Professor A.H.Sheriffdeen FRCS, Emeritus Professor of Surgery, Faculty of Medicine, Colombo.
Dr. Ruvaiz Haniffa MD, Head, Family Medicine Unit, Faculty of Medicine, University of Colombo

October 7, 2018, 12:00 pm
Introduction

Female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia or other forms of deliberate injury to the female genital organs for non-medical reasons. This practice is mostly carried out by traditional circumcisers, who often play other central roles in communities, such as attending on child births and assisting religious preparation of the dead (especially females) for burial. In many settings. Even health care providers perform FGM taking comfort in the erroneous belief that the procedure is safer when medicalized. The World Health Organization (WHO) strongly urges health professionals not to perform such procedures as it has no health benefits for girls or women. The data indicated that FGM is mostly carried out on young girls between infancy and age of 15 years.

The reason why it is performed vary from a religious to a mix of sociocultural factors within families and communities. The commonly cited reasons are;

1. Religious belief – Religious leaders take varying positions with regards to FGM, some promote it, some consider it irrelevant to religion and others contribute toward its elimination.

2. Social convention – pressure to conform to what others do and have been doing as well so as to be accepted socially and the fear of being rejected by the community over a myriad of communal settings. (In some communities FGM is universally performed and is unquestioned)

Research shows that, if practicing communities themselves decide to abandon FGM, the practice could be rapidly eliminated

In 2008, the World Health Assembly passed a resolution (WHA 61.16) on the elimination of FGM emphasizing the need for concerted action in all sectors – health, education, finance, justice and women’s affairs.This l ed to the United Nations General Assembly adopting a resolution to eliminate the practice of FGM in December 2012. Furthermore, in May 2016, the WHO in collaboration with the UNFPA-UNICEF joint programme on FGM launched the first evidence-based guidelines on the management of health complications from FGM. The guidelines were developed based on systematic review of the best available evidence on health interventions for women living with FGM – estimated to be around 200 million in 30 countries across Africa, Middle East and Asia where FGM is concentrated.

We shall deal with the topic under 4 headings;

1. The Islamic basis for/against female circumcision

2. Health benefits or lack of it as a result of female circumcision

3. The definitions/nomenclature/semantics

4. Brief discussion

1. The Islamic basis for/against female circumcision

We admit straightaway that we are not qualified at all to contest the religious scholars on the finality over this heading and we seek their learned guidance. A review of the Islamic literature indicates that religious scholars over the millennia have agreed that the “hadiths”which deal with female circumcision are at the very best ‘weak’.This means that they cannot be used to create an Islamic ruling since it is not certain whether it came from the Prophet or not.

The Quran does not mention female circumcision, even though a whole sura (chapter) is devoted to the Islamic life of the female and protection of the Health of the female. Moreover, a feature of concern is that there is evidence that the Holy Prophet

Muhammad (Peace Be Upon Him) did not subject his daughters to any of the procedures of circumcision. There is also an oft repeated narration that the Holy Prophet once looked at his eldest daughter Fathima and tears poured from his eyes and that moments later he had looked at her again and smiled. When questioned as to why he wept and smiled soon after, he had said that a vision had appeared to him of her funeral and that tears had come to his eyes and that soon after a vision had come showing him meeting up with her in paradise, which had brought the smile to his face. We leave our readers to infer and to come to their own conclusions from this relevant to this discussion.

2. Health benefits or lack of it as a result of female circumcision

According to the World Health Organization (WHO), any type of female circumcision has no known health benefit. One needs to understand that the male and female genital anatomy are totally different in terms of structure, function and susceptibility to diseases and infections and what applies to one need not necessarily apply to the other.

In the female, the clitoris is the uppermost organ in the perineum. It is a vestigial structure with no useful physiological function. It has a prepuce or “hood”.A little distance below it is the urethral orifice which transmits urine and does not get involved in sexual activity. Further below this is the vaginal orifice and passage which is a canal for sexual activity and the passage for childbirth. Sexually transmitted infections infect the vagina.

