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Female Genital Mutilation and Ethical Issues
Female Genital Mutilation and Ethical Issues
Dya Eldin M. Elsayed1, Rabaa M. Elamin2, Suad M. Sulaiman3
1) Associate Professor, Faculty of Medicine, Alzaiem Alazhari University, Sudan
2) Omdurman Teaching hospital,
3) Alnil College, Omdurman, Sudan
Correspondence:
Dya Eldin M. Elsayed, E-mail: delsayed2@gmail.com mobile : +249 918 113 930
Abstract
Female Genital Mutilation/Cutting (FGM) is practiced in so many countries in Africa and Asia. FGM is a
deeply rooted social and cultural requirement for girls before marriage. Supporters of the practice rely on
religion and tradition to defend their belief. Nowadays it is considered as an important problem, from both
public health and ethical aspects in the countries where it still exists. It violates the essential principles
of medical ethics and human rights. The main ethical drawback of FGM is that; it is a senseless practice
which provides no direct benefit to girls on whom it is performed. It also inflicts undue harm on the little
girls (who are the primary victims). It is performed without consent. So the essential principles of medial
ethics are violated. Undefined medical indications for FGM and possible risks to females make it ethically
unacceptable. Key words: Female Genital Mutilation Ethics.
Introduction
The term Female Genital Mutilation and Cutting
(FGM/C) (female circumcision) applies to any
procedure involving the removal of all or part of
the vulva and/or clitoris. It exists and is practiced
in some parts of Asia and in so many countries
in North and Sub-Saharan Africa including the
Sudan. The most frequent type of FGM that occurs
throughout Africa involves the removal of the entire
clitoris, usually with the labia minora, and in some
instances, the labia majora(1).
The justification for FGM appears to be grounded
in the social desire in terminating or reducing
feelings of sexual arousal in women so that they
will be much less likely to engage in pre-marital
sexual relationship or adultery. Nevertheless, it is
now considered a major social and health problem
in the countries where it is practiced. It has also
become of public health concern in North America
and West Europe due to emigration from countries
where it is still practiced. It is not surprising to
notice that FGM seen in some emigrants was not
performed in their home country. Evidence shows
that the practice was introduced to new countries(2).
It has, arguably, gained most attention among the
governments, religious leaders, health professionals,
individuals, families and community in Sudan as
well as worldwide. The dangers of FGM/C have been
recognized by scientific as well as nonscientific
social societies. Anti- FGM/C movements started
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in the Sudan with the rise of awareness about the
hazards and evil consequences of FGM. Also the
rising civil movements for women’s rights pushed
the topic to the forefront. These movements include
physicians and other health workers, scientists and
social activists, males and females. Anti- FGM/C
movements played, and still play, a crucial role to
draw off this social habit. They have succeeded to
draw the attention of international organizations
such as United Nations (UN) and the World Health
Organization (WHO) to the health consequences of
FGM. The latter had organized the first international
seminar on this issue in Khartoum in 1979(3).
The WHO, UN International Children’s Fund
(UNICEF), and the UN Population Fund (UNFPA)
stated that FGM causes unacceptable harm and
have called for its complete elimination. In 1984,
the African Women’s Organization met in Dakar,
Senegal, to discuss the health consequences of
female circumcision. The group formed the Inter
African Committee against Harmful Traditional
Practices (IAC) with national committees in more
than 20 African countries in that meeting. IAC was
able to bring the harmful consequences of female
circumcision to the attention of most African
Governments(4).
Anti- FGM/C movements focus, among many
other arguments, on lack of religious evidence
supporting FGM. The main accusation against FGM
is the enormous health hazards, both physical and
psychological on girls (the primary victims), is
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Female Genital Mutilation and Ethical Issues
the main accusation against it. Numerous studies
and case reports have been published on health
complications of FGM(5). Yet, several efforts are
still needed to eradicate the phenomenon. The
FGM supporters (campaign) are not silent. They
rigorously fight against anti- FGM/C movements
and disgracefully describe any achievements to
prohibit the process as unrealistic. They consider
it as an essential part of their cultural, ethnic and
religious identity and even religious legislations. So
we think it is very essential for anti- FGM movements
to understand these issues if they ever want to
eradicate it.
This article is somewhat different from what other
authors wrote about this problem. The authors
will discuss the ethics of the FGM/C and tackle this
side of the problem bearing in mind three different
limitations. Firstly, we would not be able to touch
the religious laws or codes because this debate
has not been settled yet. Secondly, we do not want
to talk about the health effects and the problems
FGM/C may cause. Highlighting health risks, albeit
very important, presents credibility problems,
because many women do not suffer from them or
are not aware of them. Thirdly, to our knowledge
not one article available in the published literature
in the Sudan has tackled the problem from an
ethical point of view. This fact gives us enthusiasm
to open up new areas in support against FGM/C. In
this article we will discuss the FGM/C in respect to
medical ethics.
