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Leaflet: Many Doctors Who Perform Female Genital Cutting In Malaysia Lack Knowledge Of Clitoral Anatomy

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). This could result in more damage inflicted on younger infants as they could be removing too much growing tissue.

Cover of the leaflet Empowering Healthcare Professionals: Unveiling the Harms of Female Circumcision.

KUALA LUMPUR, March 20 – A substantial number of doctors in Malaysia who practise female genital cutting  (FGC) have implied that they may have insufficient knowledge on clitoral anatomy and physiology, according to the leaflet Empowering Healthcare Professionals: Unveiling the Harms of Female Circumcision.

The leaflet, produced by the Asia Pacific Resource and Research Centre for Women (ARROW), Asia Network to End FGM/C, and Malaysian Doctors for Women and Children, has the stated aim of providing accurate information on the practice of female circumcision in Malaysia to health care professionals, with the ultimate objective of bringing about the cessation of this practice within Malaysia.

According to the leaflet, female circumcision is not taught in medical schools. Most doctors learn to perform female circumcision from more senior colleagues, while others learn it from traditional healers.

Additionally, 86.7 per cent of doctors do not use any form of anaesthetic and 62.7 per cent do not screen for bleeding or infectious disorders before performing the procedure.

In Malaysia, the practice of female circumcision involves nicking or picking the clitoral prepuce/hood. The clitoral prepuce is the fold of skin that surrounds and protects the clitoral glans. The clitoral hood is part of the clitoral prepuce; however prepuce and hood are often used interchangeably.

Source: Empowering Healthcare Professionals: Unveiling the Harms of Female Circumcision.

This type of procedure is classified under Type 4 female genital cutting (FGC), according to the WHO classification.

WHO defines female genital mutilation (FGM) as comprising 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. 

The types of FGC based on the WHO classification include:

  • Type 1: This is the partial or total removal of the clitoral glans (the external and visible part of the clitoris, which is a sensitive part of the female genitals), and/or the prepuce/clitoral hood (the fold of skin surrounding the clitoral glans).
  • Type 2: This is the partial or total removal of the clitoral glans and the labia minora (the inner folds of the vulva), with or without removal of the labia majora (the outer folds of skin of the vulva).
  • Type 3: Also known as infibulation, this is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoral prepuce/clitoral hood and glans.
  • Type 4: This includes all other harmful procedures to the female genitalia for non-medical purposes, e.g., pricking, piercing, incising, scraping and cauterising the genital area.

Source: Empowering Healthcare Professionals: Unveiling the Harms of Female Circumcision.

The term Female Genital Mutilation (FGM) is sometimes used interchangeably with Female Genital Cutting. However, UN organisations such as WHO and Unicef have adopted the term FGM, particularly as part of its advocacy against the practice, such as through the International Day of Zero Tolerance for Female Genital Mutilation, which falls on February 6, every year.

According to the leaflet, since “no visible alteration or disfigurement of the female genitalia is evident in the context of the Malaysian practice, although conclusions cannot be made on the impact of FGC, it is more appropriate to define the Malaysian practise as FGC,  rather than female circumcision or FGM.”

However, the leaflet acknowledges that usage of the term FGC, instead of FGM, could undermine the gravity of the harm female infants may suffer from the procedure. 

As in the leaflet, FGC is used interchangeably with female circumcision in this article as the Malaysian public is more familiar with the latter term.

The Malaysian practice of Type 4 FGC, that is, nicking or pricking causes immediate and severe pain and distress in female infants. According to the leaflet, infants feel the same intensity of pain as adults, as proven through functional magnetic resonance imaging (MRI) imaging, where brain regions that correspond to pain light up in infants in a similar way to adult brains.

Prevalence Of Female Genital Cutting High In Malaysia

In Malaysia, the prevalence of FGC is still quite high, according to Rozana Isa, executive director of Sisters in Islam who was interviewed by Lim Sue Ann on BFM last February 6 on the topic.

 However, the most recent statistic available is derived from a study conducted back in 2012 by Dr Maznah Dahlui, a professor at the Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, which found that about 93 per cent of Muslim women in the country surveyed have been circumcised.

