Aparna Mani, Georgetown University Medical School, Single Brushstroke.
Oil on paper. 22.9 × 30.5 cm.
Grahic Jump Location
The problem of female genital mutilation (FGM) inspired nearly 100 medical
students from 3 continents to submit their work for the 2002 John Conley Ethics
Essay Contest for Medical Students. Essayists discussed ethical issues that
would arise if an 18-year-old woman requested that a surgeon in the United
States perform FGM on her before she returned home to Africa, where FGM is
most commonly practiced. Also known as "female genital cutting" and "female
circumcision," FGM includes 4 types according to a classification scheme delineated
by the World Health Organization in 1995. The classification is based on increasingly
extensive excisions of the genitalia from types I to type III, with types
I and II comprising the majority of procedures. Variations of FGM that do
not meet the criteria for the first 3 types are classified as type IV.
The young woman in the scenario requested that the surgeon perform type
III, or infibulation, which is the most surgically extensive form of FGM.
Type III includes an excision of part or all of the external genitalia and
stitching of the vaginal opening, and has been associated with the most serious
Ninety-five percent of FGM is performed on girls between one day to
16 years old, particularly between the ages of 4 and 10 years. However, some
cultures perform FGM into adulthood, such as at the time of marriage. Thus,
the patient in this scenario requested to have the procedure performed at
a relatively old age.
According to the scenario, the woman wanted the surgery before returning
to her homeland in order to decrease her risk of complications that may occur
as a result of having it done under unsterile and relatively primitive conditions.
The literature on the health risks associated with FGM has mostly focused
on gynecologic problems such as hemorrhage, infection, and dysmenorrhea. Other
health-related parameters such as overall mortality and morbidity have yet
to be documented thoroughly, and the data on which advocates have argued against
FGM have been criticized for not meeting rigorous scientific standards of
evidence. Nevertheless, national and international health and government organizations
have taken strong stands against the practice, arguing that the currently
available data sufficiently document the dangers of FGM.
The winning essays in this year's contest explore ethical, moral, and
professional dilemmas raised by considering whether or not to perform FGM.
Peter Moschovis argues that FGM is wrong because it violates universal moral
values and harms the patient-physician relationship overall. Also arguing
against FGM, Kyle Brothers challenges physicians to consider relating to their
patients as covenant partners whose voices deserve to be heard. Natalie Moniaga
makes the case that a physician opposed to FGM can still perform the procedure
without contradicting his or her values. And finally Sara Cichowski relates
a fictional dialogue between a young woman requesting FGM and the surgeon
whom she asks to perform the procedure. Cichowski based the dialogue on an
actual encounter she had with a young woman who requested a similar procedure.
We thank this year's judges—Jeffrey Botkin, MD, MPH, Sally Sheldon,
PhD, and Sidney Wolfe, MD.
She cut everything—she didn't cut the big lips, but she
sliced off my clitoris and the two black little lips, which were haram—impure—all
that she sliced off like meat. Oh, Rahima, I thought I was going to die. .
. . She sliced the top off my big lips and then she took thorns like needles
and put them in crossways, across my vagina, to close it up.1
These are the words of Aman, a Somali woman, recounting her childhood
experience of circumcision. In her 1994 autobiography, she weaves a story
of growing up at the interface between her native Somali culture and Western
colonialism. The dilemma of circumcision is a microcosm of the clash of cultures
in Aman's life. Like many women from tradition-centered cultures, Aman is
torn between a profound sense of cultural loyalty and a commitment to a life
of freedom and empowerment. The meaning that she derives from her culture
is central to her self-image as a woman, but the experience is profoundly
traumatic. The tension that arises from Aman's experiences can be extended
to the broader question of the ethics of female genital mutilation (FGM).
