KUALA LUMPUR, Dec 10 – A Malaysian woman said she is triggered by the sight of blood from her menstruation every month. This is because it brings back painful memories of the time she was circumcised at the age of nine.
Another Malaysian woman, who had needling and pricking done on her when she was five, recalls the experience as being extremely painful and said she is traumatised by it.
According to the World Health Organisation (WHO), needling and pricking of the genital area falls under Type 4 of Female Genital Mutilation/Cutting (FGM/C), which proponents of the practice would argue is the least harmful of all the types of FGM/C.
Yet, the experiences of these women, who related them to Dr Hannah Nazri, a Malaysian obstetrician and gynaecologist based in the UK, indicates that the practice is far from a benign and pain free experience, not just physically but also psychologically, for those on the receiving end of it.
“When it’s done in older girls, they remember the procedure to be extremely painful to the point of momentarily losing the ability to speak, hear, or see,” Dr Hannah said at a side event on FGM/C in Asia at the International Federation of Gynaecology and Obstetrics (Figo) World Congress last October 8, which was streamed online.
Imagine an infant being subjected to the same trauma.
Preference Is To Perform FGC On Much Younger Female Infants
According to one study, Malaysian Muslim doctors prefer to perform FGC on much younger female infants, between four to six-months-old (34.7 per cent) versus at seven to 12-months-old (32 per cent).
In another Malaysian study led by Dr Dayang Anita Abdul Aziz, which is published in the book Pembangunan dan Pemerkasaan Wanita (Women’s Development and Empowerment), 15.1 per cent of baby girls are circumcised before they are even a month old. The study also found that 36 per cent of female children are circumcised between the ages of one to three years old.
The use of the term circumcision, as the practice is commonly referred to in Malaysia, does not negate the fact that it is a procedure that falls under the WHO’s definition of FGM/C and that it causes pain and suffering on the individuals subjected to it.
WHO defines FGM/C 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.”
According to Dr Dayang’s study, 56 per cent of the parents surveyed observed complications following the procedure on their child. This includes bleeding (34 per cent), swelling in the genital area (2 per cent), and redness in the genital area (14 per cent).
Among the parents who observed complications, 43 per cent said they observed a difference in their child’s genital area after being circumcised, but were not sure where or what the difference was.
The figures were even higher among doctors who performed the practice in the same study: 92 per cent of them said there were complications that included bleeding (86 per cent), continuous bleeding that can be seen on the baby’s diapers (28 per cent), and the babies crying (54 per cent).
More To Clitoris Than Meets The Eye
In her presentation at Figo, Dr Hannah poured cold water on the notion that Type 4 FGM/C is harmless by referring to the clitoral anatomy. “The mean clitoral length, which you can see externally, in newborns is about less than one centimetre, and the clitoral hood becomes more retractile as you increase in age and therefore in female infants, it’s highly adherent.
“You can see some nerves which are quite superficial (referring to her presentation), just underneath the skin. So even if you think that you’re just cutting the skin, you’re cutting the nerves as well and the blood vessels which are all there,” she explained.
She added that the mean number of fibres in an adult clitoral dorsal nerve is about 10,000, which has a nerve density that is a lot lower in comparison to the human hand. “So you have an area which is really tiny with really dense nerve fibres that has a growth potential of four times between infancy to adulthood.”
The dorsal nerve of the clitoris is important for female sexual pleasure, and may play a role in clitoral erections.
“When we’re pricking and niggling, we’re actually subjecting female infants to a lot of pain unnecessarily,” Dr Hannah said. “And in an adult, the clitoral shaft and the external clitoris can go up to like four centimetres. So whatever you cut or you prick, you’re actually removing tissue that could grow.”
Circumcision Is Condoned Due To Purported Lack Of Harm
Because FGM/C is typically perfomed on infants and young girls in Malaysia, there is a paucity of studies to confirm its long-term physical and psychosocial impact.
Testimonies like the one shared by the two women, one of whom approached Dr Hannah after she gave a presentation on FGM/C at the Royal College of Obstetrician and Gynaecologists (RCOG) World Congress, are hard to come by as many women cannot recall their experience of being circumcised.
