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Opinion Article
Updated

Female circumcision: Limiting the harm

[version 2; peer review: 2 approved, 1 approved with reservations]
(Previously titled: ‘Female genital cutting is a harmful practice: where is the evidence')
PUBLISHED 08 Nov 2012
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS

Abstract

Objective: To review the strength of evidence that links many health hazards to female genital cutting.
Material and methods: Literature search in Medline/Pubmed and Google scholar.
Results: Female genital cutting is still practiced secretly in both underdeveloped and developed countries due to prevailing strong traditional beliefs. There is insufficient evidence to support the claims that genital cutting is a harmful procedure if performed by experienced personnel in a suitable theatre with facilities for pain control and anesthesia. Cutting, however, is advised not to go beyond type I.
Conclusion: Law makers around the globe are invited to review the legal situation in relation to female genital cutting. Proper counseling of parents about possible risks is a must in order to make informed decision about circumcising their daughters. The procedure should be offered to parents who insist on it; otherwise, they will do it illegally, exposing their daughters to possible complications.

Updated Changes from Version 1

I have updated my opinion article to avoid confusing the readers and taking into consideration the feedback I received from the referees and user comments. Firstly, I want to make it completely clear to all that I do not condone female circumcision. In retrospect, the title of the first version was particularly misleading, and so I have now changed it to reflect the scientific opinion I am trying to convey.
Many believe that female circumcision helps personal cleanliness of young girls, preserves virginity, and enhances sexual pleasure for the husband, while for others, it is a religious right. Because of this, and despite the legal ban in most parts of the world, female circumcision is still practiced illegally by unqualified personnel using non-sterilized instruments.
Female circumcision is rightly recognized as a harmful practice. However, there is no high-quality medical evidence to demonstrate this: only Level III evidence exists – described in evidence-based medicine levels as the opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. Even so, no single procedure in medicine would be banned based on this evidence alone and this poses a significant problem because it would be completely unethical to aim for a higher level of evidence such as a randomised controlled trial. I believe that a total ban of the procedure is ineffective, and may lead individuals to look for illegal and often incompetent practitioners, thus exposing their daughters to possible catastrophes. The international efforts aiming to ban female circumcision should be directed towards demonstrating that it is a surgical practice with no known benefit, rather than illustrating the complications associated with it. Once people become convinced that it is of no value, they will start to question their use of the practice; in this situation, the initiative to eliminate female circumcision will be theirs. I believe that a change of strategy from “complications awareness” to “no benefit awareness” should be the first step in the long journey that must be taken before the total elimination of female circumcision can be a reality. Meanwhile, we should be able to respond to social calls for circumcision with the least possible damage.

To read any peer review reports and author responses for this article, follow the "read" links in the Open Peer Review table.

Introduction

Female genital cutting/mutilation (FGC/M), or circumcision as it was previously described1, is held responsible for a multitude of health risks. According to WHO, FGC/M is defined as “all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons”2.

The legislations enacted in most countries to ban FGC had minimal effect on its prevalence3. In the most recent estimate carried out by the WHO in 2008, an average of between 100 and 140 million women have undergone FGC in the world and every year, 3 million female children are mutilated in Africa4.

Female genital cutting in medical literature

I searched the English literature in Medline/Pubmed and Google Scholar for female genital cutting/mutilation and circumcision in the period from January 1980 until January 2012. The available studies showed that FGC may result in either physical and/or psychological injuries, immediate and/or late.

Alleged health hazards

Immediate complications

The three immediate complications are bleeding, pain and infection. They are not unique to FGC. They are liable to occur with any other type of female surgery, whether minor or major. Bleeding is liable to occur with the tiniest injury to the body, not only genitalia, and death may occur if not dealt with. Pain during genital cutting was attributed to non use of anesthesia or pain killers during the procedure5, something which is expected with any other similar situation. The procedure is illegal in most countries of the world and it is routinely performed at home using non-sterilized instruments. Infection is the normal sequel for any surgical interference performed in such an environment. We should ask ourselves what would be the percentages of these complications if FGC was performed in a well-equipped theatre by experienced personnel. They would probably not be different to any other surgical procedure.