FGM in SMC laws and regulations
Observers may notice that the Sudanese law has
fallen following the lead of the first progress. After
considering infibulations as a crime punishable by
law in 1946 and despite the lack of application, the
prohibition law was amended in 1974 to include
all types of circumcision, except the Sunnah. But an
amendment to the Criminal Code in 1983 dropped
the whole subject of female circumcision. The issue
has also been ignored in the last amendment which
was done in 1991. In May 2005 the Islamic Figh
Academy of the Presidency of the Republic issued a
fatwa saying that “Sunnah circumcision is a duty for
all Muslims, and there is even a payment to do it”.
In February 2009 the Sudanese Council of Ministers
approved the draft of the “2009-Child Act” in which
article 13 on the protection of children from female
circumcision was dropped.
By support from the WHO and the United Nation
Commission on Human Rights, FGM is prohibited
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by the law in several African, Asian and European
countries(6).
Medical practice in our country is one of the few
professions that have legal power supported by law.
The Medico-Legal and Ethical Guidelines adopted
by the Sudan Medical Council (SMC) in 1969 are
considered the guide for physicians and dentists
in their daily work. The main purpose of the
document was to ensure the provision of medical
care in adherence to the highest possible ethical
standards(7). It is not surprising that there is no clear
specific clause in the SMC regulations about FGM.
We could refer this limitation in this important
document to the fact that it was adopted in 1969.
At that time FGM was untouchable taboo, even
among Sudanese intellectuals. But now we believe
that approximately all physicians in our country
refuse to do FGM. They just follow universal ethical
rules. They leap forward while the regulations are
still lagging behind. However, many other medical
workers adhere to conventional social norms and
violate ethical “professional” rules. Unfortunately
they do not consider performing FGM an unethical
issue because, most probably, they rely on SMC laws
and regulations which have not mentioned FGM
at all. Silence of SMC about this problem however
gives some professionals insinuation to do it. It
doesn’t justify FGM anyway. Since the establishment
of SMC medico-legal and ethical guidelines in
1969, they were only reviewed and modified once
which was done in 1979(8). We think many newly
emerged health problems including FGM deserve
to be discussed and included in the SMC laws and
regulations.
Lisbon Declaration 1988 states that: “a physician
should always act according to his/her conscience,
and always in the best interests of the patient”(9).
The patient’s welfare shall be the doctor’s first
consideration. In the case of FGM, medical
professionals generally tend to ignore this rule,
while parents (families) falsely believe they are
following it and request them to do it for their
children. Neither attitude is ethically accepted
because both are not in the best interest of the
little girls. Medical professionals have a duty to
provide only medically indicated and appropriate
services; not those requested by others(10). Here, the
natures of the physician-patient relationship, and
the ethical duties of the medical profession, come
into play. Here we refer to the financial benefits
from the whole performance. Despite the technical
issues and potential harm, parents/families insist
to do it and medical professionals respond to that
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Female Genital Mutilation and Ethical Issues
pressure. Is it respect to social norms and tradition,
the deep rooted culture or fear from detachment
from the profession? In our own perspective a
third issue strongly exists. This is the financial
gain. Families are willing to pay for the operation.
Medical professionals eagerly wait for them to pay
and gladly accept the payment. This means a lot.
Financial conflict of interest is, among other issues,
responsible for the continuation of FGM. It is also
unethical to put personal benefit over the harm of
others – poor little girls.
Cultural Justifications of Female
Genital Mutilation
In societies where FGM is still practiced, including
ours, let us call it, at least in this section, circumcision
just to distinguish the social practice from FGM;
which is generally not considered as mutilation. It
is rather recommended and often highly valued.
They call it tahara which means purity, purification
etc. However, the most commonly used English
equivalent expression is chastity. According to
Oxford Dictionary chastity means “has never had
sex” or “not involving thought and feeling about
sex”. Chastity, from which, it takes its name is the
main and exceptionally solid base. Other social
bases of the practice include religion, cultural
myths; and tradition. In whichever society there
are certain behaviours or standards in which
members of a society are expected to practice in
order to successfully deal with one another such
as female circumcision. From a social point of view
the practice is right because each individual person
in the society would like his/her girl to undergo
circumcision for purification (tahara). In this context
circumcision is morally right. Morals are principles
of right and wrong conduct. At the same time we
cannot call the person who opposes circumcision as
immoral because morals define personal character
rather than collective(2, 10). If he/she does not want
to circumcise his/her daughter he/she will not be
subject to punishment. Morals are different from
ethics, which is a set of standards or codes of conduct
set by people in a specific profession(11).
