;288(9):1131-1132. doi:10.1001/jama.288.9.1131-JMS0904-3-1

She cut everything—she didn't cut the big lips, but she sliced off my clitoris and the two black little lips, which were haram—impure—all that she sliced off like meat. Oh, Rahima, I thought I was going to die. . . . She sliced the top off my big lips and then she took thorns like needles and put them in crossways, across my vagina, to close it up.1

These are the words of Aman, a Somali woman, recounting her childhood experience of circumcision. In her 1994 autobiography, she weaves a story of growing up at the interface between her native Somali culture and Western colonialism. The dilemma of circumcision is a microcosm of the clash of cultures in Aman's life. Like many women from tradition-centered cultures, Aman is torn between a profound sense of cultural loyalty and a commitment to a life of freedom and empowerment. The meaning that she derives from her culture is central to her self-image as a woman, but the experience is profoundly traumatic. The tension that arises from Aman's experiences can be extended to the broader question of the ethics of female genital mutilation (FGM).

Estimates confirm that Aman's experiences are common. In 1998 the World Health Organization estimated that more than 135 million girls and women had undergone some form of FGM, and 2 million girls are at risk each year.2 The practice is most widespread in Africa; in some countries as many as 97% of all women have been circumcised. In addition, FGM has become increasingly common in immigrant and refugee populations in Western Europe and North America.2 A landmark 1997 joint statement of the World Health Organization, UNICEF, and the UN Population Fund defined four types of genital mutilation.3 Based on this classification, Aman and the African woman in this case underwent type III FGM, which is the most radical form of genital cutting. The associated physical complications range from minor to severe for all types of FGM.4 Common postoperative complications include urinary and reproductive tract infections, dysmenorrhea, and hemorrhagic shock. Longer term complications of type III FGM include failure to heal, urinary retention or incontinence, dermoid cysts, urinary and reproductive tract infections, and dysmenorrhea.2 Several cases have been documented of girls bleeding to death after physicians performed the procedure,5 casting doubt on the assertion that the sequelae are less severe if a physician performs FGM instead of a midwife. The most frequent complication of FGM is the diminishing of the woman's sexual pleasure and libido.6 Infibulated women often require the scar to be cut open on their wedding night, especially if their husbands are unable to penetrate the small opening that remains. Some women ask to be reinfibulated after each childbirth, having the separated edges sewn back together.7

FGM is not practiced in a cultural vacuum. Virtually every culture that embraces FGM carries it out in the context of an elaborate ceremony, which for many is a mark of initiation into womanhood. An uncircumcised woman may be viewed by peers and potential spouses as less of a woman, unclean, and disloyal to her culture. As a result, women and midwife practitioners are often among the strongest proponents of the practice.8

In many cases, the ritual is associated with a woman's religious identity. One popular mythological justification for the circumcision of both men and women is the belief that the male prepuce and female clitoris represent feminine and masculine elements, respectively, and must be excised to prevent gender confusion.9 "The clitoris of the girl is in fact a symbolic twin, a male makeshift with which she cannot reproduce herself, and which, on the contrary, will prevent her from mating with a man," explains Ogotemmêli, an elder of the Sudanese Dogon people.10 Since FGM may diminish libido, many see the procedure as a means of preventing promiscuity. Another Dogon leader contends that "The uncircumcised think of nothing but disorder and nuisance."10

These accounts illustrate the profound meaning that FGM can carry for those who undergo it. They cannot, however, answer the question of whether a physician has the right to pass moral judgment on his or her patient's choices, especially when they are informed by deeply held cultural values.11

The principle of autonomy mandates that physicians respect their patients' right of self-determination: their care must parallel patients' values, interests, and desires. Because these factors are to a large extent culturally constructed, physicians are obligated to respect cultural differences and, when possible, to honor and even to learn from them. The extreme of this perspective—cultural relativism—holds that all cultures and their practices are equally valid, and that it is improper to pass judgment on another culture.5

Respect for this patient's autonomy and culture, however, does not preclude condemning the practice of genital mutilation. Even within societies that practice FGM, a plurality of views exists. Deconstructionists have argued that no culture is completely uniform, noting that policymakers often consider the voices of the powerful few while ignoring the voices of the oppressed.12 A recent study in central Sudan indicates a growing disenchantment with the practice among younger mothers, a moral flux that is important in informing discussion of FGM.13

Even a cultural relativist can use the internal standards of a culture to point out the questionable character of a tradition. For example, Islam does not condone FGM, and the practice antedates the arrival of Islam to African countries.14 Reference to cultural values that the woman already accepts allows the physician to develop an "argument from within" against the practice.

By making use of the principles that inform a patient's world view, a physician can often persuade the patient to adopt an alternate course of action.15 Furthermore, strong international precedents exist in making judgments about the ways other cultures have treated women. Examples include the Western opposition of sex slavery in Eastern Europe, the mass rapes of Bosnian women in the last decade, and prenatal sex selection and female infanticide in China. Western influences also played an important role in the eradication of Chinese foot binding.16 A rejection of cultural relativism, however, is insufficient justification for refusing to treat the patient.

The necessary added ethical force comes from the fundamental moral mandates of medicine: doing good and avoiding harm. Ethical debates about privacy rights, autonomy, and health care allocation are far from settled. However, doing good and avoiding harm form the foundation of the practice of medicine. While the specifics of beneficence and nonmaleficence certainly vary by culture and clinical context, these two principles give physicians the right—and indeed, the obligation—to withhold treatment that they consider harmful to patients.

The physician must sensitively and respectfully engage the patient in a discussion of values, eliciting contributing facts that elucidate the values underlying the available options. In this way, the physician can both honor the patient's culture while gently presenting his or her own moral perspective. Ultimately, the only direct control that physicians can exert is over whether they will personally perform the procedure. They cannot dictate their patients' actions. As Aman says, "If Somali women change, it will be a change done by us, among us. . . . To advise is good, but not to order."1

Carrying out this sort of dialogue does not diminish the difficulty of the dilemma. On the contrary, the stakes remain high, since refusing to perform the procedure may result in future harm to the patient if she develops complications by having the procedure performed in her homeland. But this potential harm must be viewed in the context of the patient-physician relationship, since performing the procedure will not only affect the individual patient's health, but alter the patient-physician dynamic overall.

Performing FGM sets a dangerous precedent in the professional relationship and may obligate the physician to provide future interventions that he or she considers improper, frivolous, or harmful.17 Physicians ultimately gain credibility by refusing to provide services that they deem unnecessary and detrimental, such as prescribing antibiotics for viral infections, even if their patients demand them. In addition, physicians who perform FGM, even while attempting to persuade patients otherwise, implicitly sanction the practice. While cultural relativists argue that a detached, nonjudgmental stance allows physicians to shift the ethical burden onto their patients, experience shows that this moral distance is artificial and impossible to maintain.18 The patient-physician relationship is based on a patient's trust that the physician is committed to the patient's best interest. When the physician compromises this commitment explicitly by providing medically unnecessary procedures, or implicitly by offering such services, the relationship suffers.

The central ethical tool for difficult decisions is the dialogue itself, for it acknowledges the need of both individuals to learn from one another. Physicians must listen to their patients and attempt to enter into their patients' framework of values as much as possible. In this context of shared moral reasoning, they can learn from the insights of their patients while contributing their own perspectives. By combining humility, respect, and commitment to the patient's good, a physician can remain true to the principles of multiculturalism and justice while maintaining an ethically sound position.

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