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Thinking About Ethics In Tackling Female Genital Mutilation (FGM)

May 19, 2017

017 (2)It was good to be invited today to attend a session of the RinGs (Research in Gender and Ethics: Building stronger health systems) meeting at the Liverpool School of Tropical Medicine.  The topic addressed by a diverse panel of experts was Gender and Ethics in Health System Research Policy and Practice.  Discussion across a broad spectrum of experience and perspectives set me thinking more deeply about what ‘being ethical’ means in the context of action and research to end female genital mutilation.  But I certainly don’t have all the answers….

This is very much work in progress – your contributions are welcome as Comment below – but specific aspects of medical / health programmes and research around female genital mutilation come immediately to mind:

Medical school / research ethical committees
FGM is above all a social malaise of immense proportion.  Two hundred million girls and women alive in the world today are thought to have experienced female genital mutilation, or to be at severe risk of it happening to them.  This constitutes by any measure an epidemic, a condition brought about by social contagion with an outcome which may even be mortal, and is at best injurious to physical and mental health.

Whilst the damaging outcomes of FGM are multiple and affect many aspects of a person’s life – and of the life of others who are connected with her – the most immediate impacts are usually medical.  It is therefore essential that the tools of clinical medicine and public health research are amongst those brought to bear when ways to eradicate this harmful traditional practice (HTP) are explored.

The conventional indices for approval by, for instance, medical school ethical committees may not on their own however be appropriate.  The impacts of possible research on individuals are always a major consideration for ethical committees, but the potential outcomes for whole communities are also critical aspects of such work.  (As an example: measles vaccination is overall effective only if it is applied at a level to secure herd immunity…. so at what level of significance should the wishes of individual parents who want to avoid it for their children be placed?) The best way to confront most of the challenges of FGM is via public health.

And whilst individual impacts may be a different consideration than social impacts for most public health research, how many mainstream clinicians and other academics are sufficiently informed to evaluate fully research proposals which examine the complexities of FGM?  Many clinicians are largely unaware of critical issues around terminologies for FGM, of differing practices in different locations, of the varying ways in which the actual damage of FGM is inflicted, or of many other aspects of this human rights abuse.

Inevitably in such nebulous contexts some clinicians and research reviewers will bring to their decision-making unexamined assumptions around gender, power and contemporary conventional thinking.

This is difficult territory; the criteria for acceptable medically-led interventions and research on FGM needs to be made very clear, transparent and overt, as soon as possible.

Legal aspects of FGM programmes and research
FGM is a crime, expressly or implicitly via legislation to prevent bodily harm, in almost every country in the world; and it is also by any measure a serious abuse of human rights.  Yet still some clinicians – like many others – perceive it primarily as a ‘culturally sensitive’ issue – albeit others challenge this view with vigour.

Several ethical question marks could be seen to arise from these varying perceptions.  For example: is it ethical to research matters which may lead to the disclosure that a subject of the contemporary research in fact committed a crime?  is it ethical not to report a historical crime which is known or strongly suspected to have been committed?  is it ever ethical – or legal, in given countries – to withhold concerns about a previous crime (FGM), perhaps for reasons of ‘patient confidentiality‘, when there may also be future victims of the same crime, unless the perpetrator is stopped? and is it ethical to attempt to prevent future possible harm to a child by legal sanction against the parent of other children, already victims of that crime?

Answers to most of these questions may seem obvious, but they will sometimes be contradictory. Sometimes, too, the answer is predicated by legal requirements which may or may not align well with the (intended) mode of action or research.

Do clinicians and other researchers always bear in mind – as they should – that those who are legally and/or professionally obliged to report any known or suspected FGM-related offence are not the ones who will eventually determine guilt and, if necessary, ensuing sanctions or penalties?  Good ethical judgements are invariably predicated on clarity.

And then we come to issues such as refugee status and asylum, or even simply to whether perhaps those  potential subjects of research or action programmes are entitled to, or can access, health care and other support – including perhaps simply enough income for themselves and their dependants to survive.  These matters are too complex to be considered here at more than a very general level, but they are often intricately woven into the life experience of the people to be approached or investigated.  They cannot be ignored.

Media engagement in eradicating FGM: knowledge for whom?
There are many different voices in efforts to eradicate FGM.  Some of them are health and law related, some based in communities, some emanating from the media.  Ideally all would share a basic commonality of understandings and perspectives about what FGM ‘means’ to those in any given context, but that doesn’t always happen, particularly as the practice is notorious for its chameleon nature.

Shared understandings in communities of why FGM is a harmful tradition would hasten progress towards eradication, but it will take time for diverse ideas to become a common language.

The media in particular can be helpful here.  We already know that different ways to present information are more or less effective in delivering messages to different groups – one RinGs seminar speaker reminded us that young men almost everywhere have mobile phones; but secluded women may depend on television for their ‘external’ information.  So it would be helpful to explore with the media which are the most effective modes of communication for specific public health messages around FGM.

