Medicalization of female genital cutting in Malaysia: A mixed methods study.

BACKGROUND: Despite the clear stand taken by the United Nations (UN) and other international bodies in ensuring that female genital cutting (FGC) is not performed by health professionals, the rate of medicalization has not reduced. The current study aimed to determine the extent of medicalization of FGC among doctors in Malaysia, who the doctors were who practiced it, how and what was practiced, and the motivations for the practice. METHODS AND FINDINGS: This mixed method (qualitative and quantitative) study was conducted from 2018 to 2019 using a self-administered questionnaire among Muslim medical doctors from 2 main medical associations with a large number of Muslim members from all over Malaysia who attended their annual conference. For those doctors who did not attend the conference, the questionnaire was posted to them. Association A had 510 members, 64 male Muslim doctors and 333 female Muslim doctors. Association B only had Muslim doctors; 3,088 were female, and 1,323 were male. In total, 894 questionnaires were distributed either by hand or by post, and 366 completed questionnaires were received back. For the qualitative part of the study, a snowball sampling method was used, and 24 in-depth interviews were conducted using a semi-structured questionnaire, until data reached saturation. Quantitative data were analysed using SPSS version 18 (IBM, Armonk, NY). A chi-squared test and binary logistic regression were performed. The qualitative data were transcribed manually, organized, coded, and recoded using NVivo version 12. The clustered codes were elicited as common themes. Most of the respondents were women, had medical degrees from Malaysia, and had a postgraduate degree in Family Medicine. The median age was 42. Most were working with the Ministry of Health (MoH) Malaysia, and in a clinic located in an urban location. The prevalence of Muslim doctors practising FGC was 20.5% (95% CI 16.6-24.9). The main reason cited for practising FGC was religious obligation. Qualitative findings too showed that religion was a strong motivating factor for the practice and its continuation, besides culture and harm reduction. Although most Muslim doctors performed type IV FGC, there were a substantial number performing type I. Respondents who were women (adjusted odds ratio [aOR] 4.4, 95% CI 1.9-10.0. P ≤ 0.001), who owned a clinic (aOR 30.7, 95% CI 12.0-78.4. P ≤ 0.001) or jointly owned a clinic (aOR 7.61, 95% CI 3.2-18.1. P ≤ 0.001), who thought that FGC was legal in Malaysia (aOR 2.09, 95% CI 1.02-4.3. P = 0.04), and who were encouraged in religion (aOR 2.25, 95% CI 3.2-18.1. P = 0.036) and thought that FGC should continue (aOR 3.54, 95% CI 1.25-10.04. P = 0.017) were more likely to practice FGC. The main limitations of the study were the small sample size and low response rate. CONCLUSIONS: In this study, we found that many of the Muslim doctors were unaware of the legal and international stand against FGC, and many wanted the practice to continue. It is a concern that type IV FGC carried out by traditional midwives may be supplanted and exacerbated by type I FGC performed by doctors, calling for strong and urgent action by the Malaysian medical authorities.

Changing prevalence and factors associated with female genital mutilation in Ethiopia: Data from the 2000, 2005 and 2016 national demographic health surveys.

SETTING: Female genital mutilation (FGM) is a traditional surgical modification of the female genitalia comprising all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for cultural or nontherapeutic reasons. It can be harmful and violates girls' and women's human rights. FGM is a worldwide problem but mainly practiced in Africa. FGM is still widely practiced in Ethiopia despite being made a criminal offence in 2004. OBJECTIVE: Using data from three Ethiopian Demographic Health Surveys (EDHS) conducted in 2000, 2005 and 2016 the objective was to assess changes in prevalence of FGM and associated factors among women of reproductive age and their daughters. METHODS: EDHS datasets for the three surveys included data on FGM prevalence and socio-demographic factors. After weighting, the data were analysed using frequencies, proportions and the chi square test for trend. Categorical variables associated with FGM in 2016 were compared using OpenEpi and presented as prevalence ratios (Pr) with 95% Confidence Intervals (CI). Levels of significance were set at 5% (P<0.05). RESULTS: There was overall decline in FGM prevalence (from 79.9% to 74.3% to 65.2%, P<0.001), especially in younger women aged 15-19 years, and in the proportion of women who believed that the practice should continue (from 59.7% to 28.3% to 17.5%, P<0.001). There was also a decreasing trend of FGM in the daughters of the mothers who were interviewed, with prevalence significantly lower in mothers who had not themselves undergone FGM. Most (88.3%) women with FGM had the surgery as a child with the procedure mainly performed by a traditional circumciser (87.3%). Factors associated with higher FGM prevalence and lack of progress over the sixteen years included living in certain regions, especially Somali where FGM prevalence remained consistently >95%, lack of school education, coming from rural areas and living in less wealthy households. CONCLUSION: Although progress has been slow, the prevalence of FGM in Ethiopia has declined over time. Recommendations to quicken the trajectory of decline targeting integrated interventions to high prevalence areas focusing on mothers, fathers, youngsters, religious leaders and schools and ensuring that all girls receive some form of education.

