Poster Reads: From the medical aspect, FGM is most harmful. Source: UNFPA

From Midwives to Doctors: Searching for “Safer” Circumcisions in Egypt?

09/25/2014 . By Sara Abdel Rahim

While the verdict in Egypt’s first female genital mutilation (FGM) trial has been delayed until October 23, a health inspector’s testimony in this milestone case may help to deliver a guilty verdict. The trial brings charges against the father and doctor of 13-year-old Sohair al-Bata’a for obtaining and performing the procedure that resulted in the girl’s death. Sohair’s father had taken her for the procedure, and, according to his testimony, a nurse moved Sohair into a recovery room after the procedure while he waited for her to wake up from the effects of the anesthesia. But Sohair never did; the health inspector’s report cites her cause of death as “a sharp drop in blood pressure resulting from shock trauma.”

Sohair’s case is truly a landmark. Not only are the doctor, Dr. Raslan Fadl, and the father, Mohamed al-Bata’a, the first to be charged under Egypt’s 2008 anti-FGM law, but the international publicity surrounding the case shatters a global perception of the practice as one that is confined to rural, “traditional” environments and performed in unhygienic settings.

In fact, the case reveals a growing phenomenon: female genital mutilation (FGM) is increasingly regarded as a medical procedure. Today in Egypt, parents opt to take their daughters for circumcisions at a clinic rather than seeing a traditional practitioner; this decision is affirmed by the sense of security in having the procedure performed under the guidance of doctors or nurses and with the assistance of modern medicine. With a doctor’s blessing, parents feel justified in their decision to circumcise their daughters, confident that this “cosmetic surgery” has helped to ensure their daughters’ marriageability.

The trial raises a series of critical questions. Despite numerous campaigns against FGM, families still seek to circumcise their daughters and doctors are continuously willing to risk girls’ lives or the quality of their lives by performing the procedure: why is a procedure that has been described over and over again as “barbaric” being performed in Egyptian clinics? Why do medical practitioners agree to perform FGM? And, most pressing, how can this medicalized phenomenon be addressed?

 

Modernizing FGM: From “Tradition” to “Procedure”

According to Egypt’s 2008—and most recent—Demographic and Health Survey (DHS), the prevalence rate of female circumcision is 91% amongst women age 15-49. While the practice is generally perceived as a Muslim tradition, in Egypt FGM is practiced by both the Muslim and Christian communities (despite the fact that it has been denounced by religious leaders in both).

And yet, motivations for FGM are not as simple as its religious or “traditional” value. Mothers ((Though mothers or other female matriarchs are the ones societally tasked with navigating the decision for their daughters, in some parts of rural Egypt men heavily weigh in on the decision to circumcise girls in the family. Abdel Rahim, Sara. Perceptions and Justifications for Female Circumcision in Egypt. 2012. [Forthcoming].)) navigate various levels of decision-making processes and justifications in making the decision to circumcise their daughters. To reach a decision generations of family members are consulted, some consult fellow females in their immediate communities, and others seek guidance from respected community leaders (often religious figures and community centers). Given the complexity of the choice, mothers often seek out a doctor’s opinion to help reach a conclusion; doctors thus have played an integral role in reshaping the practice as a contemporary one, challenging the global image of the procedure.

This increased trust in doctors represents an important shift in the practitioners of female circumcision over the past three decades. According to the 2008 DHS, 63% of women aged 15 to 49 who had undergone the procedure were circumcised by dayas (traditional birth attendants). In a narrower pool of girls aged 0-17, 71% of circumcisions were performed by doctors. This shift reveals the medicalization of female circumcision—a practice which is not, in fact, a medical procedure.

At a family planning clinic in Cairo’s suburb of Magra El Magra El-Oyoun, Amani, a mother of four daughters in her early to mid-forties, recalled her own “justification” process in deciding to circumcise her oldest daughter. She took the girl, who was 17 at the time, to a doctora (female doctor) and, upon examining the girl, the doctor explained to Amani that her daughter was not in medical need of circumcision. ((According to Amani’s explanation, the doctor explained this was because “the size is not big, it’s tiny.” In explaining the phrase, “the size is not big, it’s tiny,” Amani began to describe the female anatomy in vague terms, a sign which affirmed that she’d broached an overarching taboo subject, sex. The sensitivity of the subject adds an additional layer of complexity to how such a widespread practice is undertaken to address a subject under addressed in Egyptian society. Abdel Rahim, Sara. Perceptions and Justifications for Female Circumcision in Egypt. 2012. [Forthcoming])) “[Doctors] say when the size is larger it’s a must that [a girl] be circumcised. That’s what I know and what [doctors] told me,” was Amani’s confession of her knowledge on the necessity of the procedure. Amani’s admission revealed the immense level of trust and value mothers place on doctors in making the momentous decision of circumcising their daughters.

