Female circumcision a Sri Lankan medical perspective
Posted on October 7th, 2018

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


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”.

4 Responses to “Female circumcision a Sri Lankan medical perspective”

  1. Ratanapala Says:

    Why this Islamic obsession with human genitalia? Just leave as your god created them and all will be fine as in the rest of the world. Then all these high fluent academic or theological hair-splitting arguments will not be necessary. This obsession is the root cause of all violence against women and children both male and female in Islamic societies.

  2. Hiranthe Says:

    I fully agree with Ratanapala.

    If humans have to repair the gods creation, what is the position of this almighty god Allah?? Is he not the supreme creator according to Islam? Then, we have to come to a conclusion that humans are the supreme creators.

    It goes with the Buddhist principles. we create our own misery or success.

  3. Henry Says:

    The practice of FGM is nothing more than one more devious method employed by males to dominate females. As Dr. Sheriffdean, a good Muslim, has shown, it’s not written in stone in the Islamic faith. As described in the writings of many Islamic women, it is something that, degrades, & makes a woman rue the fact of being born a woman-the suffering they go through is immeasurable, not only in the act but also and in their lives. The internet is full of such literature-Hirsi Ali’s book is outstanding- depicting the misery this practice brings to women. It has existed from pre-Islamic times, and it is surprising that some Muslims still adhere to this barbaric practice-and that’s putting it mildly.

  4. Ancient Sinhalaya Says:

    Fastest Breeding Religion followers want to make Sri Lanka a mussie country. That is why all this halal, shariya,
    fgm etc etc. are being shoved down on us with ever increasing mussie numbers (votes). This dirty, disgusting, sub
    human trick was used to turn old Buddhist iran, afganisthan, pakesthan, maldives, bangladesh, malaysia and
    indonesia within a few hundred years of their arrivals in those countries with baby machine wives. Needless to say
    some of them are hell holes on earth like syria, yemen, iraq, libya, sudan, etc. etc. This is what mussies want
    to do to Sri Lanka with their baby machine wives.

    These learned drs must have learned Charles Darwin’s Theory of Evolution and accepted the two legged creatures
    are not any god’s work. We all know there isn’t a shred of evidence to support the god guy. No museum in
    the whole world display a god in their collection. What’s more Darwin’s book, The Tree of Life, explained how
    all these other creatures came to being. The whole world apart from the religions of conveniences followers
    accept them to be true. What is more NASA’s missions have shown that the earth’s size is a grain of sand in the
    vast vast vast vast vast universe where distances are measured in light years and no scientist knows where
    the edges are to date. God’s work? To believe such a thing in this and age one has to be brain washed or brain
    dead. Crux of the matter is, mussies want to shove these barbaric practices on our society using ever increasing
    voter base (thanks to baby machine wives) leading to another mussie hell hole like pakesthan, afganisthan, syria,
    etc. etc.

    While all these religions of conveniences which don’t regard sins as sins all honest people including all the
    law courts in the world do. The followers cheat themselves in this life only to pay for them in their next lives not
    being two legged creatures. These religions of conveniences fail the science test miserably Buddhism passes it
    with flying colours. Sri Lanka is a Buddhist country and leave it that way and if you want to practice these
    barbaric acts go back to where you came from. In the year 0000 or 600 people believed in anything. In the year
    2018, if you are still believing in a creator god, you are blindly going down a wrong road. We all know if you
    going down a wrong road, you never going to arrive at your desired destination. Why the god used the ‘grain
    of sand’ missing all these other big planets? Why did he build the grain of sand with tsunamis, earth quakes, too
    many oceans? Why people look different from country to country, race to race (The Tree of Life explains it)?
    Why did he put the ‘heater’ (the sun) 93 million miles away from the ‘grain of sand’? Why is the
    nearest galaxy to us 2 miliion light years away? God must be several light years tall to create such a place? Come on, this is year 2018. Not 600.

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