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Case Studies: Bettina Shell-DuncanSam Clark |
Jonathan Gorstein - Abstract |
Jonathan Gorstein - Outline |
Anne Marie Kimbal |
Ann Kurth Global Health Case Study: Female CircumcisionCase Janet Saitoti is a 42 year old Kenyan woman, widowed with two daughters, Leah, now age 18, and Anne, age 14. Mrs. Saitoti, her late husband, and her daughters are Maasai, an ethnic group which near universally practices female circumcision (also known as female genital mutilation, or FGM) at the time of puberty as part of a female initiation ceremony. Having been circumcised is understood to be a prerequisite to marriage. Mrs. Saitoti underwent FGM at the age of 13. After her niece bled to death following the procedure, Mrs. Saitoti and her sisters-in-law decided that the other girls would not undergo the procedure. A celebration was conducted in which Mrs. Saitoti’s daughters appeared to be circumcised by including a week-long seclusion for “recovery” and training. FGM was not, however, performed on Leah, Anne or any of the other girls with whom they were initiated. Mr. Saitoti was aware of what had been done, and when he participated in negotiating the marriage of Leah when she was 16, and “understanding” was reached with his future son-in-law. Mr. Saitoti died one month after Leah’s marriage. When Leah’s female in-laws were providing her with a treatment for fertility, they discovered her un-circumcised status. They informed elders in the community, who were outraged and demanded that all the girls who had not undergone the procedure must be circumcised. Janet Saitoti used her savings to purchase airline tickets to travel with her daughters, then ages 14 and 18, to London. After saying with friends for 10 months, they obtained false documents allowing them to travel to the U.S. When reaching the U.S., Mrs. Saitoti confessed to immigration officials about the falsified documents, and requested asylum for herself and her two daughers. Mrs. Saitoti states that even though there is a law in Kenya banning FGM on women under the age of 18, it not consistently enforced. Therefore if she and her daughters were to return to Kenya, both would be forcibly subjected to FGM
1. Introduction to the Topic Having little parallel in its ability to arouse an emotional response, the
practice of female “circumcision” has come under increasingly intense
international scrutiny from news media, feminist and human rights organizations,
health practitioners and legislators. Although opposition to female circumcision
has been articulated through the twentieth century, starting with missionaries
and colonial administrators, the current resurgence of indignation was ignited
by activists participating in a series of conferences honoring the United Nations
Decade for Women (1975-1985). A practice initially challenges as a religious
and moral shortfall has gradually been recast in discourses on women’s
health and international human rights. The least extensive type, and the only one that can be construed as analogous to male circumcision, is commonly referred to as sunna (Arabic for “tradition or “duty”) or clitoridectomy, and involves cutting all or part of the clitoris. The next form, excision, entail clitoridectomy along with partial or complete removal of the labia minora. The most radical form of circumcision is known as infibulation or pharaonic circumcision, and involves the complete removal of the clitoris and labia minora as well as most or all of the labia majora. The cut edges are stitched together so as to cover the urethra and vaginal opening, leaving only a minimal opening for the passage of urine and menstrual blood. In Sudan there is a variation known as “intermediate circumcision,” which is a modified form of infibulation that usually involves a similar amount of cutting, but stitching together only the anterior two-thirds of the outer labia, leaving a larger posterior opening. Collectively, these procedures have been referred to as “female circumcision,” or, with the spread of feminist consciousness and the development of an international women’s health movement, female genital mutilation or FGM. Objections have been raised at the use of the term “mutilation” because it implies excessive judgement, and alternative terms have been forwarded: female genital surgeries, or more commonly, female genital cutting (FGC). Currently FGC is a widespread practice, having been documented across a broad region of Africa, extending in West Africa from Mauritanai and Cameroon, across central Africa, and in the east reaching from Tanzania to Ethiopia. It is also practiced outside of Africa in places including Indonesia, Malaysia, and the Arab peninsula. Additionally, in an increasingly global world with transnational migration, the practice is found broadly throughout the African diaspora. Reliable estimates of the prevalence of female genital cutting are difficult to obtain, although better data are becoming available as the Demographic and Health Survey has added a module on FGC for many African countries. The World Health Organization estimates that over 132 million women have experienced some form of FGC. Excision and clitoridectomy are the most commonly practiced forms, accounting for 85% of all reported cases. Infibulation is largely confined to Sudan, Somalia, northeast Kenya, Eritrea, parts of Mali and a small part of northern Nigeria. A number of assumptions are associated with the practice of FGC: that it is the result of patriarchal oppression of women, that it is associated with Islam, that it is a brutal form of initiation, that it destroys women’s sexual pleasure, that it invariably results in traumatic psychological and physical damage. We will critically examine these assumptions, and look at the way that they play out in debates on health and human rights, as well as cultural relativism and Western imperialism. Learning objectives:
Readings:
2. Evidence: Female Genital Cutting as a Health Issue. What are the medical facts? Typically found in the “anti-FGM” literature is a discussion of the medical “facts” about the practice, often divided into a recitation of short-term, long-term and obstetrical complications. Short-terms complications include hemorrhage, severe pain, local and systemic infection, shock from blood loss and, potentially, death. Infection is associated with delayed healing and the formation of keloid scars. In addition, pain and fear following the procedure can lead to acute urinary retention. Long-term complications are said to be associated more often with infibulation than with excision or clitoridectomy, although this has been poorly researched. Possible long-term complications include genito-urinary problems, such as difficulties with menstruation and urination which result from a near-complete sealing off of the vagina and urethra. Untreated lower urinary tract infections can ascend to the bladder and kidneys, potentially resulting in renal failure, septicemia, and death. Chronic pelvic infections can cause back pain, dysmenorrhoea (painful menstruation), and infertility. Another frequently mentioned complication is the formation of dermoid cysts, resulting from embedding epithelial cells and sebaceous glands in the stitched area. Additionally, if the clitoral nerve is trapped in a stitch or in the scar tissue, a painful neuroma (tumor of neural tissue) can develop. All forms of female genital cutting are alleged to be potentially associated with diminished sexual pleasure and, in certain cases, inability to experience a clitoral orgasm. Infibulated women may experience painful intercourse, and often have to be cut open for penetration to occur at all. Obstetrical complications are most often reported in association with infibulation. These include obstructed labor, excessive bleeding from tearing and de-infibulation during childbirth. Obstructed labor may lead to the formation of vesico-vaginal and recto-vaginal fistulae (opening between the vagina and the urethra or rectum, allowing for urine or feces to pass through the vagina). Some researchers have suggested that increased obstetrical risk exists for excised women as well. Scar tissue may contribute to obstructed labor since fibrous vulvar tissue fails to dilate during contractions. Furthermore, hemorrhage may result from tearing through scar tissue. This laundry list of adverse health outcomes, the “medical sequelae,” is repeated in the introduction of nearly all papers in the voluminous literature on female “circumcision,” as allegations of health hazards form the cornerstone of opposition to the practice. Surprisingly little attention is devoted to considering the original source of this information--often medical observations published by British colonial surgeons and gynecologists in the 1930’s and 1940’s--or the incidence of various complications arising from different types of genital cutting. Instead, noteworthy case studies on infibulation are generalized to describe the health risks of all forms of genital cutting, and to support the view that genital mutilation should be treated as a public health problem. Learning objectives:
Readings: Mackie, G. Female genital cutting: A harmless practice? Medical Anthropolgy Quarterly 17: 135-158
3. Why is FGC a priority? Although the global campaign to eliminate FGC has succeeded in drawing international attention to the practice, and igniting public outrage and creating political pressure for international actors to prioritize the development and funding of strategies to eliminate the practice, the perception of relative importance of eliminating FGC varies in different setting. Even in cases where indigenous practitioners view it as a “problem,” the practice often does not achieve the priority it receives in the international health community. Mairo Mandara, for example, interviewed 250 medical practitioners in Nigeria. She found that the vast majority (213) did considered FGC to be a health problem, but they considered it to be a minor problem when compared and prioritized with other known medical problems in the country. Maternal mortality, diarrheal diseases, and malnutrition were listed by physicians as the most serious causes of morbidity. When comparing FGC to other health problems, the majority of respondents ranked FGC equal to Alzheimer’s disease, a condition that is practically nonexistent in Nigeria. Empricially, the urgency of intervention intended to protect women’s health diminishes if steps can be taken to make the practice of FGC safer (perhaps no more dangerous than male circumcision). Consequently, the trend of medicalizing the practice of FGC has been the subject of tremendous debate. Medical interventions have been attempted in various forms, ranging from promoting precautionary steps, such as the use of clean sterile razors on each woman and dispensing prophylactic antibiotics, to obtaining genital operations in clinics or hospitals by trained nurses and