The American Academy of Pediatrics caused some controversy last month when it appeared to support a form of female circumcision — more properly Female Genital Cutting or FGC — involving nicking or cutting the clitoris, as a less invasive procedure thought to satisfy cultural requirements for more involved or dangerous practices. The Academy’s Bioethics Committee wrote that “[i]t might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick as a possible compromise to avoid greater harm.” The AAP quickly walked back this pronouncement, which seemed to run counter to the general, worldwide consensus on the subject: “The AAP reaffirms its strong opposition to FGC and counsels its members not to perform such procedures. As typically practiced, FGC can be life-threatening. Little girls who escape death are still vulnerable to sterility, infection, and psychological trauma.”
Well, good. Indeed. And thank you.
Female genital cutting relates, as the World Health Organization defines it, to all procedures which involve the total or partial removal of all external female genitalia for reasons unrelated to health, often done in a crude, unhygienic manner using such devices as broken glass or knives. WHO classifies four major types of FGC:
1. Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).
2. Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are “the lips” that surround the vagina).
3. Infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris.
4. Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.
As terrible as might seem, FGC is strongly linked with cultural, religious and social practices, and is usually performed at the behest of a girl’s parents or caregivers, as a means of assuring chastity and controlling female sexuality, improving marriage possibilities, as a rite of passage into adulthood, or as a symbol of purity or cleanliness. Unfortunately, it is a horrible gift. Immediate complications include massive blood loss and overwhelming infection leading to sepsis, severe pain, tetanus and urinary retention. Over the longer term, it can lead to recurrent urinary and reproductive tract infection, infertility, increased infant mortality and sexual dysfunction.
In Canada, FGC is an offence under the Criminal Code, as is procuring FGC in a foreign country, even if the practice is legal in that country. Nevertheless, Toronto (among other places) has a very large population of immigrants from those places in Africa and Asia where FGC is common; there are rumours and allegations that FGC is being practised in this country, though I am unable to find any documented cases.
For nurses, the ethics of this ought to be obvious: FGC is clearly wrong, and nurses (in Ontario, at least) must report any evidence or suspicion of FGC to the Children’s Aid Society or other child welfare agencies as suspected child abuse.
How nurses can come to this conclusion is not as straightforward as it might seem. Nurses, in fact, are ethically obliged to consider and accommodate all cultural, religious and social practices of their patients in providing care, even when those practices run contrary to the nurse’s belief system or even larger societal norms. A celebrated example is the refusal of blood products by Jehovah’s Witnesses. More mundanely, accommodating dietary habits — providing halal or kosher meals, for example — is another means nurses incorporate cultural or religious practices into the care they provide. It could be argued that FGC falls under the same category. Immigrant Somali women in Toronto, for example, reported feelings of pride and purity in having undergone the procedure, despite considerable health complications. Or consider this:
Dr. Ahmadu, a post-doctoral fellow at the University of Chicago, was raised in America and then went back to Sierra Leone as an adult to undergo the procedure along with fellow members of the Kono ethnic group. She has argued that the critics of the procedure exaggerate the medical dangers, misunderstand the effect on sexual pleasure, and mistakenly view the removal of parts of the clitoris as a practice that oppresses women. She has lamented that her Westernized “feminist sisters insist on denying us this critical aspect of becoming a woman in accordance with our unique and powerful cultural heritage.” In another essay, she writes:
It is difficult for me — considering the number of ceremonies I have observed, including my own — to accept that what appears to be expressions of joy and ecstatic celebrations of womanhood in actuality disguise hidden experiences of coercion and subjugation. Indeed, I offer that the bulk of Kono women who uphold these rituals do so because they want to — they relish the supernatural powers of their ritual leaders over against men in society, and they embrace the legitimacy of female authority and particularly the authority of their mothers and grandmothers.
Indeed, it might be reasonable argued (though I would reject it) that opposition to FGC is merely another form of Western ethnocentrism. Who are we, in short, to determine what’s a reasonable for children in another culture, using are own values as a measure?
In the end, regardless of cultural, social or religious factors, nurses must fall back to the bedrock standards of ethical practice: beneficence, non-maleficence, autonomy and justice. Does the act promote the well-being of the child? Does the act harm the child? Does the child have effective voice in determining her treatment, or at least an impartial advocate? Are all persons treated in the same way in regard to the act? This means, in practical terms, arguments for and against accepting and legitimizing cultural or social norms are not helpful in determining the ethical consequences of FGC, though they may give understanding of the issues surrounding the practice and help nurses provide empathetic, nonjudgmental care to victims. But does this mean nurses have no obligations when confronted with FGC? As I stated above, I believe nurses do, strongly. Nurses cannot practice in an ethical vacuum: they are moral actors.
In the first place, consider who, exactly is forced to have the procedure. Again from WHO:
Procedures are mostly carried out on young girls sometime between infancy and age 15, and occasionally on adult women. In Africa, about three million girls are at risk for FGM annually.
Adults, mothers and fathers have the right of making decisions on behalf of their child if that child is below the age of consent. And parents do have the right to consider their own values in determining health care treatment. It is not an unlimited right. Parents only have this right if it does not put at risk or damage the health and welfare of the child. They must do what is objectively in the best interests of the child, even if it conflicts with their own values. If FGC doesn’t meet the criteria for harming a child, it is difficult to imagine what would. Ethically speaking, it is no different than holding a flame to a child’s hand.
Female genital cutting is child abuse. Nurses have an obligation to report it.