Ethical Issues in Female Genital
Mutilation
Ethics is defined as “a moral reasoning of action”
which is based on standards or codes of conduct
set by people in a specific profession. The code of
ethics determines the behaviour of people involved
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in certain professions. People in professions do not
want to commit bad, dishonest or irresponsible
actions. Ethics are governed by a set of principles.
The essential principles of medical ethics are respect
for autonomy, beneficence, nonmaleficence and
justice. Medical ethics is application of principles of
ethics into medicine and medical practices(12).
Medical Ethics is at the heart of the FGM issue
in Sudan and elsewhere primarily because it is
considered as a medical/surgical intervention
performed by some doctors and other medical
workers e.g. midwives who are the most frequent
medical workers performing genital cutting(1).
Usually, physicians or other medical professionals
are asked to perform FGM which has no recognized
medical value; but on the contrary, it harms the
victims. A very important question comes forward:
should the medical professional refuse to perform
FGM? It is not easy to answer this question. FMG
is a social custom that is practiced in our country
for millennia. We think medical professionals are
often confronted with ethical dilemmas when they
are asked to perform FGM. The society accepts
it and people expect them to do it better than the
non-medical or less-trained health workers, who
used to perform it in the past e.g. local midwives.
But the more recent rules and regulations of the
profession inhibit them from to doing it. “Ethics also
refer to the moral reasoning which underlie human
relationships and the ways in which they treat each
other”(13). The ethical dilemma with performing
FGM comes from the deeply held social and religious
beliefs about the practice and the moral beliefs that
are used by the people who support and continue
the practice. In this case if the medical professional
performs FGM, he/she does not need any reasoning
for his/her action. On the other hand refusal may
be considered as a resistance or violation to social
norms (morality) which is a very serious insult to
cultural identity. Violating social tradition [morals]
is considered as disrespect to them. The medical
professional may lose his/her credibility and
respect as a community oriented health worker.
Alternatively, performing medically meaningless
and harmful procedures by medical professionals
is not only unethical; but it is equally illegal. FGM
is considered as a surgical procedure that requires
notable medical skills and expertise. So it is an
obvious violation of the principle of nonmaleficence
i.e. does no harm.
Now let us raise another question: who performs it?
Most probably, it is done by midwives, nurse midwives
as well as village midwives (birth attendants) that
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Female Genital Mutilation and Ethical Issues
and perspectives to harm any other person, even if
this person is her own child.
FGM is an irreversible and senseless intervention, so
we think it can be postponed until these little girls
reach eighteen, the age of legal responsibility in the
Sudan. Then, they will be able to make an autonomous
decision pertaining to their own bodies. This is not
a confession from our side of the importance of the
practice; it is rather to acknowledge the right of
these victims, the potential responsible people of
the future.
are not trained or qualified to perform surgical
interventions. They are also not allowed “by law”
to perform such surgical interventions (Sudan
National Code 1991; Chapter 14, Article (1) - 139)
(14)
. They may not be aware or able to treat immediate
complications when they occur such as bleeding
and/or shock. So they carry out others’ job which is
by all means unethical and also illegal. It is unethical
because they inflict unnecessary harm and hazard
on little girls for nothing, which other wise, could
be preventable. The principles of beneficence and
nonmaleficence are violated. The logical and ethical
answer to our above noted question is yes “medical
professional” has to refuse performing such harmful
and unneeded maneuvers, because violating social
norms for the sake of society members is more
valuable and morally and ethically acceptable. This
is not a matter of personal values; but of basic,
universal and fundamental ethical principles that
apply to all people. We believe that negative response
towards performing FGM is a positive means to the
benefit females.
FGM and human rights
There is misinformation and strongly held beliefs
that FGM improves moral behaviour of females by
reducing their sexual arousal. It is also believed
that FGM preserves girls’ chastity. The supporters
are not aware [or do not want to be aware] that
sexual arousal is regulated by a complex hormonal
mechanism and directed by the nervous system.
On the other hand, human behaviour is based
on reasoning and the individual personal value
system not physical features. So both, behaviour
improvement and sexual control of women through
FGM are ethically not accepted. Then why do we
reduce their sexual activity and want them to get
married and take their social responsibility as wives
and mothers at the same time? It is a direct and
obvious violation of human rights; it is a violation
of women’s rights as human beings. FGM hinders
the women’s right to maintain both their social role
and normal and healthy sexual life. They have the
absolute right to enjoy their sexual life and it is the
society’s duty to protect this right. We cannot speak
about human rights in a society that cannot protect
its girls where FGM becomes a normal practice. This
society does not respect human rights.
