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September 4, 2002

A Woman's Rite to Health

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JAMA. 2002;288(9):1134. doi:10.1001/jama.288.9.1134-JMS0904-5-1

Physicians take an oath to do no harm. Traditionally defined as physical injury, "harm" has grown to include aspects of social and emotional well-being. For a patient requesting genital cutting, harm must be considered both in terms of her physical outcomes and cultural ideals.

Opponents of female genital mutilation (FGM) view the procedure as a form of violence against women1 and equate it with rape, domestic violence, child abuse, and female infanticide.2 While associated with many medical problems,3 FGM usually signifies passage into the social, familial, sexual, and reproductive roles of womanhood.4 Genital cutting has even symbolized a celebration of normalcy in places such as Sierra Leone, where civil unrest had once disrupted the practice. In 1997, approximately 600 women underwent FGM to commemorate the end of that country's civil war and as a show of the country's new found solidarity.5

Physicians must also consider the medical and social implications of FGM. Beauchamp and Walters6 argue that informed, autonomous, and competent adults have the right to hold views, make choices, and take actions based on their values and beliefs. Nonetheless, US Federal Law PL 104-20821 makes the practice of FGM on anyone younger than 18 years a crime.4 Furthermore, several organizations oppose the practice of FGM, citing numerous negative sequelae.5 However, the data on which such claims are based are largely confined to anecdotal case reports without comparison groups.7 One recent study found that different types of genital cutting are associated with different levels of risk for future gynecological or obstetric complications.8 Another found that commonly cited negative sequelae were not significantly more common in women who underwent type II FGM.9

One harm-reduction strategy is to medicalize FGM by having trained practitioners perform the procedure under sterile conditions. Opponents of medicalization argue that FGM is unacceptable even under sterile conditions because it would not prevent many of the long-term health consequences and that such medicalization would legitimize the procedure. Proponents of medicalization counter that FGM is already viewed as legitimate by those who believe in it and that not medicalizing it would endanger the health and lives of women.3

Denying FGM in this case will not necessarily protect the patient from harm, as she is likely to undergo the procedure in her homeland, with increased risk of infection and other complications. In returning home, the patient is choosing to abide by the norms of her culture. She may not view herself as a victim in need of protection and may actively wish to undergo the rite. Physicians must not pass judgment on the customs of their patients' cultural practices, especially when the alternative may cause harm by cultural alienation and social exclusion.

A physician cannot protect this patient from the negative consequences of undergoing FGM in her homeland. However, a physician may provide some protection by performing the surgery before she returns home. This may be a sound and compassionate approach to improving the patient's health, but should be done in conjunction with the traditional rituals associated with it. Providing FGM without regard to its meaning would defeat the patient's desire to undergo the surgery as a cultural rite.

Organizations that oppose the medicalization of FGM argue that only eradication of FGM can protect the patient's health. But legislative and institutional censure of the practice may actually be harmful if the practice is pushed underground. Rather than joining in the effort to ban FGM, physicians must educate their patients about its health risks and develop support structures in which their autonomy could be used to make healthful decisions.4 However, physicians should not be required to perform a procedure they personally consider to be wrong.

FGM can only be eradicated when the quality of life for women is raised by resolving other problems such as poverty, the effects of war, unemployment, discrimination, lack of education and health care, and women's poor legal status.10 Until then, physicians must educate their patients and work to minimize the physical, emotional, and social harms to which they are subjected.

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French  HW The ritual: disfiguring, hurtful, wildly festive. New York Times. January31 1997;A4
Beauchamp  TLWalters  L Contemporary Issues in Bioethics. 5th ed. Belmont, Calif Wadsworth Publishing Co1999;
Snow  RC Female genital cutting: distinguishing the rights from the health agenda. Trop Med Int Health. 2001;689- 91Article
Jones  HDiop  NAskew  IKabore  I Female genital cutting practices in Burkina Faso and Mali and their negative health outcomes. Stud Fam Plann. 1999;30219- 230Article
Morison  LScherf  CEkpo  G  et al.  The long-term reproductive health consequences of female genital cutting in rural Gambia: a community-based survey. Trop Med Int Health. 2001;6643- 653Article
Ahmed  IF Interview with Ellen Gruenbaum. The Female Circumcision Controversy: An Anthropological Perspective Philadelphia, Pa University of Pennsylvania Press2001;