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Thursday, June 20, 2024

Female Genital Mutilation/Cutting/Circumcision;a threat to our sovereignty?

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By Abu Zahra

If you’re wondering “how can that be?” surely a subject of such genre cannot possibly cost us our sovereignty? There exists no logical explanation as to how this topic threatens our independence, or that a few national assembly members disagreeing on a policy will eventually lead to the loss of our sovereignty? Well, you’re hitting close to the answer, knowing to ask the right questions goes a long way to finding solutions, or in this case, answers.

In fact, the purpose of the title is to first awaken that inquisitive fellow inside each and every Gambian, to move away from the dogma of “obey and complain” but rather to ask the question “why” and not just acquiesce. If you’ve followed my previous article, it is supposed to raise a number of questions in one’s mind, hopefully you did take a moment to think about them, as I am committed to feed that little curious fellow within so as to cultivate the culture of asking questions. Unfortunately, our education system does not instill sufficient amounts of that in us, for we are taught to “fall in line” and “go with flow”, don’t ask too many questions for that equals disobedience and there is no room for dissidence as that measures up to disrespect to elders. Brings to mind the exercise “odd one out”, I wonder what purpose it served. Secondly, to provide an explanation to the title of this article.

It might be that some readers may have an assumption as to the direction this article is headed, I can assure you that the path this article goes down will only be based on facts and not heresy, admitting facts where ever that may come from and questioning that which looks a little off. I encourage you to follow through to the end as the journey might actually surprise you. I intend to only add a few points with regards to FGM/C, as my last article (A NUANCED APPROACH TO FEMALE GENITAL MUTILATION/CUTTING) published by The Standard and The Point newspapers, elaborated quite well on that, I will advise to read that first as it helps to better comprehend this article.

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I believe a lot of progress have been made, as I believe by now most people would have learnt and understood that there is no place for anything that is FGM type Ib upwards as these have unacceptable consequences and as such all should be ardent advocates for the condemnation of these practices as I have alluded to in my last article. Recently, Gambian gynecologists added their voice to the debate, further emphasising the consequences of FGM/C. This act by these experts should be commended and I would add is in fact the way forward, as I learnt that if one is ignorant in a field then you’d better consult the specialists or read a book. If we actually listen to experts on all sides around the topic, we would probably by now have found a solution.

I am convinced as well that most of us have now understood that type Ia FGM cannot be associated with any of the complications that were described and hence is harmless. We did mention that it is only this type that is encouraged by Islam, as Islam would not encourage anything harmful. Mention of the Islamic justifications were also made. However, I believe the point of debate is whether type Ia has any benefits at all and the valid concern that it might increase pressure on an already strained health system.

Before heading into that discussion, I would want to add a few points to the religious part of it as one can argue that the religious backing for the practice was given however no description from that point of view was added. So here I mention a few descriptions by some classical scholars. Those scholars whom by virtue of their work, you’d want to name a son after them.

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Imam Ibn Taymiyya says in his scholarly work Majmu Al Fatawa: “circumcision consists of cutting the prepuce which is like the cock’s comb”. another by Ibn Hajar Al Asqalani says in his renowned work Fath Al Bari that it involves the removal of “the skin covering the cocks comb-like structure and not the flesh”, Imam An Nawawi in his book sharh Al Muhazzab says that “the part that has to be removed in female circumcision is the skin of the structure which is like the cocks comb above the urethral opening”. These descriptions state clearly that which is circumcision as per the Islamic recommendation.

As for the potential benefits as it refers to its analog (hoodectomy), I came across a number of expert opinions suggesting the increase in sexual satisfaction. However, I steered clear of the opinions by these specialists directly involved in the practice of the act for fear of any bias borne of potential conflicts of interest. It is however important to note that my last article mentioned a study done by   that showed equal sexual scores between type Ia and the non-circumcised. A closer look at the break down of the scores reveals higher sexual satisfaction and orgasm scores in those that had type Ia. Two other studies looking at genital rejuvenation surgeries also suggested the same   &  . It is important to note that the study by   indicated that those that had type Ia, 90% had it done by a qualified doctor (gynecologists). There are claims that type Ia is also associated with decreased incidence of urinary tract infections.

Facing the facts, however, we all know the practice of female circumcision is not really based on the fact of hoping to achieve the health benefits associated with it. The practice is mainly based on a religious or a cultural footing. So, a claim of health benefits to be the justification of the practice in The Gambia would not be valid at all.

Did you know culture does actually affect the practice of medicine? Before dwelling on that, a brief look at the position of the American College of gynecologists on hoodectomy. The college actually talked about Female Genital Cosmetic Surgery (FGCS), to which hoodectomy belongs and arguably the least invasive of the surgical procedures. They mentioned that FGCS as a whole does not have any medical indication and may have potential complications . Nevertheless, do not get carried away by the name, Female Genital Cosmetic Surgery, as attractive as that name might sound, is actually tantamount to female circumcision pro Max, and as per the WHO logic, anything that is female circumcision (hoodectomy) plus are all FGM and should not be medicalized. Right? No! This cosmetic surgery is actually practiced in America so long as you’re 18 and above you’re good to go.  It triggers the question, the “do no harm” clause is it only in our version of the oath? Though it may look pretty that the age is 18 and above, you only need to take a closer look to realise that ages below have actually had their share.