“It’s something that [doctors] don’t learn at medical school,” Dr. Mawaheb El-Mouelhy, principal investigator of a World Health Organization (WHO)-funded study into women’s sexuality and FGM explained. “The problem with a physician performing the practice is that there is no [guide] operation in the medical textbooks to teach female circumcision.” ((Ibid.))

Most mothers, however, do not realize this fact. One mother, an adamant supporter of the practice argued, “[female circumcision] could continue today because of the safety provided by having it done by a professional, such as a doctor, rather than a daya.” ((Ibid.)) This mother was replicating a tradition passed down from her own mother, but with a “modern” bend in taking her own daughters to a doctor for their circumcisions. She asked, “Why would I in the current century go to a daya and risk [my daughter’s] life?” ((Ibid.))

As mothers see the circumcision procedure as becoming more “modern” in a medicalized environment, they have adopted new language in their characterizations of circumcision. This language counters images of female circumcision as barbaric and unsanitary. Mothers use terms like “amalyet tajmeel” (cosmetic surgery) to remove “zeyadat” (excess) to achieve a more “pleasant” or “helw” appearance of girl’s anatomy. ((Ibid.)) These new terminologies do not replace the commonly perceived justification of female circumcision—ensuring girls’ piety and soutra (chastity protection)—but rather enforce it. An amalyet tajmeel is believed by mothers not only to benefit daughters by ensuring their piety and chastity (due to decreased sexual drive), but also ensure the girls future marriageability.

 

Doctors’ Roles (and Responsibilities)

To receive the procedure, mothers are often willing to pay upwards of 1000EGP (140 USD) to secure the procedure for their daughters, a hefty cost for families in a developing country where around 20% of the population lives on less than $1 USD per day. ((Ibid.)) Doctors and health professionals (often nurses) moonlight to perform female circumcision, drawn in by the lucrative additional income in a professional field that suffers from low wages. However, while monetary incentives are noted as a contributing factor, doctors do actually believe that the practice is necessary, despite having no medical basis. A 1999 study surveyed 500 physicians from the Ministry of Health in Egypt on their opinion on the practice and found that at least 50% of doctors stated that female circumcision was necessary for at least some women. The survey reveals the grave rootedness of the procedure within the medical field. ((Denniston, George C., Frederick Mansfield. Hodges, and Marilyn Fayre. Milos. “1.2 The 1950s.” Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice. 1999. 319-20.))

The alarming percentage of doctors conducting FGM in Egypt today reaffirms the need for an overdue review of medical education across the country. It further raises a responsibility to provide culturally-relative medical curricula with adequate training for young doctors to provide parents with the most accurate information about the medical risks of FGM. More so, a commitment by medical universities to ensure the proper instruction and adoption of medical ethics is an essential component to combat the growing numbers of medically performed female circumcisions.

There is an additional need for a new measure to assess the effectiveness of previous and ongoing anti-FGM programs and awareness campaigns undertaken by various groups in Egypt, in order to ensure that these address the medicalization of the practice and do not deliver mixed messages to their target audience. New measures to assess existing programs are imperative to help identify where and when specifically medical professionals began primarily performing the practice was undertaken, in order to better understand the root causes of this shift. A proven correlation between the higher level of education of women and decreased likelihood to circumcise daughters calls for a vigorous and reenergized anti-FGM campaign which inherently promotes women’s education with a mirrored commitment in governorates to ensure girls’ enrollment to eliminate the practice’s future and the false sense of “safe circumcisions.”

In the next hearing in the case against Dr. Raslan Fadl and Mohamed al-Bata’a, Egypt’s judiciary must continue to drive the message that FGM is a crime, not a beauty procedure, by setting irrevocable precedence in delivering justice to Sohair. Furthermore, it is time for the domestic and international medical community to join them in ensuring that her death is one of the last of the rampant practice and its mythical “safer” options.