Community gender systems and a daughter's risk of female genital mutilation/cutting: Multilevel findings from Egypt.

We tested a feminist social-ecological model to understand community influences on daughters' experience of female genital mutilation/cutting (FGMC) in Egypt, where over 90% of women ages 15-49 are cut. FGMC has potential adverse effects on demographic and health outcomes and has been defined as a human-rights violation. However, an integrated multilevel-level framework is lacking. We theorized that a more favorable community-level gender system, including stronger gender norms opposing FGMC and expanded extra-familial opportunities for women in the village or neighborhood, would be associated with a daughter's lower risk of FGMC and would strengthen the negative association of a mother's opposition to FGMC with her daughter's risk of cutting. Using a national sample of 14,171 mother-daughter dyads from the 2014 Egypt Demographic and Health Survey, we estimated multilevel discrete-time hazard models to test these relationships. Community gender norms opposing FGMC had significant direct, negative associations with the hazard that a daughter was cut, but women's opportunities outside the family did not. Maternal opposition to FGMC was negatively associated with cutting a daughter, and these associations were stronger where community opposition to FGMC and opportunities for women were greater. Results provided good support for a gender-systems framework of the multilevel influences on FGMC. Integrated, multilevel interventions that address gender norms about FGMC and structural opportunities for women in the community, as well as beliefs about the practice among the mothers of at-risk daughters, may be needed for sustainable declines in the practice.

The Problem of Female Genital Cutting: Bridging Secular and Islamic Bioethical Perspectives.

Recent events, including the arrest of physicians in Michigan, have renewed bioethical debates surrounding the practice of female genital cutting (FGC). The secular discourse remains divided between zero-tolerance activists and harm-reduction strategists, while Islamic bioethical debates on FGC similarly comprise two camps. "Traditionalists" find normative grounds for a minor genital procedure in statements from the Prophet Muhammad and in classical law manuals. "Reformers" seek to decouple FGC from Islam by reexamining its ethico-legal status in light of the deficiencies within narrations ascribed to the Prophet, the health risks posed by FGC, and contemporary perspectives on human rights, and thereby delegitimize the practice. This paper argues that alignment between secular and Islamic views can be found in a harm-reduction strategy by demonstrating that the impetus to reduce harms is found within Prophetic statements on FGC. From an Islamic ethico-legal standpoint, it is justified to acknowledge the permitted status of FGC procedures that do not harm-in other words, the ritual nick-and at the same time the prohibited status of procedures that lead to credible medical and psychological harms. Bringing these multiple perspectives and data points into conversation forges a common ground to delegitimize and eradicate harmful genital procedures among Muslim communities.

Female genital cutting in Malaysia: a mixed-methods study.