Reverting to effects of culture on the practice of medicine, did you know the definition of beauty has been so dynamic and mainly dependent on the culture at the time. The definition of the “ideal figure” has changed from a full body figure, curvaceous, to slender body types. The definition extends to skin tone, dress codes and more. Hence to look “beautiful”, you’ve got to look a certain way and dress a certain way, and the media didn’t miss out on the opportunity of shoving this “ideal image” or this “definition” of beauty down everyone’s throat. It is so far reaching, just take a glance at our society today and you’ll get the gist of my point. However, it is even more so in the west.

Point made! How does it affect the practice of medicine I hear you ask? Well, this “ideal image” contributed its fair share to the booming of the cosmetic and plastic surgery industry. Plastic surgery is a surgical specialty that has a number of subspecialties under it. The arm that concerns our topic today is aesthetic surgery, also called cosmetic surgery, and it entails primarily to change the appearance from choice. That is to say, should one not be happy with how a certain part of their body looks, they can have it changed.

The vast majority of their clients are women and the procedures range from facial fillers to make the face/ skin appear younger by removing wrinkles, nose jobs to make the nose look a certain way, breast lift, butt lifts – (oops PG 18! Alas TV and mobile phones have ensured that is now probably PG 10) – to name but a few. They can almost “lift” any part of your external appearance that you’re not happy with. Yet these are not without complications, some of those quite severe and potentially deadly. Keep in mind, these procedures do not have a medical indication, yet despite the complications, are legal procedures. If you’re thinking, but these are mainly consenting adults and may do what they wish with their body, you’ve missed the point! Stay with me a little longer and we’ll dive in a little deeper.

The concern that the procedure will strain an already strained health care system is quite valid. But why is that? Why is the health care system already strained? Why is it that a procedure that should last about 30 minutes be an added strain to the system? Is it due to the number of specialists? The university of The Gambia medical school was established in 1998, medical school training should be 7 years, specializations should be between 4 – 7 years, I wonder why we still do not have sufficient specialists 26 years following inauguration? Or is it due to no adequate space to accommodate the procedure? The EFSTH, then RVTH, was founded in 1853 yet after over a century and half it has not gained much in terms of expansion. Why is that? These are really those questions that need be asked and answers sought if we are really serious about our health system as a people.

Finally, to the real trigger for this article, the reason why I felt the need to put pen to paper or better still finger to keyboard, and that is; it was recently reported on QTV news that a suggestion was made at a certain gathering that the MPs that are pro repeal of the anti FGM law should be subjected to visa bans. This is quite perturbing. Well, “it’s just a suggestion”. No, it’s not! I’ll tell you what a suggestion is. 

For those who do not know the hierarchy of doctors or better still those who think doctors are simply just doctors, the consultant is normally the head of the team and there are other junior doctors including senior and junior residents, medical officers and house officers. If the consultant were to ask, what approach to take with regards to the surgery of a particular patient, the response of the junior doctors, now that is a suggestion. If the consultant says “ok I think we’ll take this approach”, even though he said “I think”, the whole team would know what that meant. They’d understand that, that was not a suggestion.

We cannot have the UK foreign secretary say “let’s use travel bans…” on a certain people and take that to be a suggestion, this is anything but a suggestion, this is a threat! And its nauseatingly disturbing. Such audacity! What would give one the courage to go to the extent of meddling in our internal affairs to the point of threats? Utterly unacceptable! Disgusting to the core! Yet that which is even more perplexing is why there has not been any rebuking and condemnation of this distasteful act.

One may ask, but “why”, surely, they are only concerned for the rights of women, and are worried that such procedures might have fatal complications. As honorable as that may seem and am certain that is what they would rather have us believe, this is barely the case. If the UK were, in fact, concerned about the rights of women or even their lives then UK would not be of those countries sponsoring Israel’s war on Gaza in terms of weapon, intelligence, spy planes and more, in order to enable Israel perpetuate the war. One may interject, but they support and send humanitarian aid? Then I’ll charge that it requires no rocket scientist to know that the humanitarian aid would not be required if the conditions which led to it were stopped. i.e., simply stop funding the war, yet the UK prime minister had failed woefully to back an immediate ceasefire. Recently, he is against the applications for arrest warrants by the International Criminal Court (ICC) against those individuals responsible for these atrocious crimes against humanity. So how can a people, blatantly supporting such, teach us anything of morality?

In case you missed the point, I’ll hit closer to home. I believe you still remember the FGCS, it’s also practiced in the UK, we’ve already established that this practice is also the same as FGM. Recall the relationship between culture and medicine, the same applies to FGCS, because there is a perception of how this area is supposed to “ideally” look like, hence these surgeries despite doctors trying to hit home several times that there is not really a ‘normal” that is applicable to everyone. Guess what, the UK does have an anti FGM laws. Flabbergasted?! How can there be anti FGM laws yet FGM is being practiced but called FGCS and that is legal? when is it FGM and when is it FGCS? Or better still when is FGM not FGM?

