Sunkaru Touray, MD, FACP, FCCP
The recent landmark ruling on a case of female genital cutting (FGC) in The Gambia has sparked public discussions and exposed fault lines in Gambian society regarding the issue. There are generally three opinions on the matter. Firstly, gender and human rights activists view FGC as a violation of women’s health and reproductive rights. Secondly, there is a conservative group, mostly Islamic/traditionalists, who contend that the practice is harmless and argue that those supporting the ban are motivated by western influences, intent on eradicating our culture and religion. Lastly, there is a silent group who do not express their views on the issue in public, either because they do not want to cause controversy or for political reasons, as they see it as a divisive topic that could affect their electability.
As a Gambian specialist physician, I feel compelled to address the harmful effects of female genital cutting (FGC) or mutilation on women’s health in The Gambia from a medical perspective. The word “doctor” is derived from the Latin verb “docere,” which means to teach or be a scholar. Doctors have a fiduciary responsibility to educate and share their knowledge on matters concerning the health and well-being of their patients, and society as a whole. It is with this perspective that I approach this issue.
Firstly, it is important to be clear about terms and define what the debate is centered on. Female genital cutting (FGC), also known as female circumcision or genital mutilation (FGM), is a culturally determined practice. FGM/C refers to 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 World Health Organization (WHO) categorizes FGM into four major types:
1. Type 1: Clitoridectomy: This involves the partial or total removal of the clitoris, the visible part of the female genitalia.
2. Type 2: Excision: This entails the partial or total removal of the clitoris and the labia minora (inner folds of the vulva). In some cases, the labia majora (outer folds of the vulva) may also be removed.
3. Type 3: Infibulation: This is the most severe form of FGM and involves the narrowing of the vaginal opening through the creation of a seal by cutting and repositioning the labia minora or labia majora. This can also involve the removal of the clitoris. The sealed opening leaves a small hole for urine and menstrual fluid to pass through. Sometimes, the opening may need to be cut open for sexual intercourse or childbirth.
4. Type 4: Other procedures: This category includes all other harmful procedures to the female genitals for
Type I (commonly referred to as clitoridectomy) and Type II (commonly referred to as excision) are the most common forms widely practiced in The Gambia. It is important to note that Gambian girls are subjected to all 4 types of FGC. It is also important to note that no type of FGM is benign and all are associated with adverse health outcomes for women. Evidence supporting this assertion comes from a World Health Organization (WHO) study that compared obstetric outcomes of women with and without FGC and found that compared to women who did not have FGC, circumcised women had a higher risk of needing cesarean delivery, bleeding after delivery (postpartum hemorrhage), and extended hospital stay for the new mothers. This study also found that infants of mothers who had FGC, were at significantly higher risk of requiring resuscitation and of dying in the hospital than patients without FGC.Patients with all types of FGC also had higher rates of episiotomy and perineal tears.
The Gambia has one of the highest death rates for women, and about 1 in 3 deaths occur during childbirth. The leading cause of death among Gambian women is bleeding and complications during delivery. Anyone who follows this issue knows how frequently we see social media outrage when a young mothers die “due to lack of blood” at our hospitals. The reason they need blood in the first instance is because they bleed a lot, and they are usually low in blood levels in the first instance. Low blood levels (anemia) in young women is due to bleeding during mensuration and nutritional deficiency (especially iron and a vitamin called folic acid). All types of FGM/C are associated with an increased risk of bleeding during childbirth. FGM/C is a contributing factor to this. It is important to recognize this connection because failure to do so will continue to drivemore unnecessary maternal deaths.
The complications of FGC to women’s reproductive health extends beyond childbirth. Scarring of the birth canal caused by FGC/M can lead to narrowing, thereby prolonging labor and obstructing delivery. It can also result in painful menstruation, pain during sexual intercourse, and chronic vaginal infections. Additionally, FGC is associated with a higher infertility rate compared to the general population. This is likely due to difficulties and pain during sexual intercourse, as well as a higher propensity for pelvic infections that can block the fallopian tubes and prevent conception. While some argue that FGC reduces sexual urges in women as a way of maintaining chastity, a large study of 1836 Nigerian women with FGC found that it did not reduce sexual feelings or frequency of sexual intercourse but was rather associated with a higher frequency of abnormal vaginal discharge and pelvic pain.