OBJECTIVE: This study aimed to understand the reasons for the practice by the Muslim community, traditional practitioners and the views of religious scholars as well as the medicalisation trend of the practice of female genital cutting (FGC). DESIGN: This is a mixed-method (qualitative and quantitative) study. A questionnaire was created and used by three trained research assistants for the quantitative component of the study. The qualitative component of the study included in-depth interviews and focus group interviews. SETTING: This study was conducted in rural areas of two states in the Northern Peninsular Malaysia. PARTICIPANTS: Due to the sensitive nature of the study, the study sample was chosen using a snowball sampling method. Two of the three Northern states Mufti's approached consented to participate in the study. RESULTS: Quantitative: There were 605 participants, most had undergone FGC (99.3%), were in the opinion FGC is compulsory in Islam (87.6%) and wanted FGC to continue (99.3%). Older respondents had FGC conducted by traditional midwives (X2=59.13, p<0.001) and younger age groups preferred medical doctors (X2=32.96, p<0.001) and would permit doctors (X2=29.17, p<0.001) to conduct FGC on their children. These findings suggest a medicalisation trend. Regression analysis showed the odds of FGC conducted by traditional midwives and nurses and trained midwives compared with medical doctors was 1.07 (1.05; 1.09) and 1.04 (1.01; 1.06), respectively. For every 1-year decrease in age, the odds of participants deciding medical doctors should perform FGC as compared with traditional midwives increase by 1.61.Qualitative: Focus group discussions showed most believed that FGC is compulsory in Islam but most traditional practitioners and the Mufti's stated that FGC is not compulsory in Islam. CONCLUSION: Almost everyone in the community believed FGC is compulsory in Islam and wanted the practice to continue, whereas the traditional practitioners and more importantly the Mufti's, who are responsible in issuing religious edicts, say it is not a religious requirement.

Female genital mutilation/cutting in Africa: A complex legal and ethical landscape.

While international and regional human rights instruments have recognized female genital mutilation/cutting (FGM/C) as one of the most prevalent forms of violence against women and girls, in many African states FGM/C is a deeply entrenched cultural practice. There is a consensus against FGM, as evidenced by its criminalization in several African countries. The mere fact that the practice continues despite legislative measures to protect women and girls against FGM raises the question of whether change can be legislated. The present article summarizes the trends and effectiveness of FGM criminalization in Africa, including prohibition of medicalization of FGM. Against the backdrop of emerging debate on medicalization of FGM as a harm reduction strategy, we also examine its complex legal and ethical implications. The article argues that while criminalization may not be the best means of stopping FGM, it creates an enabling environment to facilitate the overall strategy of African governments in eradication of the practice.

The lived experience of female genital cutting (FGC) in Somali-Canadian women's daily lives.

Many of the Somali women who have immigrated to other countries, including Canada, have experienced Female Genital Circumcision/ Mutilation/ Cutting (FGC). While there is literature on the medical aspects of FGC, we were interested in understanding the daily life experiences and bodily sensations of Somali-Canadian women in the context of FGC. Fourteen women living in the Greater Toronto Area were interviewed. Interview data were analyzed using a phenomenological approach. We found that the memory of the ceremonial cutting was vivid but was frequently described with acceptance and resignation-as something that just is; that was normal given the particular context, familial and cultural, and their young age. Most of the women recounted experiencing pain and discomfort throughout their adult lives but were intent on not noticing or giving the pain any power; they considered themselves healthy. The following themes emerged from our interviews: Every Body Had It: Discussing FGC, I'm Normal Aren't I?, and Feeling in My Body-all themes that work at normalizing their bodies in a society that they know views them as different. They dealt with both pain and pleasure in the context of their busy lives suggesting resilience in spite of the day-to-day difficulties of daily life.

On Female Genital Cutting: Factors to be Considered When Confronted With a Request to Re-infibulate.

According to the World Health Organization, female genital cutting affects millions of girls and women worldwide, particularly on the African continent and in the Middle East. This paper presents a plausible, albeit hypothetical, clinical vignette and then explores the legal landscape as well as the ethical landscape physicians should use to evaluate the adult patient who requests re-infibulation. The principles of non-maleficence, beneficence, justice, and autonomy are considered for guidance, and physician conscientious objection to this procedure is discussed as well. Analyses of law and predominant principles of bioethics fail to yield a clear answer regarding performing female genital cutting or re-infibulation on an adult in the United States. Physicians should consider the patient's physical, mental, and social health when thinking about female genital cutting and should understand the deep-rooted cultural significance of the practice.