Like clinicians, media professionals have ethical guidelines and professional codes.  Currently however there has been little formal examination of how these different mores are, or could be, aligned. The imperatives and rationales of the media are necessarily more immediate than those of (say) public health, the methodologies by which ‘consumer markets’ are segmented for messaging perhaps differ*, and the criteria for ‘success’ may sometimes also be divergent.  [*The example of successful Guardian programmes to counter FGM, with young journalists in traditionally practising communities, is especially interesting here.]

The major ethical question in all this is, do we know who we are most significantly benefitting or disadvantaging when public health messages about FGM are being promoted?  How should public health and media programmes best be aligned?

The granular approach
As we have noted, FGM is an especially chameleon phenomenon.  It is a centuries- (sometimes millennia-) old practices which changes whenever it is under threat.  The belief of those who practise it is that it must continue, whatever others say.  Sometimes this belief is blatantly underscored by economic and ‘commercial’ factors, sometimes it arises from perceptions of purity, sometimes it even arises as a response to perceived external danger (as when mothers in war zones reluctantly arrange FGM to ‘prevent’ their daughters being raped).

Ethical assessments of intended FGM research (and especially action-research) programmes must always therefore be context specific.  There are fundamentals which remain the same – all FGM is harmful and must be stopped – but the impacts and outcomes of actions by researchers and clinicians working in different communities may differ.  An acute sensitivity to what is going on in communities around the ‘FGM problem’ as defined by the intended research is an ethical imperative.

Intersectionality ‘versus’ power and patriarchy
One further issue comes to mind as we consider ethics in tackling FGM action and research.

There is an increasing tendency, even in matters directly relating to women and girls’ lives, to see gender and sex as factors amongst the many which influence and shape people’s lives.  This move towards intersectionality is a constructive reminder that at best only in a very few circumstances can outcomes be attributed to only a single factor, even one as powerful as gender.  Ethicity, ‘race’, age, wealth, (dis)ability and much more are also always critical.

Demands to embrace intersectionality have have sometimes however become almost a rebuke by observers of other who may not place the same emphasis as the person who admonishes them.  This has been particularly understandable in respect, for instance, of FGM and ethnicity, given – as many point out – that the large majority of women who experience it (not all of them) are persons of colour…. a consideration which has particular and even greater purchase in some nations (such as the USA) and communities than in others.
(And yes, I do know that there is also an important debate to be had about aspects of male circumcision / MGM – a blog listed below indicates where any who wish are welcome to add their thoughts on this matter.)

But whilst such an intersectional critique must always be welcomed and is absolutely central to much discourse on FGM, it can also sometimes result in an unintended but diminishing emphasis on other critical factors such as economic disadvantage (overall, women have less wealth than men – and women of colour even more in some circumstances than others), human rights (many other forms of human rights abuse are also gendered) and the fundamental power of patriarchy.

FGM is, after all, patriarchy incarnate.  It could be supposed that if (some) men did not have significantly more power and consequent wealth than most women, FGM would not occur.

The factors influencing such matters must be taken case by case, but in every instance they all need to be incorporated as elements of ethical review.  It surely serves no-one’s long term best interests to permit the evaluation of programmes and / or research addressing fundamental abuses of human rights on the basis of a personal or social preference for a single, or very few, factor/s  if, in doing so, other perspectives are thereby put aside.

So, intersectionality is an immensely complex and sensitive issue, but that does not excuse us from considering how it can best (or may not) serve the interests of  both those who promote it – hopefully, all of us to a considered extent – and those who may be vulnerable to future abuse if, should deeper aspects of, say, patriarchal power be thereby eclipsed.

We all have a right and a duty, ethically speaking, to address and challenge abuse which harms the most vulnerable in our communities.   In such broad contexts a wider intersectional perspective, always vital tool in understanding what we see though it is, can only take us some of the way.  The real fundamental is power.

Which leads me to my final consideration at this point in thinking about ethics and work around FGM…

Vulnerability
Many who campaign against FGM, directly or using their professional / academic skills, have been scarred by it. (Even simply writing about it – let alone direct experience – can be disturbing.)  No-one can have a complete picture and no-one has perfect judgement when it comes to such a difficult subject.  Both humility and respect for our co-workers are consistently required of us all.

This must also be understood by those who are in a position to support – or not support – campaigns and research to end FGM and other gendered violence and abuses, especially as many of them will be men without personal engagement with this ‘women’s issue’.  Many community activists against FGM are sensitive on questions about funding and support particularly because they are often unpaid volunteers, whilst those who ‘supervise’ and / or fund them are paid officers of mainstream organisations benefitting (as the volunteers see it) from unpaid endeavours at the point of advocacy and service delivery.

Decision-makers (directors of services, grant-awarders, politicians, administrative professionals) must themselves take steps to be fully conscious of the ethical parameters such as these within which they operate; and they need to understand also that FGM is at least as much a challenge for men as it is for women.

If those who decide which efforts to stop FGM and support survivors should be continued (or halted) fail in this ethical endeavour to understand, others – activists and others – who already often give much of themselves in their work may become hurt, more vulnerable still. That will have repercussions well beyond the individuals directly concerned.