Late complications

The alleged late risks include a wide variety of complications. Scars and keloid formation may occur6. It is well known that the type of scar depends on the mode of healing, whether by primary or secondary intention. Healing with secondary intention and the formation of ugly scars occurs if the wound is left to heal on its own without repair. This pattern of healing is expected because the procedure is usually performed by the traditional illiterate birth attendant (IBA) at home. Epidermoid cysts may form probably due to cutting with non sharp instruments or imprecise cutting by the traditional IBA or un-experienced surgeon7. The occurrence of both complications can be minimized if the procedure is performed in a well-prepared theatre. Controversy exists as for sexual pleasure. Although many researchers reported that female genital mutilation interferes negatively with women’s sexual pleasure, others provided contradictory evidence and confirmed that women with types I and II cuttings were able to enjoy their sex lives8,9. Lightfoot-Klein10 conducted a study on infibulated females “type III cutting” in Sudan and, based on her findings, she stated that nearly 90% of all women said that they experienced orgasm or had experienced it at various periods in their marriage. Thabet et al. showed that women with type II cutting complain of defective sexuality compared to non circumcised women, while women with the more extensive type III cutting are not different to controls11. This is not logical. If FGC is responsible for defective sexuality, those with type III cutting should have the maximum suffering. The explanation for this contradiction is because sexual arousal is not only dependent upon clitoral stimulation. It involves the stimulation of nerve endings in and around the vagina, vulva, cervix, uterus and clitoris, with psychological response and mindset also playing a role12,13.

There are claims that women who have undergone genital cutting may have a feeling of inferiority14. This is apparent when these women immigrate to western societies which do not practice FGC. This psychological burden probably stems from the fact that their new societies consider FGC as abnormal contradicting the traditions and beliefs they have grown up with. There are other claims that infertility may also complicate FGC. Reasons are anatomic disfigurement due to excessive scarring after infibulation “type III” probably resulting from healing by secondary intention. Another cause is the associated infection; that might arise after FGC, to the internal genitalia causing inflammation and scarring and subsequent tubal block15. Infection again is due to the improper environment where the procedure was performed.

The WHO reported that obstetric complications are more likely to occur with genital cuttings and the risk increases with more advanced cutting16. This conclusion was based on a WHO collaborative prospective study which included 28,393 women attending for singleton delivery at 28 obstetric centers in Burkina Faso, Ghana, Kenya, Nigeria, Senegal, and Sudan. The WHO study and few others also showed that a higher percentage of cut women deliver by Cesarean section compared to uncut women due to an increased number of obstructed labors. There is a higher incidence of infant resuscitation, stillbirth, or neonatal death in mothers with FGC1618. One of the major drawbacks of the WHO study is that the population studied is not representative for the whole population in the selected countries. In poor societies, only high-risk and complicated pregnancies are referred to hospitals. Such cases are more liable for adverse obstetric outcomes. This may have overestimated the rate of complications in women with FGC who attended hospitals to deliver. Claims for increased Cesarean deliveries in cut women were attributed to obstructed labor most likely due to excessive scarring at the pelvic outlet probably resulting from the imperfect healing of the genital cutting and possible associated infection. However, the high Cesarean rate in this population cannot be attributed solely to obstruction due to excessive outlet scarring; obstructed labor may occur due to a variety of reasons. In fact, excessive scarring at the pelvic outlet is the easiest reason to deal with, using a generous episiotomy. The reason for increased stillbirth and/or neonatal death in mothers with FGC is probably related to the obstructed labor; whatever the reason is, it is not a direct complication of FGC.

Comments

The decline in FGC practice is not proportionate to the efforts exerted3. It is not easy to give up your traditions and cultural beliefs for what is considered, by many, to be an attempt to westernize societies in the third world. Many believe that national and international feminist organizations and child rights’ advocates have propagated misleading or unproven information through the media in order to force governments to prohibit the procedure. In fact, all the above-mentioned health hazards were concluded from studies that showed inconsistent findings. Some of them confirmed the hazards of FGC while others failed to prove them. In the era of evidence based medicine, level I evidence, derived from either systematic reviews or randomized controlled trials (RCTs), to support the ban against FGC is not available. Such studies were never considered by the WHO or any other international health organization before the ban of FGM takes place in most countries. In fact, the design and implementation of a RCT to address the effects of FGC cannot be justified and seems to be unethical. In light of this fact and in the absence of any scientific evidence to support the practice of female circumcision, the available level III evidence, derived from retrospective studies and studies depended on self-reported FGC and its health consequences, should be taken into consideration in spite of their imprecision and low reliability19,20.

Religious and cultural views

In Islam and Judaism, male circumcision is a must while female is not. In Islam, if female circumcision is desired by parents, it should not go beyond type I FGC (Ia is removal of the prepuce and Ib is removal of the prepuce and clitoris) according to hadith “Sunna type of circumcision”. This type of female genital surgery is equated with male genital surgery21. In support of hadith, many studies showed that women with clitoridectomy “type I cutting” are less likely to develop gynecologic or obstetric complications compared to infibulated women “type III”6. Considering that the number of Moslems in the world ranks second, it seems logical to reconsider the legal attitude towards female circumcision and probably avoids the ban directed towards Sunna circumcision.