The role of older women in contesting norms associated with female genital mutilation/cutting in Senegambia: A factorial focus group analysis.

Social norms theory has become prominent framework for understanding the perpetuation of female genital mutilation/cutting (FGM/C), and has influenced the design of interventions aimed at stopping the practice. Theoretical advances draw attention to the fact that FGM/C is often upheld by multiple interconnected norms that may vary and shift over time, offering a potential resource for social transformation. Analyzing focus group data from Senegambian women, the questions we explore are: What are the constellation of norms associated with FGM/C? When are existing practices and norms being contested, and how does this reflect prevailing structures of power and authority? Our research identifies four overarching themes: 1) pressure to conform with FGM/C arising from sanctions such as ostracization, and moral norms linked to the embodiment of virtue; 2) upholding tradition as a means of venerating ancestors; 3) upholding social hierarchy by displaying respect for elders; and 4) shifting beliefs about the healthful vs. harmful nature of FGM/C. While strong value is placed on upholding tradition, there is also an appreciation that elements of tradition must be revised to meet fluctuating realities, including the novel threat of HIV infection. Moreover, older women are uniquely positioned to realize the dual goal of honoring tradition while negotiating change. Rather than resisting change, we find that some older women express an openness to reassessing norms and practices as they seek solutions to maintaining the physical well-being, moral integrity and cultural identity of girls in their families. Moreover, given the authority of older women over younger women, they also have power to negotiate change. By recognizing older women as potential change leaders, and drawing on variability and fluidity in social norms, it may be increasingly possible to design interventions that will shape possibilities for action and accelerate abandonment of FGM/C without undermining the cultural value of tradition.

A survey of honor-related practices among US obstetricians and gynecologists.

OBJECTIVE: To assess patterns of honor-related practices-including virginity testing, virginity restoration, and female genital mutilation (FGM)-among US obstetrician-gynecologists (OBGYNs). METHODS: Between June 1 and August 31, 2016, 1000 members of the American College of Obstetricians and Gynecologists were invited by email to complete an anonymous online survey. The survey comprised 42 questions evaluating the demographic and practice characteristics of the respondents. RESULTS: Overall, 288 of the 909 practicing US OBGYNs with functioning email addresses completed the survey (31.7% response rate). In the 12 months before the survey, 168 (58.3%) respondents had provided care to one or more patients who had previously undergone FGM. Care was also provided for patients who requested virginity testing or virginity restoration by 29 (10.1%) and 16 (5.6%) respondents, respectively. Ten (3.5%) respondents performed virginity testing on request, whereas 3 (1.0%) performed virginity restoration. CONCLUSION: Some respondents performed honor-related practices, which indicated a need to educate all practicing US OBGYNs about their ethical and legal obligations in the care of such patients.

Factors associated with the support of pricking (female genital cutting type IV) among Somali immigrants - a cross-sectional study in Sweden.

BACKGROUND: Pricking, classified as female genital cutting (FGC) type IV by the World Health Organization, is an under-researched area gaining momentum among diaspora communities. Our aim was to explore factors associated with being supportive of pricking among Somalis in Sweden. METHODS: In a cross-sectional design, attitudes and knowledge regarding FGC, and measures of socioeconomic status, acculturation, and social capital, were assessed by a 49-item questionnaire in four municipalities in Sweden. Data were collected in 2015 from 648 Somali men and women, ≥ 18 years old, of which 113 supported the continuation of pricking. Logistic regression was used for the analysis. RESULTS: Those more likely to support the continuation of pricking were older, originally from rural areas, and newly arrived in Sweden. Further, those who reported that they thought pricking was: acceptable, according to their religion (aOR: 10.59, 95% CI: 5.44-20.62); not a violation of children's rights (aOR: 2.86, 95% CI: 1.46-5.61); and did not cause long-term health complications (aOR: 5.52, 95% CI: 2.25-13.52) had higher odds of supporting pricking. Religion was strongly associated with the support of pricking among both genders. However, for men, children's rights and the definition of pricking as FGC or not were important aspects in how they viewed pricking, while, for women, health complications and respectability were important. CONCLUSIONS: Values known to be associated with FGC in general are also related to pricking. Hence, there seems to be a change in what types of FGC are supported rather than in their perceived values.