Overt consideration of the ethics of efforts to eradicate FGM is not as yet a fully developed field; and it is unlikely to become so until the required paradigm for a whole-subject approach, supported by enlightened top-level leadership, emerges.

In my view the paradigm will come about when we move from the current ‘multi-agency’ approach to one with genuine interdisciplinary perspective.  People from different parts of the movement to eradicate FGM must come together overtly to share information on the basis of developing knowledge.

There are undoubtedly aspects of these ethics questions which have already been addressed in various fora, and it would be good to know more.

If you have information or views, please share them via the Comments below; I welcome any contributions which help us to move further along the path towards understanding the ethical complexities we must all embrace as we strive to stop FGM.

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Books by Hilary Burrage on female genital mutilation

Eradicating Female Genital Mutilation: A UK Perspective (Hilary Burrage, Ashgate / Routledge 2015).   Full contents and reviews   HERE.

FEMALE MUTILATION: The truth behind the horrifying global practice of female genital mutilation  (Hilary Burrage, New Holland Publishers 2016).   Full contents and reviews   HERE.

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FURTHER INFORMATION AND ACTION

There is a free FGM hotline for anyone in the UK: 0800 028 3550, or email:fgmhelp@nspcc.org.uk

Details of NHS Specialist Services for FGM here.

More info and posts on FGM here.

Activists, service providers and researchers may like to join the LinkedIn group Female Genital Mutilation (FGM): Information, reports and research, which has several hundred members from around the world.

The (free) #NoFGM Daily News carries reports of all items shared on Twitter that day about FGM – brings many organisations and developments into focus.

Also available to follow at no cost or obligation is the #NoFGM_USA Daily News.

Twitter accounts:          @NoFGM_UK  @NoFGMBookUK @FemaleMutlnBook  @FGMStatement  @NoFGM_USA @NoFGM_Kenya  @NoFGM_France  @GuardianEndFGM [tag for all: #NoFGM] and @StopMGM.

Facebook page: #NoFGM – a crime against humanity

Email contact: via Hilary

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[NB The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, which has a primary focus on FGM, is clear that in formal discourse any term other than ‘mutilation’ concedes damagingly to the cultural relativists – though the terms employed may of necessity vary in informal discussion with those who by tradition use alternative vocabulary. See the Feminist Statement on the Naming and Abolition of Female Genital Mutilation,  The Bamako Declaration: Female Genital Mutilation Terminology and the debate about Anthr/Apologists on this website.]

PLEASE NOTE:

This article concerns approaches to the eradication specifically of FGM.  I am also categorically opposed to MGM, but that is not the focus of this particular piece.

Anyone wishing to offer additional comment on more general considerations around infant and juvenile genital mutilation is asked please to do so on the relevant dedicated thread, originally developed in June 2012:

The Other FGM Debate: Is Male Circumcision (MGM) Also Child Abuse?

Pending further notice, discussion of the general issues re M/FGM will not be published unless they are posted on this dedicated page. Thanks.

2 Comments leave one →
  1. May 26, 2017 12:47

    Thank you, Hilary, for a broad, deep and yet concise consideration of these ethical issues and your invitation to embroider and respond. Here are a few thoughts.

    First, we know how empathic healthcare providers chafe at the duty to report, fearful that connection to criminal justice will dilute trust, an ideal ingredient in the patient-physician relation that in fact promotes healing. But you guide doctors to consider that they, in fact, do not determine the results of revelations. You remind them they are not the ones to apply the rule of law but simply to open channels to child protection. You ask whether “clinicians and other researchers always bear in mind – as they should – that those who are legally and/or professionally obliged to report any known or suspected FGM-related offence are not the ones who will eventually determine guilt and, if necessary, ensuing sanctions or penalties.” …

    Second, in my experience in Germany since the day a movement dawned (way back in the late 1970s), media’s role has been hotly debated and media training offered to activists, often on the EU’s tab. For instance, I talked about “INTACT: a controversial advertising campaign” at the European Union DAPHNE-sponsored seminar on Media organized by the European Network against Harmful Traditional Practices including FGM and co-sponsored by AIDoS at The Women’s Building in Rome on 14 December 2002. Ideally, we learned how to respond to, avoid or avert the potential damage inflicted on victims and the movement by certain news outlets’ preference for sensational narratives and visuals.

    Fortunately, media has emerged in the intervening years as an ally, and an advancing sense of productive partnership among reporters, activists and scholars exists. But an ethical challenge, previously present, has recently intensified: hijacking of the issue by right-wing media hell-bent on using FGM to promote Islamophobia. Consider Trump and Breitbart, among others.

    You also mention intersectionality above. I’d make it clear that FGM campaigns must not only promote women’s health and intact bodies, but also oppose racism. An explicit discourse in this regard is, I believe, essential.

    • May 26, 2017 13:01

      Thank you Tobe! Your long experience of these matters is invaluable… and I couldn’t agree with you more, on every count.

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