Estimates confirm that Aman's experiences are common. In 1998 the World
Health Organization estimated that more than 135 million girls and women had
undergone some form of FGM, and 2 million girls are at risk each year.2 The practice is most widespread in Africa; in some
countries as many as 97% of all women have been circumcised. In addition,
FGM has become increasingly common in immigrant and refugee populations in
Western Europe and North America.2 A landmark
1997 joint statement of the World Health Organization, UNICEF, and the UN
Population Fund defined four types of genital mutilation.3
Based on this classification, Aman and the African woman in this case underwent
type III FGM, which is the most radical form of genital cutting. The associated
physical complications range from minor to severe for all types of FGM.4 Common postoperative complications include urinary
and reproductive tract infections, dysmenorrhea, and hemorrhagic shock. Longer
term complications of type III FGM include failure to heal, urinary retention
or incontinence, dermoid cysts, urinary and reproductive tract infections,
and dysmenorrhea.2 Several cases have been
documented of girls bleeding to death after physicians performed the procedure,5 casting doubt on the assertion that the sequelae
are less severe if a physician performs FGM instead of a midwife. The most
frequent complication of FGM is the diminishing of the woman's sexual pleasure
and libido.6 Infibulated women often require
the scar to be cut open on their wedding night, especially if their husbands
are unable to penetrate the small opening that remains. Some women ask to
be reinfibulated after each childbirth, having the separated edges sewn back
FGM is not practiced in a cultural vacuum. Virtually every culture that
embraces FGM carries it out in the context of an elaborate ceremony, which
for many is a mark of initiation into womanhood. An uncircumcised woman may
be viewed by peers and potential spouses as less of a woman, unclean, and
disloyal to her culture. As a result, women and midwife practitioners are
often among the strongest proponents of the practice.8
In many cases, the ritual is associated with a woman's religious identity.
One popular mythological justification for the circumcision of both men and
women is the belief that the male prepuce and female clitoris represent feminine
and masculine elements, respectively, and must be excised to prevent gender
confusion.9 "The clitoris of the girl is
in fact a symbolic twin, a male makeshift with which she cannot reproduce
herself, and which, on the contrary, will prevent her from mating with a man,"
explains Ogotemmêli, an elder of the Sudanese Dogon people.10 Since FGM may diminish libido, many see the procedure
as a means of preventing promiscuity. Another Dogon leader contends that "The
uncircumcised think of nothing but disorder and nuisance."10
These accounts illustrate the profound meaning that FGM can carry for
those who undergo it. They cannot, however, answer the question of whether
a physician has the right to pass moral judgment on his or her patient's choices,
especially when they are informed by deeply held cultural values.11
The principle of autonomy mandates that physicians respect their patients'
right of self-determination: their care must parallel patients' values, interests,
and desires. Because these factors are to a large extent culturally constructed,
physicians are obligated to respect cultural differences and, when possible,
to honor and even to learn from them. The extreme of this perspective—cultural
relativism—holds that all cultures and their practices are equally valid,
and that it is improper to pass judgment on another culture.5
Respect for this patient's autonomy and culture, however, does not preclude
condemning the practice of genital mutilation. Even within societies that
practice FGM, a plurality of views exists. Deconstructionists have argued
that no culture is completely uniform, noting that policymakers often consider
the voices of the powerful few while ignoring the voices of the oppressed.12 A recent study in central Sudan indicates a growing
disenchantment with the practice among younger mothers, a moral flux that
is important in informing discussion of FGM.13
Even a cultural relativist can use the internal standards of a culture
to point out the questionable character of a tradition. For example, Islam
does not condone FGM, and the practice antedates the arrival of Islam to African
countries.14 Reference to cultural values
that the woman already accepts allows the physician to develop an "argument
from within" against the practice.
By making use of the principles that inform a patient's world view,
a physician can often persuade the patient to adopt an alternate course of
action.15 Furthermore, strong international
precedents exist in making judgments about the ways other cultures have treated
women. Examples include the Western opposition of sex slavery in Eastern Europe,
the mass rapes of Bosnian women in the last decade, and prenatal sex selection
and female infanticide in China. Western influences also played an important
role in the eradication of Chinese foot binding.16
A rejection of cultural relativism, however, is insufficient justification
for refusing to treat the patient.
The necessary added ethical force comes from the fundamental moral mandates
of medicine: doing good and avoiding harm. Ethical debates about privacy rights,
autonomy, and health care allocation are far from settled. However, doing
good and avoiding harm form the foundation of the practice of medicine. While
the specifics of beneficence and nonmaleficence certainly vary by culture
and clinical context, these two principles give physicians the right—and
indeed, the obligation—to withhold treatment that they consider harmful
The physician must sensitively and respectfully engage the patient in
a discussion of values, eliciting contributing facts that elucidate the values
underlying the available options. In this way, the physician can both honor
the patient's culture while gently presenting his or her own moral perspective.