Gender equality and human rights approaches to female genital mutilation: a review of international human rights norms and standards.

Two hundred million girls and women in the world are estimated to have undergone female genital mutilation (FGM), and another 15 million girls are at risk of experiencing it by 2020 in high prevalence countries (UNICEF, 2016. Female genital mutilation/cutting: a global concern. 2016). Despite decades of concerted efforts to eradicate or abandon the practice, and the increased need for clear guidance on the treatment and care of women who have undergone FGM, present efforts have not yet been able to effectively curb the number of women and girls subjected to this practice (UNICEF. Female genital mutilation/cutting: a statistical overview and exploration of the dynamics of change. 2013), nor are they sufficient to respond to health needs of millions of women and girls living with FGM. International efforts to address FGM have thus far focused primarily on preventing the practice, with less attention to treating associated health complications, caring for survivors, and engaging health care providers as key stakeholders. Recognizing this imperative, WHO developed guidelines on management of health complications of FGM. In this paper, based on foundational research for the development of WHO's guidelines, we situate the practice of FGM as a rights violation in the context of international and national policy and efforts, and explore the role of health providers in upholding health-related human rights of women at girls who are survivors, or who are at risk. Findings are based on a literature review of relevant international human rights treaties and UN Treaty Monitoring Bodies.

Punishment of Minor Female Genital Ritual Procedures: Is the Perfect the Enemy of the Good?

Female genital alteration (FGA) is any cutting, removal or destruction of any part of the external female genitalia. Various FGA practices are common throughout the world. While most frequent in Africa and Asia, transglobal migration has brought ritual FGA to Western nations. All forms of FGA are generally considered undesirable for medical and ethical reasons when performed on minors. One ritual FGA procedure is the vulvar nick (VN). This is a small laceration to the vulva that does not cause morphological changes. Besides being performed as a primary ritual procedure it has been proposed as a substitute for more extensive forms of FGA. Measures advocated or taken to reduce the burden of FGA can be punitive or non-punitive. Even if it is unethical to perform VN, we argue that it also is unethical to attempt to suppress it through punishment. First, punishment of VN is likely to cause more harm than good overall, even to those ostensibly being protected. Second, punishment is likely to exceed legitimate retributive ends. We do not argue in favor of performing VN. Rather, we argue that non-punitive strategies such as education and harm reduction should be employed.

Socioeconomic and Reproductive Health Outcomes of Female Genital Mutilation.

BACKGROUND: Female genital mutilation (FGM) is one of the important aspects of reproductive health. The economic, social and health consequences of FGM threaten the achievement of sustainable development goals. The purpose of this study was to assess the economic, social and reproductive health consequences of FGM from the perspective of individual, family, community and health system. METHODS: In this study, we reviewed 1536 articles from 1979 to 2015. Fifty-one studies were directly related to our goal. Research papers, review articles, case studies and books on the research topic were used. RESULTS: The results of this review showed that most studies on FGM, have investigated health complications of FGM, and few studies have addressed its socioeconomic aspects. The complications from the FGM can impose a significant economic burden on individuals, society and health system. Social consequences of FGM are more irritating than health consequences, so to tackle this practice; its social aspects should be more emphasized. Significant short and long term consequences of FGM threaten women's reproductive health; Reproductive health is one of the essential prerequisites of sustainable development. Sustainable development will be achieved if women are healthy. This practice can threaten achieving sustainable development. In Iran, FGM is performed in some areas, but there are no official statistics about it and there has yet been no plan to deal with FGM. CONCLUSION: FGM is a form of social injustice which women suffer. Ending FGM requires a deep and long-term commitment. Knowing its consequences and its effects on individual, families, the health system and community will help supporters to continue fighting this practice. Any money spent on eliminating this harmful practice, compared with the costs of complications, would not be wasteful.  It seems that further studies are needed to assess socioeconomic effects of FGM and the relationship between type of FGM and induced complications. Such studies will help policymakers to tackle this practice.