Women who have undergone FGC/M are also more likely to have difficulty having babies. Infertility rates (the inability to conceive a child naturally or carry a pregnancy to full term) almost twice in females with FGC compared with the general population. The frequency of infertility appears to correlate with the extent of FGC, with ascending rates among the different types.
It is important to consider these findings in the context of the purported benefits and reasons for why people subject their children to FGC/M. Often, FGC/M is done with the intention of providing benefit rather than causing harm. Parents initiate this procedure with the aim of helping their daughters, as being a wife and mother is considered a female’s livelihood in Gambian society. There is a false notion that FGC promotes sexual abstinence and ensures eligibility for marriage, thereby protecting one’s future. However, studies have not shown that circumcised girls are more chaste than their uncircumcised counterparts.
Given this overwhelming evidence showing harm, it is clear that FGC/M offers hardly any benefit to the health and well-being of women. Any perceived cultural significance or benefit is overshadowed by a lifetime of pain, suffering, and increased risk of death. No conversation about reducing maternal mortality in The Gambia will be complete without addressing the contribution of FGC/M to these deaths. The weight of scientific evidence overwhelmingly supports discouraging and abolishing this practice as a public health strategy to reduce maternal mortality in The Gambia and improve the health and well-being of our mothers, sisters, daughters, aunts, and grandchildren. Reputable international organizations from around the world including the World Health Organization, the American Medical Association, and the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists condemn the practice of FGM and supports all efforts to eliminate the practice.
The overwhelming evidence from multiple clinical studies conducted by skilled professionals from around the world cannot be ignored. Islamic tradition has deep respect for scientific knowledge, observation, and the pursuit of understanding. It is therefore very disappointing to see the Gambia Supreme Islamic Council issue a “fatwa” indicating that the (sic) “cutting off only a tiny upper part of the clitoris without removing it or touching any part of the labia”, this is Type I FGM/C they are referring to, which as indicated above is associated with a whole myriad of adverse health outcomes. Did they GSIC consult with the medical fraternity before issuing this fatwa? This omission, flies in the face of the progressive tradition of Islam as a religion that promotes scientific inquiry and integrates evidence-based information to make recommendations for how society should be run. In the area of maternal and reproductive health, FGC/M has no benefits, and as the scientific evidence shows, it is associated with a high risk of death and suffering. Therefore, Islam does not support any practice which can harm the health and wellbeing of a society. How then did the GSIC arrive at their fatwa? Did they consult with doctors, scientists, or the medical community? Or is the GCSIC against scientific advancement?
Religion, tradition, and culture are not static and have evolved over time. When confronted with strong evidence that something is harmful, the insistence on continuing that practice is retrogressive. We must continue to speak truth to power and reevaluate our premises and understanding, especially when presented with new information. It is easy to engage in anti-science rhetoric, but the evidence overwhelmingly supports the abolition of this practice based on the harm it causes to Gambian women.
The Gambian medical fraternity, specifically the Gambian Medical and Dental Association, the Gambia Nurses and Midwives Council, and the Gambia Association of Public Health Officers, must come together to and inform this debate by way of a position statement, as the subject matter experts, using the best scientific evidence which supports the abolition of FGC/M. An endorsement from professionals with the knowledge, expertise, and experience of the harmful effects of FGC/M will inform the government, political parties, the GSIC and society at large on the best course of action.
When people are presented with good information by respected professional organizations, on matters that affect their health or the health of their loved ones, they are more likely to change their behavior. Societal change is a gradual process, and GAMCOTRAP (the NGO that brought the case to court) and other NGOs working on FGC/M must be commended for the work they have done in the preceding decades. If anything, this national debate is a stark reminder that more work needs to be done. We must teach the harmful effects of FGC/M in our schools, as part of physical and health education, so that young adults coming out of our education programs are adequately informed about the harms of the practice.
We must consider the harm this practice causes and work towards its elimination. We must prioritize the health and well-being of our women and strive for a future where they can thrive without the burden of unnecessary pain, suffering, and increased risk of death. The law should be used as a tool to enforce the abolition of FGC/M and protect the rights and health of women in The Gambia. The GSIC’s fatwa is not rooted in scientific evidence and is a public health threat to the sexual and reproductive health rights of Gambian women.
Dr. Sunkaru Touray, MD, FACP, FCCP is an American Board-Certified specialist in Pulmonary Diseases and Critical Care Medicine, and the Co-Founder of the Permian Health Lung Institute.