Ultimately, the only direct control that physicians can exert is over whether
they will personally perform the procedure. They cannot dictate their patients'
actions. As Aman says, "If Somali women change, it will be a change done by
us, among us. . . . To advise is good, but not to order."1
Carrying out this sort of dialogue does not diminish the difficulty
of the dilemma. On the contrary, the stakes remain high, since refusing to
perform the procedure may result in future harm to the patient if she develops
complications by having the procedure performed in her homeland. But this
potential harm must be viewed in the context of the patient-physician relationship,
since performing the procedure will not only affect the individual patient's
health, but alter the patient-physician dynamic overall.
Performing FGM sets a dangerous precedent in the professional relationship
and may obligate the physician to provide future interventions that he or
she considers improper, frivolous, or harmful.17
Physicians ultimately gain credibility by refusing to provide services that
they deem unnecessary and detrimental, such as prescribing antibiotics for
viral infections, even if their patients demand them. In addition, physicians
who perform FGM, even while attempting to persuade patients otherwise, implicitly
sanction the practice. While cultural relativists argue that a detached, nonjudgmental
stance allows physicians to shift the ethical burden onto their patients,
experience shows that this moral distance is artificial and impossible to
maintain.18 The patient-physician relationship
is based on a patient's trust that the physician is committed to the patient's
best interest. When the physician compromises this commitment explicitly by
providing medically unnecessary procedures, or implicitly by offering such
services, the relationship suffers.
The central ethical tool for difficult decisions is the dialogue itself,
for it acknowledges the need of both individuals to learn from one another.
Physicians must listen to their patients and attempt to enter into their patients'
framework of values as much as possible. In this context of shared moral reasoning,
they can learn from the insights of their patients while contributing their
own perspectives. By combining humility, respect, and commitment to the patient's
good, a physician can remain true to the principles of multiculturalism and
justice while maintaining an ethically sound position.
At its best, the patient-physician relationship is not simply a contract,
but a covenant. Unlike a contract, the focus of a covenant is not on rigid
duties and obligations, but on what the two parties can achieve together to
optimize the patient's health. The physician's responsibility is to respond
with commitment, empathy, and creativity, especially when the patient's health
is at risk, as in the case of the 18-year-old female African patient.
In Covenant, Community, and the Common Good,
Eric Mount builds on a Jewish philosophical tradition to describe the way
a covenant relationship can accommodate the "vulnerable other."1
Like the groups that Mount discusses, the stranger, the fatherless, the poor,
and the widow, this woman is vulnerable in that she may face considerable
harm if left to confront her situation alone. Because this patient's experience
of the world is so different from that of the physician, he or she may misperceive
the patient's beliefs and attitudes. Due to this "otherness," her world is
"accessible only to the extent that genuine dialogue occurs."
The difference between the cultures of the physician and the patient
is a specific type of "otherness" that poses a considerable threat to communication.
Many argue that applying Western concepts of feminism, sexuality, and human
rights ignores the cultural values of the societies that participate in female
genital mutilation (FGM). For example, Sudanese women may view infibulation
as an "assertive, highly meaningful act that emphasizes female fertility by
de-emphasizing female sexuality."2 However,
it would be a mistake to assume that this patient supports the practice of
FGM. There are wide variation in the beliefs of African women about this practice,
and this patient's time in the United States may have further altered her
The physician must engage in a dialogue with the patient to discover
her perceptions of FGM within her own community. I will consider 2 opposing
responses to the question "What are your own beliefs about female circumcision?"
to illustrate issues that may arise.
Response 1: I don't want to have the surgery! Please
help me get out of this situation! This is a call to action to the
physician, who could respond by referring her to African groups that work
to replace or eliminate FGM. One project in Kenya offers a "noncutting ritual
event" as a replacement for coming of age ceremonies involving FGM. If similar
programs exist in the patient's home country, they might be a viable option.