If you’re asking these questions, great! If only we scratch a little bit further than the surface, take a look a little closer, listen a bit more attentively or read a bit beyond that which we are forced to consume then we would see easily beyond this shaky foundation upon which the facade of “spearheading” human rights activism is built upon.

The following statement on the debate on these double standards mentioned in the article by    does it for me even though it was said before the prohibition of Female Circumcision Act 1985, Lord Hatch stated that:

“If a black girl – a girl from a society, African or Asian where female circumcision is the norm – gets mental depression or psychological depression because she is not allowed to be circumcised in this country, she has to work her way through that mental depression. If on the other hand, another girl, while or black – but certainly the vast majority, if not all such cases, will be white – gets mental depression because she cannot have a cosmetic operation, she is allowed to have that operation on the ground of mental health.”

For clarity, the Crown Prosecution Service’s (CPS) statement on the Female Genital Mutilation Act 2003 states that FGCS is “likely to be caught by the definition provided by the 2003 Act”  . However, there are exceptions and that is, should the procedure be necessary for the woman’s physical and mental health  . Physical health is a given but what does mental health entail. For instance, if a woman wants their genitalia to look a certain way, which we’ve already established is influenced by culture, and not having the surgery affects them mentally, then they can have the surgery. If so, it’s only fair that other cultures are accorded the same, but no rather there is an exception to this exception and that is, if the disturbances to one’s mental health is due to their belief that they need the procedure for customary or other rituals  .

Its leaves me completely gobsmacked, that not only are you practicing FGM and calling it something else but being hypocritical about it, that you believe you can take a moral high ground and teach us morality. It is as though to say, “we cannot trust you to make civilized modern decisions” or “that we don’t think you have it in you, the capability, to make sensible decisions” and to my dismay, that which really breaks my heart, leaving me feeling totally dejected is that not a single voice, not even a sound to condemn this till today is heard. Did we miss this or is it me taking things out of proportion? I believe a proper assessment of the possible outcomes is in order.

By the way, I do understand that the views of these few leaders is not necessarily the view of the entire citizenry of the UK. In fact, polls had shown that the majority of the citizenry did actually want to see a ceasefire in the Israel-Gaza war. So, this article is not for them but rather the leaders that are so mentioned. To add, did you know, the head of the ICC, Karim Khan, reported being told that ICC was meant for Africa and thugs like Putin? The commitment of Africa to these courts still baffles me.

I imagined two scenarios both of which birthed undesirable outcomes then a third occurred to me and I hope that is instead adopted. First is that the MPs advocating for the repeal decide to stand their ground despite the threat, considering no compromise at all, then the anti FGM law gets repealed. This measures up to opening pandoras box and we certainly do not want to go down that lane.

On the other hand, the MPs give in and abandon their advocacy, that is probably a gloomier and more somber path to go down, as it sets a very scary precedence. The MPs are policy makers, one can say the guardians of the policy, tasked with debating, sieving and carefully enacting laws that are in the best interest of the country. Should it be seen that this threat of visa bans worked, it means, henceforth, should the UK or its leaders disagree with any policy being discussed at the level of the national assembly, they need only but make a statement and we will fall in line. Why does that so much sound like colonialism? I still can’t get my head around the audacity, if you’re thinking it’s mainly our own doing, you’re probably right. It would be naïve of any Gambian, even if advocating against the repeal of the law to take this threat for the winning blow.

Thirdly, and I so hope this is what ends up happening, is that the MPs maintain decorum, stay collected, debate the issue based on available evidence to come to a conclusion that is best for the nation and its people.

To conclude, it is apparent from the discussion above that culture does have a role to play in the practice of medicine and ours should not be an exception. It’s important to note, however that should evidence come to us with regards to the harmful nature of certain aspects of our culture, we should do away with them completely and not adopt double standard positions. Hence, as recommended anything from type Ib of FGM upwards should be abandoned.

However, considering the fact that type Ia is not associated with the complications cited for the other types of FGM and there is even the slightest potential for benefits, and allowing this type gets to end the debate on the topic thereby allowing for other pressing issues to be discussed. Shouldn’t that be considered? Regardless of the practice based on religion or culture.

The concern about the strain on the health system can be dealt with by employing task shifting, like that which is employed when general nurses are trained to conduct deliveries like midwives, or even nurses trained to do male circumcision.

Note: Female circumcision does not have to be done at birth, as per the study by  , the age range for those that had type Ia was between 9 – 12yrs.

I hope to see a statement, sooner rather than later, condemning these threats in no uncertain terms and that we finally conclude on the topic of FGM. Hopefully, it has opened our eyes to a lot of double standards and by now we would graduate from using the “west” as our reference for a moral compass. Until I have to write again and hopefully not on FGM, peace be upon you!upon you!

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