The male organ, the penis on the other hand serves as a passage for urine, sperms and comes into direct mucosal contact with the vagina during intercourse. Mucosal to mucosal contact facilitates transmission of sexually transmittable diseases from female to male and vice versa. The male urethra is thus vulnerable to sexually transmitted diseases, especially gonorrhea.

Circumcision in the male exposes the distal end of the penis, the glans penis to outside air resulting in change of its outer covering from mucosa to stratified squamous epithelium. There is Level 3 (weak) evidence to show that such circumcision protects some males from HIV infections. The clitoris on the other hand, being some distance from the site of sexual activity, has no role to play in transmitting or receiving sexually transmitted diseases. Female circumcision therefore plays no part in protecting a female from these diseases including the Human Papilloma Virus (HPV). HPV is commonly found in females who have unprotected sex with multiple partners; whether the female is circumcised or not. A more reliable preventive strategy of prevention of HPV infection and its consequences and complications is vaccination. The HPV vaccine is offered to all females routinely through the world.

The role of smegma (a sebaceous secretion in the folds of the skin, especially under the foreskin of the male penis), as a causative factor in genital tract malignancies particularly in the male is under continuing discussion. The current evidence suggests that smegma itself is probably not responsible for penile cancer, but it can irritate and inflame the penis, which can increase the risk of cancer (American Cancer Society). In this context the smegma originating from the uncircumcised clitoris and it leading to unpleasant and other more serious health consequences pale into comparison as in the female more smegma is produced under the labia. No amount of ‘hoodectomy’(Type 1a Female Genital Mutilation) or washing only the clitoris is going to reduce this.

3. The definitions/nomenclature/semantics

The words “Hoodectomy”,”Clitoridectomy”and “Infibulation”are certainly meaningful to the informed. The complete typology and subdivisions of Female Genital Mutilation can be obtained from: http:/www.who.int/reproductivehealth/topics/fgm/overview/en/)

4. Discussion

The vital questions in the performance of female circumcision are;

a. Who is going to perform this surgical procedure?

b. Who maintains standards/ quality control?

The person undertaking such procedure should mandatorily be required to be aware of the different types of procedures as described in medical/surgical texts and been trained in them.

This training will require also managing the associated complication of such procedure primarily the complication of scarring. There is evidence that such scarring causes stricture or severe narrowing of vaginal passage giving rise to complications such as obstructed labour, foetal and even maternal death of the mutilated child later on in life. (http:/data.unicef.org)

For males, there is the traditional village “Ostad”who has acquired expertise passing it from father to son or an acolyte through apprenticeship. Then there are MBBS doctors trained to carry this out usually under local anesthesia in an operation theatre environment. Thirdly there are even Consultant Surgeons who carry them out.

Circumcision in the male is a therapeutic operation for a condition called “Phimosis”where the foreskin or prepuce cannot be retracted. One of us has over 50 years of experience in surgical practice. He has seen a fair number of young boys, even infants with horrendous injuries to the penis as a result of errors/misadventures during the act of circumcision. These have occurred in spite of the male penis being very much larger and easily accessible when compared to the clitoris and its hood which is hidden in the labial folds, especially in children. Such injuries usually go undisclosed and are closely hidden as parents do not want negative publicity for and stigmatization of the unfortunate victim.

During the times of “ignorance”before the birth of Islam, as propagated by Prophet Muhammad (Peace Be Upon Him), female children were often killed soon after birth or even buried alive. Female circumcision too was a cultural practice prevalent in pre-Islamic Arabia. One of the proud achievements of Islam is the banning and stopping of these barbaric practices, together with emancipation of the innocent little girl child and protection of women. We need not go back.

We wish to conclude by reminding the reader that as recommended by the First International Conference on Islamic Medicine held in Kuwait in January 1981, the following were identified as six basic characteristics of Islamic Medicine;

i. Adhering to Islamic teachings and etiquette

ii. Adhering to logic in practicing medicine

iii. Holistic approach paying equal attention to body, mind and soul for individuals as well as for societies

iv. Universal approach, taking into account all resources and aiming to benefit all people

v. Scientific approach, based on logical conclusions drawn from sound observations, accurate statistics and trustworthy experience

vi. Excellence, achieving what other kinds of treatment has failed to achieve”.