Referral to such a group could provide the patient with support and may allow
her to avoid infibulation altogether. This simple step would empower the patient
and help her to reclaim her autonomy. However, the patient might reply that
she will nonetheless be obligated to undergo FGM to avoid ostracism and to
be eligible for marriage. If she experiences this obligation as a form of
coercion, the physician could help the patient to explore options such as
Response 2: Female circumcision is a tradition of
my people, and I will not stray from it. In this case, the physician
must realize that beliefs or values considered irrational in one culture may
be rational in another, and remember that patients have the right to make
informed decisions about their health. Regardless of his or her personal views,
the physician needs to provide impartial information about different types
of FGM procedures and the risks associated with them. The physician must also
consider the legal, professional, and personal consequences of performing
FGM. Physicians performing this procedure in the United States might face
prosecution, since FGM is considered to be a form of assault under federal
and state laws.4- 5
Simply refusing to perform FGM would do nothing to resolve the patient's
dilemma. The special covenant relationship requires that the physician offer
alternatives to the patient. For instance, the physician could help the patient
investigate the availability of trained health professions who are willing
to perform FGM under sterile conditions in her home country. Mandara6 discusses the results of interviews with 250 Nigerian
physicians, 20% of whom supported the medicalization of FGM, suggesting that
this patient may find a similar alternative once she returns home.
A dialogue between the patient and physician is the foundation of providing
a satisfactory response to the patient's status as the vulnerable other. What
begins as an ethical quandary can then serve to provide empowerment to the
patient. In the end, the vulnerable other is made less vulnerable, and opportunity
is found in her otherness.
Physicians take an oath to do no harm. Traditionally defined as physical
injury, "harm" has grown to include aspects of social and emotional well-being.
For a patient requesting genital cutting, harm must be considered both in
terms of her physical outcomes and cultural ideals.
Opponents of female genital mutilation (FGM) view the procedure as a
form of violence against women1 and equate
it with rape, domestic violence, child abuse, and female infanticide.2 While associated with many medical problems,3 FGM usually signifies passage into the social,
familial, sexual, and reproductive roles of womanhood.4
Genital cutting has even symbolized a celebration of normalcy in places such
as Sierra Leone, where civil unrest had once disrupted the practice. In 1997,
approximately 600 women underwent FGM to commemorate the end of that country's
civil war and as a show of the country's new found solidarity.5
Physicians must also consider the medical and social implications of
FGM. Beauchamp and Walters6 argue that informed,
autonomous, and competent adults have the right to hold views, make choices,
and take actions based on their values and beliefs. Nonetheless, US Federal
Law PL 104-20821 makes the practice of FGM on anyone younger than 18 years
a crime.4 Furthermore, several organizations
oppose the practice of FGM, citing numerous negative sequelae.5
However, the data on which such claims are based are largely confined to anecdotal
case reports without comparison groups.7
One recent study found that different types of genital cutting are associated
with different levels of risk for future gynecological or obstetric complications.8 Another found that commonly cited negative sequelae
were not significantly more common in women who underwent type II FGM.9
One harm-reduction strategy is to medicalize FGM by having trained practitioners
perform the procedure under sterile conditions. Opponents of medicalization
argue that FGM is unacceptable even under sterile conditions because it would
not prevent many of the long-term health consequences and that such medicalization
would legitimize the procedure. Proponents of medicalization counter that
FGM is already viewed as legitimate by those who believe in it and that not
medicalizing it would endanger the health and lives of women.3
Denying FGM in this case will not necessarily protect the patient from
harm, as she is likely to undergo the procedure in her homeland, with increased
risk of infection and other complications. In returning home, the patient
is choosing to abide by the norms of her culture. She may not view herself
as a victim in need of protection and may actively wish to undergo the rite.
Physicians must not pass judgment on the customs of their patients' cultural
practices, especially when the alternative may cause harm by cultural alienation
and social exclusion.
A physician cannot protect this patient from the negative consequences
of undergoing FGM in her homeland. However, a physician may provide some protection
by performing the surgery before she returns home. This may be a sound and
compassionate approach to improving the patient's health, but should be done
in conjunction with the traditional rituals associated with it. Providing
FGM without regard to its meaning would defeat the patient's desire to undergo
the surgery as a cultural rite.
Organizations that oppose the medicalization of FGM argue that only
eradication of FGM can protect the patient's health. But legislative and institutional
censure of the practice may actually be harmful if the practice is pushed
underground. Rather than joining in the effort to ban FGM, physicians must
educate their patients about its health risks and develop support structures
in which their autonomy could be used to make healthful decisions.4 However, physicians should not be required to perform
a procedure they personally consider to be wrong.