The practice is performed by mak bidan (traditional midwives) and doctors in this country. According to the leaflet though, midwives who have conducted FGC demonstrated inadequate knowledge of the female genital anatomy as they believed that if circumcision is not performed, the clitoris will expand and obscure the vaginal orifice, posing a challenge for penetration and depriving sexual pleasure.

The leaflet also maintained that some midwives have stated that female circumcision is done to prevent girls from becoming promiscuous. However, there is no evidence to suggest that uncircumcised girls are more prone to promiscuity than girls who have been circumcised.

Female circumcision may however impair their sexual motivation and ability to enjoy sexual intercourse due to the damage to the clitoral tissue.

Medicalisation Of Female Genital Cutting In Malaysia 

Increasing concern among parents about midwives’ use of unsterilised instruments, their lack of medical knowledge, and inability to prevent infection has led to the medicalisation of FGC in Malaysia.

“By medicalising it in terms of a procedure done in private clinics and hospitals, then they feel that they can try and minimise the harm,” said Rozana, adding that some medical professionals have said it’s only a matter of pricking enough just to draw blood.

“But it’s still something we really do need to interrogate because even the practice of this, culturally, has shifted from being done to girls as young as seven, eight or nine, at one point, to now being done onto babies.”

And while babies may already have their female genital organs, they may not be fully developed yet, she said. “So what are you actually pricking, cutting and what consequences this will have on the genitalia will not be fully known because babies can’t speak, essentially.”

Although female circumcision procedures are not taught as part of medical training in Malaysia, it is practised in private clinics and hospitals in the country, Rozana said, adding that the facilities advertise these services with banners and all-in-one packages.

As such, she said awareness about the harmful effects of FGC should not only be targeted to the public, but also to the medical fraternity so that they would better understand why the practice needs to end.

“We are just putting our daughter’s genitalia right into the hands of a medical practitioner and not knowing what is actually being done,” said Rozana. 

In a study cited in the leaflet, 20.5 per cent of doctors surveyed believe that the procedure should be performed by them to reduce the risk of infection. These doctors believe that FGC was necessary due to religious requirements and health reasons.

Alarmingly though, many of the doctors appeared to lack adequate knowledge about clitoral anatomy and physiology as evidenced by their responses from interviews conducted for the leaflet (see box below).

Source: Empowering Healthcare Professionals: Unveiling the Harms of Female Circumcision.

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), according to the leaflet, which added that this could result in more damage inflicted on younger infants as they could be removing too much growing tissue.  

It notes that it is extremely difficult to not injure or damage nerves and blood vessels which are mere millimetres underneath the clitoral prepuce/hood, and retraction of the clitoral hood is more difficult in infants.

Source: Empowering Healthcare Professionals: Unveiling the Harms of Female Circumcision.

Furthermore, 36 per cent of the 20.5 per cent of doctors who admitted to performing circumcision used surgical scissors to cut a small piece of the external clitoris, which means their procedure falls under type 1 FGC.

Extremely Painful To The Point Of Momentarily “Losing The Ability To Speak, Hear Or See”

The immediate physical complications of type 1 FGC include severe pain, genital swelling, haemorrhage, and wound infections (including tetanus), which can lead to septicaemia and death.

Over a longer period, the complications may include chronic pain, keloid scarring, growth of nerve tissues that cause pain during intercourse, cysts, and sexual dysfunction.

In a personal communication with the leaflet’s lead author, Dr Hannah Nazri, an anonymous respondent said that when FGC type 1 was done among older girls aged five to seven-year-old, such as in the Muslim Bohra community in Sri Lanka, the girls recalled the procedure to be extremely painful to the point of momentarily “losing the ability to speak, hear or see.”

In order to perform female circumcision safely, you would need microsurgical tools, said Dr Hannah, who is a fellow with the UK’s National Institute of Health and Care Research (NIHR), during an interview with Melissa Melina Idris on Astro Awani last March 10.

“And this is not available in any GP surgery that I’m aware of in Malaysia. So it is not done safely anyway.”

Dr Hannah opined that awareness about the harmful effects of FGC should be inculcated among health care professionals from the early stages of their medical education.

