Watch the video recording of the webinar or read a quick review on the subject. Special thanks to Prof Dato’ Dr Abdul Rashid Khan, the Head of Public Health Medicine Department of RCSI-UCD (Royal College of Surgeons Ireland-University College Dublin) Malaysia Campus, and Mr Brian Earp, the Associate Director of Yale-Hastings Program in Ethics and Health Policy at Yale University and The Hastings Center, and a Research Fellow in the Uehiro Centre for Practical Ethics at the University of Oxford, for their contribution and thoughts on the topic.
Summary of webinar by Dr Janani Devaraja
Female Genital Mutilation (FGM) is defined by the World Health Organization (WHO) as all procedures involving partial or total removal of female external genitalia or any other injury to female genital organs for non-medical reasons. Approximately 200 million girls worldwide have been subjected to FGM. During the United Nations Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) meeting in February 2018, Malaysia was criticised by a number of Muslim majority countries for continuing the practice of FGM, which they believed was not in line with Islamic teachings. The Malaysian representatives claimed that FGM is obligatory in Malaysia as per the country’s fatwa, it is safe as it is performed by medical professionals and it is Type 1 and Type 4 FGM as opposed to the practice of infibulation (Type 3) as practiced in the continent of Africa. The types of FGM are defined as below:
- Type 1: Partial/ total clitoridectomy
- Type 2: Partial/ total removal of clitoris and labia minora +/- removal of labia majora
- Type 3: Infibulation (narrowing the vaginal opening by cutting and repositioning the clitoris and labia)
- Type 4: All other procedures to the female genitalia including pricking, piercing, cutting, scraping, or burning.
This webinar was to discuss the practice of female circumcision (also known as sunat perempuan or khitan perempuan) in Malaysia, if it is a form of FGM and to discuss whether the practice should continue in Malaysia.
Prof Dato’ Dr Abdul Rashid Khan discussed the practice of female circumcision (or female genital cutting – FGC) in Malaysia. The practice of FGC predates Islam. Infibulation is believed to have started in Nubia, Sudan in 800-350 BCE. Most FGC activity occurs in Asia and Africa. There is no national data on FGC prevalence in Malaysia but from Prof Dato’ Dr Abdul Rashid’s FGC study, it can be extrapolated that at least 90% of Malay Muslim girls have been circumcised. There is no data on non-Malay Muslim girls and non-Muslim girls in Malaysia. Islam came to Malaysia in the 11th century CE via traders from India and Arab countries. It is likely FGC was introduced to Malaysia as a Type 1 or Type 2 practice which evolved to a milder Type 4 practice as part of assimilation to the Islamic faith by native Malaysians.
The majority of Malaysian Muslims are Sunni Muslims who follow the Shafi sect. FGC is not mentioned in the Quran but it is in the Hadith and/or Sunnah. Shafie sect believes FGC to be mandatory. The Maliki and Hanbali sect recommends FGC only whereas the Hanafi sect does not follow the practice. However various Islamic experts regardless of sect disagree on whether FGC is mandatory in Islam due to disagreements whether the evidence of FGC from Hadith /Sunnah is weak or strong. Many religious scholars in Malaysia also disagree with FGC. A survey done by Prof Dato’ Dr Abdul Rashid Khan found 88% of Malay ladies believe FGC to be compulsory in Islam and 99% want the practice to continue in Malaysia.
Initially, FGC was conducted on young babies in Malaysia by the Mak Bidans (traditional midwives). It started off as a prick to the clitoris to elicit a drop of blood. It is uncertain where the requirement for ‘a drop of blood’ came as it is not in any Islamic resources. This then progressed to the use of blades and scissors. With the decrease in the number of Mak Bidans, families started going to clinics and now there is a preference for doctors to perform the procedure due to the perceived expertise of doctors and the cleanliness of the equipment and surroundings.
However, doctors are not trained to perform FGC. FGC is not taught in any medical school in Malaysia. Only 50% of doctors who perform FGC in Malaysia have received training to carry out FGC, and this is informal training from senior doctors who do the procedure, from the Mak Bidans themselves, or from the Internet. Carrying out FGC also violates medical ethics as FGC has no medical benefits, and causes pain and injury. It is therefore seen as an unnecessary medical procedure that is against doctors’ ethics to promote.
The change from Mak Bidans to doctors has led to the medicalisation of FGC in Malaysia. This has therefore led to the promotion that FGC is safe and acceptable. However, FGC carries health risks including pain, excessive bleeding, infections, scar tissue formation and urination problems. The risk of infection is mitigated by doctors using sterilised equipments. However, due to the medicalisation and perceived safety, there are doctors who feel more genital tissue can be removed. Therefore from previously being a Type 4 practice in Malaysia, there has been a worrying move towards Type 1 FGC in Malaysia. This carries with it more health risks and irreversible genital changes.
FGC in Malaysia is unusual in Malaysia that unlike in the African continent, FGC is not a requirement for marriage. Families and societies do not enquire of a girl whether she has had FGC or not and no judgement is made on a girl or family’s morality and status based on FGC. Currently, it is only done as it is seen as a religious obligation which is a controversial opinion in Muslim circles. Prof Dato’ Dr Abdul Rashid Khan is emphatically against any type of FGC. However, he feels the term female genital mutilation (FGM) is controversial. It was designed to carry a negative judgement against communities that practice FGC regardless of the type of practice. He feels vilifying a community for carrying out the practice will only drive the practice underground. He believes raising awareness among the society and encouraging discussions will lead to the practice gradually stopping on its own. But he is firmly against doctors carrying out any type of FGC and says Malaysian Medical Council needs to declare a stand that doctors should not carry out any FGC procedures with immediate effect.
