Medicalization of FGC in Africa Medicalization of FGC in Africa --and in the United States?--and in the United States?

Wednesday, November 8, 2000Wednesday, November 8, 2000

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Medicalization of FGC in AfricaMedicalization of FGC in Africa

Should medicalization Should medicalization be encouraged and be encouraged and promoted?promoted?

What is medicalization? (1)What is medicalization? (1) Making FGC safer for traditional Making FGC safer for traditional

excisersexcisers– girls brought to clinics day before ritualgirls brought to clinics day before ritual– receive anti-tetanus injections & receive anti-tetanus injections &

antibioticsantibiotics– parents given sterile razor bladeparents given sterile razor blade

What is medicalization? (2)What is medicalization? (2)

ClinicalizationClinicalization– in-clinic (antiseptic in-clinic (antiseptic

environment)environment)– trained health trained health

personnelpersonnel– use of anesthesiause of anesthesia– cutting decreasedcutting decreased

What is medicalization? (3)What is medicalization? (3) Use of physicians Use of physicians

widespread already (20% widespread already (20% in urban Sudan; up to in urban Sudan; up to 45-55% in urban Egypt)45-55% in urban Egypt)

Should governments Should governments regulate and render these regulate and render these practitioners more secure practitioners more secure (training, open (training, open discussion, insurance)?discussion, insurance)?

The health value of The health value of medicalizationmedicalization

In Kenya study, 1997-1998: families that In Kenya study, 1997-1998: families that received anti-tetanus, antibiotics, and sterile received anti-tetanus, antibiotics, and sterile razors had 70% lower risk of infection and razors had 70% lower risk of infection and complicationscomplications

clinics and doctors’ offices: even higher clinics and doctors’ offices: even higher reductions of riskreductions of risk

Grassroots criticism of medicalizationGrassroots criticism of medicalization Anesthesia detracts from ritualAnesthesia detracts from ritual

– Kenya: “I think it is good to give us antibiotics. But we should not Kenya: “I think it is good to give us antibiotics. But we should not perform the ritual in a clinic, where they inject the child with perform the ritual in a clinic, where they inject the child with anasthesia. This is very much against the value of the rite.”anasthesia. This is very much against the value of the rite.”

Clinicalization undermines ritualClinicalization undermines ritual– ““If girls go into the clinic to do it, what is the meaning of it? They If girls go into the clinic to do it, what is the meaning of it? They

must have it together, in the group, where they are being must have it together, in the group, where they are being initiated!”initiated!”

Excisers fear loss of authorityExcisers fear loss of authority– ““I do not agree with nurses doing it. They have not learned the I do not agree with nurses doing it. They have not learned the

meaning of these things – they do it like they are giving a shot. meaning of these things – they do it like they are giving a shot. Then no one will respect it – no one will respect it!”Then no one will respect it – no one will respect it!”

Criticism by medical profession Criticism by medical profession and international organizationsand international organizations

Since 1982: WHO’s statement: it is unethical for Since 1982: WHO’s statement: it is unethical for FGC to be performed by “any health officials in any FGC to be performed by “any health officials in any setting”setting”

Since 1994: resolution by International Federation of Since 1994: resolution by International Federation of Gynecology and Obstetrics: “health care personnel Gynecology and Obstetrics: “health care personnel should refuse to perform any such surgery”should refuse to perform any such surgery”

Since mid-1990s: UNICEF on board against Since mid-1990s: UNICEF on board against medicalization; many ministries of health in Africamedicalization; many ministries of health in Africa

Reason 1: Medically unethicalReason 1: Medically unethical

WHO 1982 statement: “The argument that female WHO 1982 statement: “The argument that female genital mutilation performed under medically genital mutilation performed under medically controlled conditions is a lesser evil compared to the controlled conditions is a lesser evil compared to the greater risk of severe complications is not greater risk of severe complications is not acceptable, since the cause of the risk is human acceptable, since the cause of the risk is human behavior, which can be changed, and not an behavior, which can be changed, and not an uncontrollable pathology. It is therefore unethical for uncontrollable pathology. It is therefore unethical for a health professional to damage a healthy body in a health professional to damage a healthy body in order to prevent more destructive human behavior.” order to prevent more destructive human behavior.”

Reason 2: Perpetuates FGCReason 2: Perpetuates FGC UNICEF statement: “It is sometimes claimed that UNICEF statement: “It is sometimes claimed that

medicalization is part of a policy of eradication. We, however, medicalization is part of a policy of eradication. We, however, believe that in fact medicalization institutionalizes and believe that in fact medicalization institutionalizes and perpetuates FGM.”perpetuates FGM.”

Some evidence from Egypt: Some evidence from Egypt: – 1970s: anecdotal evidence of decline in urban Egypt; 1970s: anecdotal evidence of decline in urban Egypt; – 1996 survey found same high rates in both urban and rural 1996 survey found same high rates in both urban and rural

areasareas– 1996 survey found increase in use of clinics in last 10 -15 1996 survey found increase in use of clinics in last 10 -15

years (17% of urban women over 30 had FGC in clinics; years (17% of urban women over 30 had FGC in clinics; 55% of their 15-20 year old daughters had done so)55% of their 15-20 year old daughters had done so)

Reason 3: Legitimates Reason 3: Legitimates “offensive” practice“offensive” practice

International Federation of Gynecology and International Federation of Gynecology and Obstetrics: Obstetrics:

““Medicalizing FGM legitimates a practice Medicalizing FGM legitimates a practice that is offensive to the dignity of women. that is offensive to the dignity of women. Surgeons who are contemplating performing Surgeons who are contemplating performing such a procedure should consider their role such a procedure should consider their role in endorsing this social practice with its in endorsing this social practice with its implications for the status of women.” implications for the status of women.”