“It has to be from university and we have to keep re-educating health care professionals about it. I’m not saying that they’re not aware of it, but they’re probably not too aware of it.”

 A Pseudo Religious Practice

She questioned why a procedure that does not bring any medical benefit is still being widely practised in the country. “It is not taught in any medical school worldwide. It is not a medical procedure. It’s a pseudo religious practice, which we know is not justified in Islam,” said Dr Hannah.

There is no mention of FGM or FGC in the Quran, according to Rozana, who added that it is the hadiths (sayings of the Prophet Muhammad) that is used to validate the practice of female circumcision.

She quotes a hadith which says: ‘Fitrah itu ada lima: berkhatan, mencukur bulu kemaluan, mencabut bulu ketiak, memendekkan misai, dan memotong kuku.’ (Five things that are in accordance with the religion: circumcision, removing the pubic hair, trimming the moustache, cutting the nails, and plucking the armpit hair). 

While that hadith is considered authentic, said Rozana, “there is still no specific command for female circumcision.”

The leaflet points out that authentic hadiths do not directly address female circumcision, let alone endorse it. They may allude to circumcised organs but often use the term for male circumcision (khitan or khatan) rather than female circumcision (khifaadh) in Arabic.

Additionally, the practice of female circumcision is not documented among the female family members in the Prophet’s household, nor among early Muslim communities, according to the leaflet.

Rozana agreed with this. “The Prophet himself has not carried out these practices onto his own daughters. That is something that is very clear and known.” 

Carrying On A Tradition

Based on focus group discussions run by her organisation with young fathers and mothers, tradition has been cited as a reason for the practice of FGC.

“It’s done because of tradition, because it’s always been done in the family. And we find it very interesting that women would want to continue the practice because this has been done by their grandmothers to their mothers and to them,” Rozana said, adding that for these women, the prospect of breaking with tradition might be a burden too great for them to bear.

“So they do it without really questioning as to why it’s being done. Although we do find there are more young mothers who are trying to learn more about the reasons why the practice is being conducted.”

She said young fathers with daughters have also started questioning the necessity of the procedure. However, they face challenges having the discussion with family members, particularly with their in-laws, in trying to make sense of the tradition.

“This is a very interesting development that young fathers are now being more involved in terms of trying to understand certain traditional practices and raising questions. But the challenge is having to deal with it in the context of the family, where there is family pressure to continue a practice,” Rozana said. “And the reason so far is not entirely well explained or well understood by the families themselves.”

Women in a focus group discussion in Kelantan comprising mothers and grandmothers were informed that the practice of female circumcision is not a religious requirement nor an obligation. They were also surprised to learn that states like Perlis do not make it obligatory to perform FGC. Despite all that, when asked if they would consider ending the practice, since it is not necessary, the women said no.

“They responded by saying no, we would want to continue the practice because it is a tradition,” said Rozana. “And when you ask them the reasons why, (they say) because it has always been carried on as a practice in the family. So I think that really is the biggest barrier towards ending the practice because it’s not something that families are willing to do away with.”

She maintained that MOH needs to take a stronger position on the issue. “I think they can have a much bigger influence on the public, in terms of educating the public, that this is a practice that does not bring medical benefit,” she said.

“They need to do it in a way that incorporates smart messaging to address religious and cultural myths that have been perpetuated as tradition, without knowing why it’s being done in the first place.”

Recognising Women’s Agency Over Their Bodies

It is also about recognising the fact that there is such a thing as sexual and reproductive health and rights (SRHR), said Rozana. 

“And the way forward is to inform women about their sexual and reproductive health and rights, and to make sure that there are services supporting her SRHR, her agency to make decisions, the recognition of her agency over her full bodily autonomy.

“I mean, how many women have actually seen their own genitalia. Do you know what it looks like in terms of its anatomy? Do you know what the functions are? And I think this is something that we should have a more open discussion about.

“We need to know ourselves before we put our bodies in the hands of another to make a decision for us. And oftentimes, with regards to women and their bodies, it’s always someone else making the decision. It’s not women themselves.”

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