Informed consent and FMG/C
As we described earlier, FMG/C is considered a
surgical intervention which requires obtaining
prior informed consent from the person on whom
the surgery will be performed. Informed consent
is a procedure that should be assigned without any
questions or counter arguments. It is justified to
show respect for autonomy, to ensure justice and
to minimize risk(15). Informed consent is usually
obtained from a competent person i.e. an adult
person with a sound mind. In the case of children,
informed consent is sought from their parents or
any other legal guardian. This is the practice in
daily scheduled medical and health care. The only
exception is permissible in emergency situations
where urgent interventions are to be performed.
FGM is neither a medical emergency nor is it
important from a medical point of view. To our
knowledge, in the case of FGM, informed consent
is usually not sought in our country. Nevertheless,
medical professionals are often asked to perform
FGM by the mother (sometimes by other family
members), not for herself; but for another person
– her little daughter. Here, the mother is acting as
a proxy decision-maker. The proxy decision-maker
does not have the right to make her values and
perspectives; instead she must do what is in the
best interest of her little incompetent daughter.
Also, she does not have the right to make her values
Conclusion
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We see that there are so many individuals, people,
as well as entire societies, who still believe in
the usefulness of female circumcision. They still
consider it a normal process that merits support
and continuality. We appreciate and respect culture,
traditions and social norms. We think they are of
paramount importance to everyone in the society.
For those people FGM is circumcision.
FGM is no longer seen as a traditional custom and
has become a health problem of public concern in
many countries where it is still practiced. Culture
alone cannot justify serious damage to female
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Female Genital Mutilation and Ethical Issues
Guidelines. Khartoum: SMC. 1969.
9. World Medical Association. World Medical
Association declaration of Lisbon on the rights of
the patient [online]. Available from: http://www.
wma.net/en/30publications/10policies/l4/index.
html.pdf. [Accessed on 08 August 2010].
10. Mangan R. Rights and wrongs: intercultural ethics
and female genital mutilation. Melbourne Journal
of Politics. 2006; 31: 56-74.
11. Singer P, editor. Ethics . Oxford: Oxford University
Press; 1994.
12. Beauchamp TL and Childress JF. Principles of
Biomedical Ethics. 5th ed. New York: Oxford
University Press; 2001.
13. Kluge EH. Female circumcision: when medical
ethics confronts cultural values. CMAJ. 1993;
148(2): 288-289.
14. Abdel Aziz MI. Changing policy for female genital
mutilation and the case of change: A consensus
statement. Sudanese Journal of Public Health.
2009; 4 (2): 236-240.
15. Bottrell MM, Alpert H, Fischbach RL, Emanuel
LL. Hospital informed consent for procedure forms:
facilitating quality patient-physician interaction.
Arch Surg. 2000; 135(1): 26-33.
genital organs and no wise defense could be made to
preserving such a practice. It is important, however,
that for those who are adherent to the culture to have
a backward glance to see how many malpractices,
which were considered social norms, were thrown
out of the social memory. FGM obviously violates the
fundamental ethical principles of bodily integrity,
autonomy and self determination without the full
informed consent of the victim. Therefore, it violates
the same social norms and social integrity.
The essence of our argument is the following: except
for unquestionably curative therapeutic reasons, any
procedure made on the body is considered unethical.
The drastic nature of FGM; its irreversibility and lack
of urgency without consent, or at least by parent
consent make it an even more illegal action.
Acknowledgement
We would like to express our gratitude to Dr. Nancy
Kass and Margaret Murphy from Berman Institute
of Bioethics at Johns Hopkins University for helping
us in preparing the early draft of this paper and
precious advice and recommending useful literature.
Our gratitude extends to Dr. Awadakareem Elhassan
from Alzaiem Alazhari University for editing the
early draft of this paper.
References
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an ethical dilemma. J Soc Work Values Ethics.
2007; 4(1): Online publication.
2. Gibeau AM. Female genital mutilation: when a
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dilemmas. J Obstet Gynecol Neonatal Nurs. 1998;
27(1): 85-91.
3. World Health Organization. Khartoum seminar on
Traditional practices affecting the health of women
and children, Khartoum, Sudan held on 10-15
February 1979. 1979.
4. Althaus FA. Female Circumcision: Rite of Passage
or Violation of Rights? Int Fam Plan Perspect.
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5. Toubia N. Female circumcision as a public health
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10(1): 30-34.
7. Elsayed DM, Elamin RM. Medical Ethics: What
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8. Sudan Medical Council. Medico-Legal and Ethical
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