Medicalization of FGC in the Medicalization of FGC in the US?US?

African immigration to the USAfrican immigration to the US– Currently: 150,000 women from Africa living Currently: 150,000 women from Africa living

in the US either are cut or face possibility of in the US either are cut or face possibility of being cut (acc. to CDC)being cut (acc. to CDC)

– 7000 more every year 7000 more every year – about 30,000 from infibulating societies about 30,000 from infibulating societies

(Somalia, Sudan, etc.), due in part to wars of (Somalia, Sudan, etc.), due in part to wars of 1990s1990s

Harborview caseHarborview case Issue faces hospitals across the countryIssue faces hospitals across the country 3500 Somalis in Seattle by 19963500 Somalis in Seattle by 1996 Proposal for nick to clitoris of girls (8-10 Proposal for nick to clitoris of girls (8-10

years old): no tissue excised, local years old): no tissue excised, local anesthetic, on children “old enough to give anesthetic, on children “old enough to give consent”consent”

The two justificationsThe two justifications

Parents said they Parents said they would get girls cut by would get girls cut by one of 3 local one of 3 local midwives; or would midwives; or would return for operation to return for operation to SomaliaSomalia

Operation would help Operation would help process of eradication: process of eradication: older versus younger older versus younger women: operation women: operation becoming less becoming less invasiveinvasive

Opinion of State Attorney GeneralOpinion of State Attorney General Stated that the proposal, if enacted, would violate Stated that the proposal, if enacted, would violate

Illegal Immigration Reform and Immigrant Illegal Immigration Reform and Immigrant Responsibility Act (September 24, 1996) Responsibility Act (September 24, 1996)

Whoever knowingly circumcises, excises, or Whoever knowingly circumcises, excises, or infibulates the whole or any part of the labia infibulates the whole or any part of the labia majora or labia minora or clitoris of another majora or labia minora or clitoris of another person who has not attained the age of 18 person who has not attained the age of 18 years shall be fined under this title or years shall be fined under this title or imprisoned not more than 5 years, or both.imprisoned not more than 5 years, or both.

Response, counter-responseResponse, counter-response

Harborview invoked Harborview invoked clause 2: “[An clause 2: “[An exception is given exception is given when ] the operation is when ] the operation is necessary to the health necessary to the health of the person on whom of the person on whom it is performed”it is performed”

Attorney General Attorney General invoked clause 3: “In invoked clause 3: “In applying this applying this exception, no account exception, no account shall be taken of the shall be taken of the effect of any belief effect of any belief that the operation is that the operation is required as a matter of required as a matter of custom or ritual.”custom or ritual.”

The torrent of lettersThe torrent of letters

100s from Seattle residents100s from Seattle residents Some were supportive (as in editorial Some were supportive (as in editorial

assigned to you):assigned to you): ““Who are we to impose our values on Who are we to impose our values on

them? This is a cultural practice that must them? This is a cultural practice that must be respected.”be respected.”

But most of the letters went the But most of the letters went the other way...other way...

““Even talking about cutting female genitals Even talking about cutting female genitals legitimizes a barbaric practice, one that legitimizes a barbaric practice, one that disempowers women and serves to keep disempowers women and serves to keep them out of the American mainstream.”them out of the American mainstream.”

Pat Schroeder (D-Colo) wrote a letter like Pat Schroeder (D-Colo) wrote a letter like this...this...

Letter from a social workerLetter from a social worker ““I have heard Somali women say ‘We were taught I have heard Somali women say ‘We were taught

that this was a way of ensuring a girl's good that this was a way of ensuring a girl's good behavior. Women should be meek, simple and behavior. Women should be meek, simple and quiet, not aggressive and outgoing. This is quiet, not aggressive and outgoing. This is something we just accept.’ How can we help something we just accept.’ How can we help support a practice that has this effect? Shouldn’t support a practice that has this effect? Shouldn’t these women be encouraged to move toward the these women be encouraged to move toward the American mainstream?”American mainstream?”

Letter from an Ethiopian womanLetter from an Ethiopian woman

““How dare it even cross their minds? What How dare it even cross their minds? What immigrants like me need is an education, not immigrants like me need is an education, not ‘sensitivity’ to culture. . . When Americans are ‘sensitivity’ to culture. . . When Americans are ‘sensitive’ to culture, they keep us locked into ‘sensitive’ to culture, they keep us locked into tradition, which of course Americans like, because tradition, which of course Americans like, because it is exotic… I’ll bet that most of the Somali it is exotic… I’ll bet that most of the Somali women don’t want this, but the few who do are women don’t want this, but the few who do are getting all the attention! They must be brought getting all the attention! They must be brought into the 20th century!”into the 20th century!”

Letter from a Somali womanLetter from a Somali woman

““I am happy to be in this country, where I am happy to be in this country, where cutting is against the law. I am young and I cutting is against the law. I am young and I do not want to continue this custom. . . Here do not want to continue this custom. . . Here we do not have to do it. Please do not turn we do not have to do it. Please do not turn back the clock with this. Now I can say: ‘I back the clock with this. Now I can say: ‘I will not cut my daughter, because we are in will not cut my daughter, because we are in a country that disapproves of this.’ What a country that disapproves of this.’ What will I say if the plan goes through?”will I say if the plan goes through?”

How it ended...How it ended...

Plan droppedPlan dropped Since then, no other hospital in US has tried Since then, no other hospital in US has tried

thisthis Cutting continues… but hard to documentCutting continues… but hard to document So: did Harborview do the right or wrong So: did Harborview do the right or wrong

thing?thing?