Mr Brian Earp discussed the ethics around female circumcision. He felt the term ‘mutilation’ carries with it a value judgement and therefore it is based on the values of the person defining the term. In his talk, he considered FGC and male genital circumcision (MGC) based on several different points. He raises the pertinent point that MGC is carried out in societies that both practice and do not practice FGC yet MGC is not generally considered ‘male genital mutilation’ or a human rights violation.
FGC and MGC were looked at from a medical necessity argument. There is no medical necessity for FGC currently identified. A potential health benefit for MGC in infants could be a reduced risk of urinary tract infections. However, based on current evidence, potentially 100 infants will need to undergo MGC to prevent one urinary tract infection. Furthermore, urinary tract infections are easily treatable and there are other ways of prevention that do not include circumcision. Another potential benefit for MGC often quoted is the reduced risk of HIV infection. However, the studies on this have only been carried out in adult men who undergo voluntary circumcision. There have been no studies on male infants who were circumcised. Secondly, the protection seems to only be for men, and women may be at increased risk of HIV if they have sex with HIV-positive circumcised men. MGC also offers no added benefit if the man is faithful to his partner who is HIV negative or uses a condom when engages in sexual activity.
The potential of harm due to FGC and MGC was discussed. Female genital tissue is rich with nerve tissue and all loss of healthy tissue can be harmful. The physical harm caused by FGC is well documented and evidenced. There are also many survivor narratives on the negative psychological impact. However, there is no data on the psychological impact of undergoing FGC in women who experienced Type 4 FGC which is currently the most common type in Malaysia. With regards to MGC, there have been documented narratives by Western men who have undergone MGC as an infant who experienced feelings of inadequacy and being incomplete when older. The loss of choice is seen as harmful. There is also a contradiction between the way WHO perceives MGC and FGC. FGC is considered a human rights violation and illegal when it is performed on female infants and children. It is still considered a human rights violation even when performed on consenting female adults. WHO opposes FGC on children and adults and has made statements saying girls have a right to bodily integrity. However, MGC on male infants, children, and adults is not considered a human rights violation, regardless of whether it is consensual or non-consensual. It is hypocritical that MGC and FGC are not considered equally by WHO, especially as MGC can be more invasive than Type 4 FGC. Like Prof Dato’ Dr Abdul Rashid Khan, Mr Brian Earp feels that the definition of FGM by WHO is inadequate. He also feels that the policies by WHO with regards to FGC are biased. WHO condemns all forms of FGC regardless of whether it is on a child or adult. However comparable procedures like cosmetic labiaplasty are not condemned by WHO. In the UK and Australia, cosmetic labiaplasty is allowed for females above 18 years of age, yet if the girl wishes to be circumcised for cultural or religious reasons, it is not allowed. MGC which can be more ‘mutilating’ than FGC is also not condemned.
We need to acknowledge that parents who perform FGC on a child are not ‘monsters’. Most are loving parents who performed FGC with the belief that it enhances the child’s body as per societal and religious norms. The permissibility/ non-permissibility of FGC is context-dependent and with new information and perspectives, societal norms can evolve to eradicate FGC.
In the future, Mr Brian Earp wants to see a change in perspective of not differentiating between FGC and MGC but rather whether the person has the autonomy to make the decision on circumcision for themselves. He wants the norm to be that cutting any genital tissue (male or female) without the consent of the person is seen as a serious human rights violation. Thus circumcision on any child will be illegal as children are unable to give informed consent. However, an adult can choose to undergo circumcision of any form if they have the autonomy and can provide informed consent.
Several questions were asked at the end of the presentations. Prof Dato’ Dr Abdul Rashid Khan confirms that JAKIM (Department of Islamic Development Malaysia) has come out with a fatwa in 2009 making FGC compulsory. However, of note, fatwas in Malaysia are non-binding on Muslims. For example, there is a fatwa against smoking in Malaysia yet this is ignored by many Muslims. Circumcision by proxy was discussed and whether that is the same as FGM. Circumcision by proxy refers to practices in a community where instead of FGC, a potato or (any form of vegetation) is cut in front of the child’s genitals as done by a tribe in Indonesia or a piece of cloth is rubbed against the vulva as done by the Bangsamoro tribe in the Philippines. This was felt not to be on par with FGC or FGM and it was a way communities evolved to maintain the tradition but not cause any physical injuries to female genitals. The psychological impact of FGC on a person will depend on the age FGC is done, visible change to the vaginal anatomy, complications that occurs, and the strength of the belief in the person that FGC is a necessary cultural/religious requirement.
Both Prof Dato’ Dr Abdul Rashid Khan and Mr Brian Earp do not think changing the term from FGM to FGC will change how Malaysians will feel about the practice. We discussed that what was previously accepted practices in Malaysia (foot binding, carrying spittoons for public spitting, etc) are no longer accepted showing that people and practices can evolve with time and changes in perspectives. There is an agreement that there is a need to be more open discussions and awareness raised about the history and practices of FGC. Banning the practice in Malaysia will not stop the practice but rather make it underground, leading to further harm to females. Parents who want to circumcise their children or adults who want to be circumcised should do it as an informed decision, rather than in response to societal pressures. However, hopefully, the practice will stop with time as more awareness is raised. As a first step, the practice of carrying out FGC by doctors must stop as there is no health requirement and therefore violates medical ethics. Malaysian Medical Council needs to come up with a statement about this practice and disallow their doctors from performing it.