It therefore seems that the prohibition of FGC for those who strongly believe in circumcision in the absence of solid scientific evidence does not respect their traditions and cultural beliefs. Women in societies which practice FGC and the practicing immigrant minorities living in the west consider that strength and identity partly come from the pain and difficulty which FGC causes, making them ‘strong’ and ‘desirable’ women22,23.

Conclusions

To conclude, law makers all around the globe are invited to review the legal situation of female circumcision. Parents, especially immigrants to the western world from the practicing societies, should be properly counselled for the possible complications, but should also be informed that these data were not derived from randomized controlled trials. Those who insist on circumcising their daughters should be allowed to do so, but advised not to exceed type I cutting; otherwise, they will go for it secretly and illegally by inexperienced personnel in a poorly hygienic environment with the possibility of complications.

Comments on this article Comments (5)

Version 2
VERSION 2 PUBLISHED 08 Nov 2012
  • Author Response 24 Dec 2012
    Mohamed Kandil, Department of Obstetrics and Gynecology, Faculty of Medicine-Menofyia University, Shibin Elkom, Egypt
    24 Dec 2012
    Author Response
    In reply to Malcolm Griffiths

    Thank you for your comment.

    In fact these 2 statements are not contradictory if you consider the title “limiting the harm”. It is true that I said in my conclusion that parents who INSIST should be allowed to do so. This is applicable to poor and illiterate societies where the traditions cannot be overcome by law. In such societies, when doctors refuse to perform the procedure, the child is usually taken to a barber who performs the procedure with unsterilized razors with possible catastrophes to the young girls. In this situation and only in this situation, which is better? To allow medical professionals to perform the procedure with the mildest possible degree (“type 1” ) or leave it to a barber to perform it? That is the message I am trying to convey.

    I agree with you that a civilized mother or father would not agree to perform the procedure for his/her daughter but an illiterate parent would, especially in areas where illiteracy rates exceed 60% and together especially when extreme poverty and social traditions prevail.

    In reply to Malcolm Griffiths

    Thank you for your comment.

    In fact these 2 statements are not contradictory if you consider the title “limiting the harm”. It is true that I said in my conclusion that parents who INSIST should be allowed to do so. This is applicable to poor and illiterate societies where the traditions cannot be overcome by law. In such societies, when doctors refuse to perform the procedure, the child is usually taken to a barber who performs the procedure with unsterilized razors with possible catastrophes to the young girls. In this situation and only in this situation, which is better? To allow medical professionals to perform the procedure with the mildest possible degree (“type 1” ) or leave it to a barber to perform it? That is the message I am trying to convey.

    I agree with you that a civilized mother or father would not agree to perform the procedure for his/her daughter but an illiterate parent would, especially in areas where illiteracy rates exceed 60% and together especially when extreme poverty and social traditions prevail.

    Competing Interests: No competing interests were disclosed. Close
  • Reader Comment 29 Nov 2012
    Malcolm Griffiths, Obstetrics and Gynaecology, Luton & Dunstable Hospital, UK
    29 Nov 2012
    Reader Comment
    The author states that he does not condone FGM, yet in his conclusions he says:
    "Those who insist on circumcising their daughters should be allowed to do so, but advised not ... Continue reading
  • Reader Comment 08 Nov 2012
    Robert Van Howe, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, USA
    08 Nov 2012
    Reader Comment
    I applaud the courage of the editorial staff in publishing this important opinion piece. In 2010 the American Academy of Pediatrics Committee on Bioethics concluded that forms of female genital ... Continue reading
Version 1
VERSION 1 PUBLISHED 05 Oct 2012
Discussion is closed on this version, please comment on the latest version above.
  • Reader Comment 12 Oct 2012
    F1000 Research, UK
    12 Oct 2012
    Reader Comment
    Thank you for the concerns you raise. We consider every article carefully on its scientific merit, not on whether we agree with the view of the scientist. I agree it ... Continue reading
  • Reader Comment 11 Oct 2012
    Vitaly Citovsky, Department of Biochemistry and Cell Biology, USA
    11 Oct 2012
    Reader Comment
    As a member of the scientific community and the editorial board of this journal, I would like to express my total opposition to any attempts to justify female genital mutilation ... Continue reading
  • Discussion is closed on this version, please comment on the latest version above.
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Kandil M. Female circumcision: Limiting the harm [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2012, 1:23 (https://doi.org/10.12688/f1000research.1-23.v2)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 2
VERSION 2
PUBLISHED 08 Nov 2012
Views
32
Cite
Reviewer Report 19 Nov 2012
Ali Akoum, Department of Obstetrics and Gynecology, Laval University, Québec, PQ, Canada 
Approved with Reservations
VIEWS 32
I personally think that the study is well performed. The author made a fair presentation of the literature and outlined the various studies and statistics on this subject, which, the least we can say is delicate and controversial.