It is on this hill that proponents of FGM/C defend the practice as the notion of no harm or minimal harm is invoked, especially in comparison to the way FGM/C is perfomed in Africa, to justify its continued practice.
The argument that it renders no harm, as evidence that suggests otherwise is lacking or limited, is used to condone circumcision because it is purportedly a religious or cultural obligation.
For example, the Malaysian Federal Territories Mufti Office (FTMO) has declared that female circumcision is wajib (obligatory), specifying that for females, the area to be circumcised “is the part of the skin above the urethra (clitoris), which is like the rooster’s skeleton.”
It also added a caveat that “for females, circumcision is only to be thinned or trimmed, and not to go too far in cutting, such as the practice of female genital mutilation, which damages and disfigures the clitoris.”
While the FTMO made a distinction between female circumcision and FGM/C, a recently released policy brief by RCOG and various Asian based NGOs, argue that such pronouncements are not based on a concrete understanding of female genital anatomy, especially in infants.
“The assumption that minimal cutting equates to no harm fails to recognise the anatomical complexity and sensitivity of the clitoral structure, as well as the broader ethical, psychological, and human rights implications of the practice,” noted the brief.
It also pointed out that female circumcision is not a procedure included in the curriculum of any health care accredited degree programme worldwide.
“Tug Of War” Between Religious Bodies And Medical Authorities
Although the practice has no foundation in medical science, many medical professional bodies in South and Southeast Asia appear to have self-imposed a gag that bars them from speaking out against the practice, primarily in deference to the religious or cultural status quo.
According to the brief: “Rather than taking a clear stance against it, some choose to remain non-committal, hoping the issue will quietly resolve itself.”
In Malaysia, the silence from the Malaysian Medical Council on FGM/C is reflective of what Dr Hannah describes as the “tug of war” between religious bodies and medical authorities that dance in circles around each other to avoid putting their feet in their mouths.
As the policy brief pointed out, the fear to speak out or condemn the procedure may be misconstrued as measures motivated by religious intolerance.
While Dr Hannah calls it as she sees it: “It is a pseudo-religious practice. We have to acknowledge that”, she also acknowledges that the plural legal system in many Southeast Asian countries, where the lines between civil, Syariah, and customary laws can become entwined in a Gordian knot, complicates matters.
However, she said medical experts have the benefit of their professional training to discern for themselves whether there is any merit to the practice.
Use Principles Of Medical Ethics As Guideline
“When we look at medical procedures or any medical treatment that we offer to patients, you need to satisfy all four of these,” Dr Hannah said, referring to Beauchamp and Childress’ principles of medical ethics in her presentation, which are: beneficence, non-maleficence, autonomy, and justice.
“Is there a benefit to doing this procedure? And that needs to be balanced with any complications that you may have, and the patient’s right to decide whether the procedure or treatment is appropriate for them,” she continued, explaining how the principles should be taken into account by doctors considering a procedure.
She said the principle of justice arises when doctors who perform circumcision are neglecting more important responsibilities because they are preoccupied with the procedure. It should also be a guiding principle when consent is being considered.
“I remember when I was giving an online talk with OGSM (Obstetrical and Gynaecological Society of Malaysia), someone mentioned that parents can give consent. Is it right for parents to give consent over procedures that have no medical benefit? It’s not the same as consenting someone for an appendicitis surgery.”
It comes back to the principle of non-maleficence or do no harm, which is also a central tenet of the medical profession.
While evidence on the harms of FGM/C as it is perfomed in Malaysia, from the patients’ perspectives may still be wanting, international bodies including Figo have not wavered in their position that it is a human rights violation with no medical benefit.
“Health care professionals must not perform or condone any form of FGM/C, including medicalisation. And this is not a new or ad-hoc stand,” said Dr Hannah, adding that it has been the cumulative consensus of the global OBGYN community for decades now.