physicians. Without consideration of health improvements resulting from various forms of medicalization, these approaches have been strongly criticized. Opposition to all forms of medicalization is central in international efforts to eliminate female “circumcision.” In 1982 the World Health Organization issued a statement declaring it unethical for female genital cutting to be performed by “any health officials in any setting - including hospitals or other health establishments”. Additionally, other medical organizations and ministries of health in many African countries have issued similar statements. This staunch opposition to medical intervention rests on one central assumption: that medicalization will counteract efforts to eliminate female “circumcision.” This assumption is, however, not based on empirical evidence, and deserves critical examination. The merits and drawbacks of medicalization of female genital cutting may be clarified if it is compared and contrasted to other programs that seek to improve human health by adopting interim solutions that fall short of total abolition – so-called “harm reduction” programs. A number of different approaches to intervention have been employed in different sites. One approach sometimes referred to as “compensate the cutters” involves publically honoring circumcisers for their decision to cease cutting, and providing training in alternative income generating activities. Critics, however, point out that this addresses only the “supply” side of the equation, and does not address the demand for the practice. Some communities have also experimented with alternative initiation rituals in places where FGC is or recently was part of a coming of age ritual for girls. Other intervention projects have developed an “integrated approach,” addressing FGC along with other community needs. One such program is an intervention known as Tostan, has coupled internvention on FGC with other issues such as child vaccination, prenatal healthcare, and literacy training. This project, which is arguably the most successful intervention project on FGC, has convinced over 1,000 Senegalese villages to declare to stop practicing FGC. Learning objectives:
Readings:
4. Cultural Meaning and “Insider” Perspectives Much of the existing literature conveniently overlooks the cultural, political and historical contexts of the various types of genital cutting performed by different actors in widely varying contexts. The tendency to present generalized lists of reasons for the practice contributes to what has been called the “trivialization of culture in the political literature”. Items that often appear on such a “laundry list” of rationales include control of women’s sexuality, premarital protection of virginity, promotion of marriagability, enhancement of fertilility, conforming with mandates of Islam, a rite of passage into womanhood in which female bodies are constructed, or simply that it is “tradition.” While the practice is often described as a deep-seeded tradition that is seemingly static, immutable and timeless, Lori Leonard has described a community in Chad in which young girls have recently adopted FGC as a sort of fashion statement, against the wishes of their elders. This underscores the fact that th e nature and meaning of the practice is often fluid, reflecting changing social conditions and needs. Although each of the “explanations” for practicing FGC are often discussed distinctly, they are in fact interconnected and mutually reinforcing and, taken together, form overwhelming unconscious and conscious motivations for its continuation. While there is a tendency for Westerners to view FGC as an “exotic” and “cruel” practice, little attention is drawn to way in which the body is modified in our own culture in a seemingly “normal” and uncontrovertial way. Male circumcusion, body piercing, and cosmetic surgeries, while not universally condoned, do not draw the shock, horror and moral outrage that has been directed at FGC. While former Senator Carol Moseley-Braun has justified legislation against female-but-not-male circumcision by describing the latter as “quick, relatively painless, and without long-term consequences for men” (in Fernandez-Romano 1999), others disagree. There is, in fact, a growing “pro-intact” movement that argues that male circumcision should be considered male genital mutilation, and subjected to the same laws as FGM. Others have drawn parallels to non-medically necessary cosmetic surgeries performed on female bodies to enhance attractiveness, such as breast enhancement surgeries. Even closer parallels exist with an increasingly common type of plastic surgery, popularly referred to as Female Genital Cosmetic Surgeries (FGCS) or “designer vaginas.” Such procedures include: labia minora reduction, labia majora remodeling, pubic liposuction and lifts, and clitoral reduction (see www.altermd.com), some of which resemble quite closely – in results, if not in the context of the surgeries – genital cutting procedures done “traditionally” in African societies. The irony of widely varying valuation of these procedures provides an important lens for assessing ethnocentricism, and testing moral and legal limits of objections to FGC. Learning objectives:
Readings: Navarro (2004) The most private of makeovers. New York Times, November 28. Sheldon, S. and Wilkinson, S. (1998) Female genital mutilation and cosmetic surgery: Regulating non-theraputic body modificiation. Bioethics 12: 263-285.