The author presents ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Akoum A. Reviewer Report For: Female circumcision: Limiting the harm [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2012, 1:23 (https://doi.org/10.5256/f1000research.600.r500)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Version 1
VERSION 1
PUBLISHED 05 Oct 2012
Views
68
Cite
Reviewer Report 16 Oct 2012
Hisham Kandil, Department of Obstetrics and Gynecology, Cairo University, Cairi, Egypt 
Approved
VIEWS 68
I approve the validity of this opinion article with some minor remarks.

I personally do not approve of female genital cutting as a general routine, however it is commonly practiced in rural areas of third world countries. Due to this, it
... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Kandil H. Reviewer Report For: Female circumcision: Limiting the harm [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2012, 1:23 (https://doi.org/10.5256/f1000research.122.r314)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Views
63
Cite
Reviewer Report 11 Oct 2012
Ahmed Fetouh, Faculty of Medicine, Al-Azhar University for Girls, Cairo, Egypt 
Approved
VIEWS 63
My own personal stand is against female genital cutting except ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Fetouh A. Reviewer Report For: Female circumcision: Limiting the harm [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2012, 1:23 (https://doi.org/10.5256/f1000research.122.r312)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (5)

Version 2
VERSION 2 PUBLISHED 08 Nov 2012
  • Author Response 24 Dec 2012
    Mohamed Kandil, Department of Obstetrics and Gynecology, Faculty of Medicine-Menofyia University, Shibin Elkom, Egypt
    24 Dec 2012
    Author Response
    In reply to Malcolm Griffiths

    Thank you for your comment.

    In fact these 2 statements are not contradictory if you consider the title “limiting the harm”. It is true that I said in my conclusion that parents who INSIST should be allowed to do so. This is applicable to poor and illiterate societies where the traditions cannot be overcome by law. In such societies, when doctors refuse to perform the procedure, the child is usually taken to a barber who performs the procedure with unsterilized razors with possible catastrophes to the young girls. In this situation and only in this situation, which is better? To allow medical professionals to perform the procedure with the mildest possible degree (“type 1” ) or leave it to a barber to perform it? That is the message I am trying to convey.

    I agree with you that a civilized mother or father would not agree to perform the procedure for his/her daughter but an illiterate parent would, especially in areas where illiteracy rates exceed 60% and together especially when extreme poverty and social traditions prevail.

    In reply to Malcolm Griffiths

    Thank you for your comment.

    In fact these 2 statements are not contradictory if you consider the title “limiting the harm”. It is true that I said in my conclusion that parents who INSIST should be allowed to do so. This is applicable to poor and illiterate societies where the traditions cannot be overcome by law. In such societies, when doctors refuse to perform the procedure, the child is usually taken to a barber who performs the procedure with unsterilized razors with possible catastrophes to the young girls. In this situation and only in this situation, which is better? To allow medical professionals to perform the procedure with the mildest possible degree (“type 1” ) or leave it to a barber to perform it? That is the message I am trying to convey.

    I agree with you that a civilized mother or father would not agree to perform the procedure for his/her daughter but an illiterate parent would, especially in areas where illiteracy rates exceed 60% and together especially when extreme poverty and social traditions prevail.

    Competing Interests: No competing interests were disclosed. Close
  • Reader Comment 29 Nov 2012
    Malcolm Griffiths, Obstetrics and Gynaecology, Luton & Dunstable Hospital, UK
    29 Nov 2012
    Reader Comment
    The author states that he does not condone FGM, yet in his conclusions he says:
    "Those who insist on circumcising their daughters should be allowed to do so, but advised not ... Continue reading
  • Reader Comment 08 Nov 2012
    Robert Van Howe, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, USA
    08 Nov 2012
    Reader Comment
    I applaud the courage of the editorial staff in publishing this important opinion piece. In 2010 the American Academy of Pediatrics Committee on Bioethics concluded that forms of female genital ... Continue reading
Version 1
VERSION 1 PUBLISHED 05 Oct 2012
Discussion is closed on this version, please comment on the latest version above.
  • Reader Comment 12 Oct 2012
    F1000 Research, UK
    12 Oct 2012
    Reader Comment
    Thank you for the concerns you raise. We consider every article carefully on its scientific merit, not on whether we agree with the view of the scientist. I agree it ... Continue reading
  • Reader Comment 11 Oct 2012
    Vitaly Citovsky, Department of Biochemistry and Cell Biology, USA
    11 Oct 2012
    Reader Comment
    As a member of the scientific community and the editorial board of this journal, I would like to express my total opposition to any attempts to justify female genital mutilation ... Continue reading
  • Discussion is closed on this version, please comment on the latest version above.
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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