As a member of the RCOG, Dr Hannah said it was incumbent upon her to point out that the RCOG maintains the same position as it believes that FGM/C “can cause significant lifelong harms.”
She added that in the UK, clinicians’ legal and safeguarding responsibilities include mandatory reporting of cases as FGM/C is illegal in the UK.
Not A Western Agenda
While the policy brief noted that advocacy against FGM/C is viewed as part of a ‘Western agenda’, that has strengthened the resolve of communities to continue the traditional practice in defiance of Western imposition, a leaflet co-produced by the Malaysian Doctors for Women and Children, an organisation founded by Dr Hannah, maintained that FGM/C was not always mainly the domain of Muslim communities and African countries.
Accoding to the leaflet, clitoridectomies, a procedure that fits the description of FGM/C, were first promoted by Dr Isaac Brown in the 1860s, who had set up a clinic in Notting Hill, London for “women diagnosed with‘hysteria’, epilepsy, depression, masturbation, and distaste of their spouse.”
The clinic was banned after the Obstetric Society of London debated the ethics of its operations. However, the ban imposed was not due to the harm it caused women, but rather because it couldn’t be resolved whether the father or husband should be allowed to provide consent for the procedure to be performed on women.
Clitoridectomies completely ceased from being practised in the UK during the 1870s. In the US, the practice continued into the mid-20th century (1933-1967) for reasons that were antithetical to each other: to prevent masturbation, and to enable women to achieve sexual orgasm.
The rationale for the procedure back then in those Western countries is echoed today in the reasoning of traditional midwives in Malaysia who have justified the practice as necessary to curb wild sexual urges and prevent promiscuity among girls and women.
They may not be exactly the same reasons as stipulated by the Western medical professionals of yore, but use of the procedure as a means of dominating and subjugating female individuals and their sexual proclivities appears to have stood the test of time.
However, while even a tiny cut during circumcision can affect the ability to experience sexual satisfaction and achieve orgasm when growing tissues are removed, there is no evidence to suggest that FGM/C has any impact on sexual behaviour and libido.
Sexual Desire Is A Lot More Complex
“Sexual desire is a lot more complex than that. It’s influenced by: drive, what happens in your brain neuroendocrinologically; motivation, the psychological interest to engage in sexual behaviour; and wish, which is influenced by your cultural values,” Dr Hannah explained.
“And of course, this leads to sexual arousal, the physiological response. So I think it’s really important to point this out to parents that if you want your daughters to grow up to be able to regulate themselves sexually, the better way is actually to educate them.”
She added that if religion was a concern among parents, then the religious perspective on promiscuity and abstinence should be incorporated into the educational discussion on sex.
“You don’t need to cut anyone’s genitalia,” Dr Hannah said, adding that there are also a lot of psychosocial aspects to enjoying sex. “When we tell women they can’t enjoy sex, I think it’s detrimental to them as well because the clitoris is not just what you see outside, it’s a lot more inside.”
Recommended Actions, Measures Against FGM/C
Advocacy against FGM/C must be grounded in facts and respect for local expertise, adapting appoaches that are suitable to the local cultural context, she said, adding that it was imperative to understand the legal system and the religious authorities involved before swooping in to declare that the practice should be banned.
Health care professionals can refer to the new WHO guideline on FGM/C, which was released earlier this year, said Dr Hannah. “It provides the latest global clinical standard, emphasises sensitive refusal skills and brief counselling messages, because we know that it’s really hard for doctors and health care professionals in communities (that) are not (supported) with legal frameworks to actually refuse this.”
She added that to hold them accountable, health care professionals found to engage in FGM/C should face meaningful sanctions, mandatory reporting mechanisms should be put in place, and the WHO global stategy to stop health care providers from performing FGM should be implemented at the national level.
“When it comes to patients and parents, we must understand that they love their children and educate them appropriately,” she continued. “I believe that before we go into any legal bans, education should be our first port of call.”
Most importantly, Dr Hannah said that stereotypes of victimhood or assumptions of harmful intent should be avoided. Instead, girls and women in the region should be framed with dignity and agency.