FGM can only be eradicated when the quality of life for women is raised
by resolving other problems such as poverty, the effects of war, unemployment,
discrimination, lack of education and health care, and women's poor legal
status.10 Until then, physicians must educate
their patients and work to minimize the physical, emotional, and social harms
to which they are subjected.
Beatrice did not greet me as I walked into the exam room, and I knew
something was wrong. "I'm worried. I only think about one thing," she began.
"When I return to Sudan I must be circumcised. But I fear the pain, and I
have seen infection kill my cousins. I want you to perform my circumcision."
Almost before the magnitude of her request hit me, an excuse leaped
out of my mouth, "But I don't do that—I've never performed a female
"But you can help me," she replied quietly.
"Who told you that you must be circumcised?" I wondered aloud.
"I told myself that I must be circumcised," Beatrice answered.
"But do you want to be circumcised?" I challenged, hoping that someone
forced this on her.
"I cannot carry my head proudly if I return to my people uncircumcised
and unmarried at 18. They'll laugh," she explained.
"Beatrice, I can't consent to do a surgery on you that I do not know
you have chosen. Is it your desire to be circumcised?"
"Americans value their personal choices. The right to choose overwhelms
me. Our ways, our people, our culture will disappear if we do not let our
ancestors choose our path. I have known my choice since being a little girl.
As little girls, we played by pretending that our turn had come. What will
be said of me if I am not circumcised?"
"Yes, but I will cause you pain and . . ." I argued, but Beatrice interrupted,
"Doctor, that pain is my duty to bear as a woman."
I explained that I was unwilling to surgically remove parts of her body
without medical cause. I was frustrated that she could not see the violence
of this procedure nor the bondage of being marked as tribal property. Incredulous,
but wanting to understand her perspective, I asked why she wanted the circumcision.
"I want a man from my tribe to marry me," Beatrice explained, "and no
decent man will take me as his bride now. After circumcision, I will please
my husband. If I refuse, my father will not receive the bride price he deserves.
Circumcision will mark me as a woman."
She saw two choices: circumcision performed by me or by a village elder.
I saw two different ones: to accept or to refuse circumcision.
I saw a potentially liberated, revolutionary woman in charge of her
own body. She saw an ancestor willing and eager to carry on her people's traditions.
I mentioned I had physician friends in Sudan who were advocating abolishing
the practice and that she could find ways to avoid having the procedure done.
"Doctor, that is not my fight. We need your immunizations, food, and
education. We do not need your traditions. But, I would like your help to
get a circumcision. Other tribes' mark with tattoos, piercings, or cuttings.
Our mark is circumcision. It defines us as women of our tribe. The only reason
we do not circumcise with anesthetic and clean blades is because we cannot
afford them. Do not ask me to rebel against my people. I would have no home."
I hesitated. "If I were to give you the anesthetic, a clean blade, antibiotics,
bandages, and suture, could your village elder use them?"
"If you will not perform my circumcision then I would appreciate these
things," Beatrice answered.
I reasoned that giving her these things still left her the option of
refusing circumcision. But as I gathered the sterile blade, topical anesthetic,
suture, and bandage, and wrote the prescription for antibiotics, I couldn't
completely escape the sense that I had betrayed her and myself. I tried again
to convince myself that I had washed my hands of her blood.
As Beatrice left the exam room, I knew that I had made the right decision.
I did what I could to stop her, and when I couldn't, I fulfilled my duty to
You have two patients: a mother and her adult daughter. The mother has
begun to show signs of early Huntington disease (HD). A test for the genetic
mutation causing HD confirms your clinical suspicion. You have counseled the
mother that her daughter's risk of carrying the genetic mutation is 50%, but
the mother has refused to discuss the issue with her daughter. She has also
forbidden you to do so because she doesn't want her daughter to be burdened
with the knowledge that she might get HD. The daughter has told you recently
that she is thinking of starting a family. She knows nothing about the family
history of HD because her mother is the only source of information. The HD
mutation is autosomal dominant and 100% penetrant. What do you do? What are
your obligations to your two patients? What ethical considerations should
be taken into account?
Entries must be postmarked by February 1, 2003,
and sent to Conley Essay Contest, c/o MSJAMA, 515
N State St, Chicago, IL 60610. The author(s) of the best essay(s) will be
awarded $5000 or a portion thereof. More information about the contest is
available online at http://www.msjama.org.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and
Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early
dhildhood mortality and growth failure data and their association with maternal
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