5. Recasting FGC as a Human Rights Issue: Cultural Imperialism or Protection of Women’s Rights One critical question that has plagued the global movement to eliminate FGC is what justifies intervention? Several commentators have argued that, in order to avert accusations of cultural imperialism, it was essential at the outset to frame FGC as a health issue to legitimize intervention. Following a 1984 seminar in Dakar, the Inter-African Committee (IAC) was formed, and FGM became labeled one of 4 “harmful traditional practices, “ along with childhood marriage and early pregnancy, nutritional taboos, and child spacing and delivery practices. As grounds for intervention, a health approach has fallen from favor for several reasons: education on purported health risks has failed to motivate people to abandon the practice, is believed by some to have encouraged medicalization of the practice. A 1995 Joint Statement on FGM first draft by WHO, UNICEF, UN Family Planning Association and United Nations Development Program “labeled the medical basis for anti-FGC policies a ‘mistake’” It suggested tha t medical discourses had been exaggerated and counterproductive. Since the early 1990’s the global campaign has actively attempted to divorce itself from the health approach, adopting, alternatively, a human rights framework for the opposition of FGC. At the 1993 Vienna World Conference on Human Rights two important historic events occurred. First, “female genital mutilation” became classified as a form of violence against women, and second, the issue of violence against women was for the first time acknowledged to fall under the purview of international human rights law. Prior to the 1990’s violence against women (VAW) was nearly invisible in international law and traditional understandings of human rights because both originally operated on the assumption that public and private domains are sharply divided. The beating, rape, or “mutilation of women in their home at the hand of relatives” was viewed as a private matter, and beyond the scope of international human rights law. The 1993 Vienna World conference was a landmark event in which a coalition of groups with diverse interests in domains of VAW joined efforts to seek judicial protection. In attempting to frame FGC as a human rights violation, several scholars have adopted a doctrinist approach, assessing the applicability of existing international human rights conventions and doctrines. In this vein, the human rights approach has been broken down into claims based on: 1) the rights of the child; 2) the rights of women; 3) freedom from torture; and 4) the right to health and bodily integrity. It has been pointed out, however, each of these approaches carries with it potential problems, although, ironically, the right to health claim is argued to be the most tenable approach. More broadly, however, FGC often appears as a test case in the ongoing debate between cultural relativism and universalism. Learning objectives:
Readings: Dembour, M. (2001) Following the movement of a pendulum: Between universalism and relativism. In (Cowan, J. K., Dembour, M., Wilson, R.) Culture and Rights: Anthropological Perspectives.
6. Legislative Approaches and Asylum – National and Transnational Concerns Reviews of strategies for eliminating FGC have often concluded that legislation is a poor tool for evoking behavior change. Several well-known examples of responses to laws enacted under colonial rule provide evidence that legislation can be ineffective or counterproductive, failing to act as a deterrent, and instead sparking reactance. Despite the unproven effectiveness of legislation in bringing about change in the practice of FGC, an increasing number of nation-states around the world have adopted legislation specifically banning FGC in the wake of mounting international pressure to protect girls and women from human rights violations. One compellingly motivating factor for African governments to pass anti-FGM legislation lies with policies linking foreign aid to FGC policies. Thus, African governments are increasingly pressured by, for example the United States, as certain forms of aid and loans are tied conditionally to presenting evidence of combating FGM. Divergent views of the potential effects of legislation have been forwarded. On one hand, members of the international community who are increasingly urging African countries to adopt legislation explicitely banning FGC believe that legal prohibition will accelerate abolition of the practice. Conversely, others argue that top-down approaches are perceived as coercive and derail local efforts to end the practice. The primary intended effects of legislation appears to be two-fold: first, to provide a deterrent effect for supporters of FGC, and second, for those already opposed to provide that extra support against social pressures to circumcise their daughters. However, the effectiveness of national laws in terms of reducing or eliminating the practice of FGC, and their potential unintended effects, remain unclear. This is partly attributable to the fact that the climate of intolerance and threat of legal sanctions serves, in certain instances, to drive the practice underground. Moreover, even in the presence of specific laws against FGC, enforcement is variable. Some scholars worry, as well, about the broader negative ramifications of enforcement: What is the psychological effect on a young, newly-circumcised girl witnessing the arrest of her parents? What is the financial impact of imposing fines on people who are already poor? Given that women are the prime initiators and practitioners of FGC, would enforcement lead to the systematic imprisonment of women? Finally, in some settings, controversy has arisen around the issue of monitoring, and in particular European and Australian proposals to conduct physical exams on immigrant girls to detect any genital cutting. Some states in Australia allow the court to make an order preventing a person from removing a child from the State; seizing the child’s passport and subjecting her to ‘periodic examination’ to ensure surgery has not taken place. Genital screening of all African – but not European - children starting school has been instituted in some cities in Denmark and France, and screening measures are being contemplates elsewhere. Asylum seekers and refugees struggle to gain sanctuary under widely varying
legal frameworks around the “Western” world. In the United States
a few highly publicized cases, notably those of Kassindja and of Abankwah,
have served to crystallize the conditions under which a woman can be granted
political asylum if claiming to fear FGM for herself or her children if returned “home.” Additionally
recent 9th Circuit Court of Appeals ruling, in the case of Mohamed v. Gonsalez,
dramatically widens the grounds for FGM-related asylum. It was determined that
already having suffered genital mutilation constitutes ongoing persecution
(in a previous, similar ruling, the Court ruled that having been made to undergo
forced sterilization constitutes ongoing persecution, as well), thus making
many more women potentially eligible.. Learning objectives:
Readings: Shell-Duncan, B. and Hernlund, Y. Legislating Change? Responses to Criminalization of Female Genital Cutting in Africa. |
