WMA Statement on Female Genital Mutilation

Adopted by the 45^th World Medical Assembly, Budapest, Hungary, October 1993
and editorially revised by the 170^th WMA Council Session, Divonne-les-Bains, France, May 2005
and revised by the 67th WMA General Assembly, Taipei, Taiwan, October 2016 

PREAMBLE

The World Medical Association joins with other international agencies in condemning the practice of genital mutilation or cutting of women and girls, regardless of the level of mutilation, and opposes the participation of physicians in these practices.

Stopping female genital mutilations (FGM) requires action on strict enforcement of laws prohibiting the practice, medical and psychological care for women who are victims and prevention of FGM by education, risk assessment, early detection and engagement with community leaders.

FGM is a common practice in more than 30 countries of the world, including some in Africa, Asia and the Middle East. The phrase FGM is used to convey a number of different forms of surgery, mutilation or cutting of the female external genitalia. The term female circumcision is no longer used as it suggests equivalence with male circumcision, which is both inaccurate and counterproductive.  Most girls undergo FGM/C between the ages of 7 and 10.  There is no medical necessity for any such cutting, which is often performed by an unqualified individual in un-hygienic surroundings.

FGM of any type is a violation of the human rights of girls and women, as it is a harmful procedure performed on a child who cannot give valid consent.  As a result of migration a growing number of girls living outside countries where the practice is common are being affected.

Respecting the social norms of immigrants is increasingly posing problems for physicians and the wider community.

Because of its impact on the physical and mental health of women and children, and because it is a violation of human rights, FGM is a matter of concern to physicians.  Physicians worldwide are confronted with the effects of this traditional practice.  They may be asked to perform this mutilating procedure or to restore the result of mutilating “surgery” on women after childbirth has reopened the introitus.

There are various forms of FGM, classified by WHO.[1] It can be a primary procedure for young girls, usually between 5 and 12 years of age, or a secondary one, e.g., after childbirth. The extent of a primary procedure may vary: from an incision in the foreskin of the clitoris, up to the maximally mutilating so-called pharaonic infibulation which involves partly removing the clitoris and labia minora and stitching up of the labia majora so that only a small opening remains to allow the passage of urine and menstrual blood. The majority of procedures performed are somewhere in between these two extremes.

While the term female circumcision is no longer used it remains useful, familiar and readily accessible in the context of physician/patient consultations in some cases.

FGM has no health benefits and harms girls and women in many ways, regardless of which procedure is performed.  Research shows grave permanent damage to health, including: haemorrhage, infections, urinary retention, injury to adjacent organs, shock and very severe pain. Long-term complications include severe scarring, chronic bladder and urinary tract infections, urologic and obstetric complications, and psychological and social problems. FGM has serious consequences for sexuality and how it is experienced, including the loss of capacity for orgasm. There are also many complications during childbirth including expulsion disturbances, formation of fistulae, and traumatic tears of vulvar tissue.

There are a number of reasons given for the continuation of the practice of FGM: custom, community tradition (preserving the virginity of young girls and limiting the sexual expression of women) and as part of a girl’s initiation into womanhood. These reasons do not justify the considerable damages to physical and mental health.

None of the major religions supports this practice, which is otherwise often wrongly linked to religious beliefs.  FGM is a form of violence usually perpetuated on young women and girls and represents a lack of respect for their individuality, freedom and autonomy.

Physicians may be faced with parents seeking a physician to perform FGM, or they may become aware of parents who seek to take girls to places where the practice is commonly available.  They must be prepared to intervene to protect the girl.

Medical associations should prepare guidance on how to manage these requests which may include invoking local laws that protect children from harm and may include involving police and other agencies.

When patients who have undergone FGM give birth, physicians may receive requests to restore the results of the FGM. They should be confident in handling such requests and supported with appropriate educational material that will enable them to discuss with the patient the medically approved option of repairing the damage done by FGM and by childbirth. Physicians also have a responsibility to have a discussion with the spouse of the patient, with the consent of the patient, who might otherwise seek “restoration” of the FGM, if not given a full explanation of the harm that is done by FGM.

There is a growing tendency for physicians and other health care professionals in some countries to perform FGM because of a wish to reduce the risks involved. Some practitioners may believe that medicalization of the procedure is a step towards its eradication.  Performing FGM is a breach of medical ethics and human rights, and involvement by physicians may give it credibility.  In most countries performing this procedure is a violation of the law.

Governments in several countries have developed legislation, such as prohibiting FGM in their criminal codes.

RECOMMENDATIONS

1. Taking into account the psychological needs and ‘cultural identity’ of the people involved, physicians should explain the dangers and consequences of FGM and discourage performing or promoting FGM. Physicians should integrate women’s health promotion and counselling against FGM into their work.
2. Physicians should assist in educating health professionals and work with local community, cultural and social leaders to educate them about the adverse consequences of FGM. They should support persons who want to end FGM and the establishment of community programmes designed to outlaw the practice, offering medical information about its damaging effects as necessary.
3. There are active campaigns against FGM that are led by women leaders and heads of state in Africa and elsewhere.  These campaigns have issued strong statements against the practice.
4. Physicians should work with groups such as these and others who manage pregnant women including midwives, nurses and traditional birth attendants, to ensure all practitioners have standardized and sensitive information about FGM.
5. Physicians should cooperate with any preventive legal strategy when a child is at risk of undergoing FGM.
6. National Medical Associations should stimulate public and professional awareness of the damaging effects of FGM.
7. National Medical Associations should ensure that FGM education and awareness are part of its advocacy to prevent violence against women and girls.
8. National Medical Associations should work with opinion leaders, encouraging them to become active advocates against FGM.
9. National Medical Associations should stimulate government action in preventing the practice of FGM. This should include sustained advocacy programmes and the development of legislation prohibiting FGM.
10. NMAs must prohibit involvement by physicians in the practice of FGM, including re-infibulation after childbirth. Physicians should be encouraged to perform reconstructive surgery on women who have undergone FGM. Physicians should seek to ensure the provision of adequate (and non-judgemental) medical and psychological care for women who have undergone FGM.
11. Physicians should be aware that the risk of FGM might be a justification for overriding patient confidentiality, and allow disclosure to social or other relevant services to protect a child from serious harm.