F1000Research 2012, 1:23 Last updated: 16 MAY 2019
OPINION ARTICLE
Female circumcision: Limiting the harm [version 2; peer
review: 2 approved, 1 approved with reservations]
(Previously titled: ‘Female genital cutting is a harmful practice: where is the evidence')
Mohamed Kandil
The Department of Obstetrics and Gynecology, Faculty of Medicine-Menofyia University, Shibin Elkom, Egypt
First published: 05 Oct 2012, 1:23 ( Open Peer Review
v2 https://doi.org/10.12688/f1000research.1-23.v1)
Latest published: 08 Nov 2012, 1:23 (
https://doi.org/10.12688/f1000research.1-23.v2)
Reviewer Status
Abstract Invited Reviewers
Objective: To review the strength of evidence that links many health 1 2 3
hazards to female genital cutting.
Material and methods: Literature search in Medline/Pubmed and Google
scholar. report
version 2
Results: Female genital cutting is still practiced secretly in both
published
underdeveloped and developed countries due to prevailing strong 08 Nov 2012
traditional beliefs. There is insufficient evidence to support the claims that
genital cutting is a harmful procedure if performed by experienced version 1
personnel in a suitable theatre with facilities for pain control and anesthesia. published report report
Cutting, however, is advised not to go beyond type I. 05 Oct 2012
Conclusion: Law makers around the globe are invited to review the legal
situation in relation to female genital cutting. Proper counseling of parents
about possible risks is a must in order to make informed decision about 1 Ahmed Fetouh, Al-Azhar University for Girls,
circumcising their daughters. The procedure should be offered to parents Cairo, Egypt
who insist on it; otherwise, they will do it illegally, exposing their daughters
2 Hisham Kandil, Cairo University, Cairi, Egypt
to possible complications.
3 Ali Akoum, Laval University, Québec, PQ,
Canada
Any reports and responses or comments on the
article can be found at the end of the article.
Corresponding author: Mohamed Kandil (kandeelcando@yahoo.com)
Competing interests: No competing interests were disclosed.
Grant information: The author(s) declared that no grants were involved in supporting this work.
Copyright: © 2012 Kandil M. This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Data associated with the article
are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).
How to cite this article: Kandil M. Female circumcision: Limiting the harm [version 2; peer review: 2 approved, 1 approved with
reservations] F1000Research 2012, 1:23 (https://doi.org/10.12688/f1000research.1-23.v2)
First published: 05 Oct 2012, 1:23 (https://doi.org/10.12688/f1000research.1-23.v1)
Page 1 of 8
F1000Research 2012, 1:23 Last updated: 16 MAY 2019
Alleged health hazards
Changes from Version 1 Immediate complications
The three immediate complications are bleeding, pain and infec-
I have updated my opinion article to avoid confusing the readers
and taking into consideration the feedback I received from the tion. They are not unique to FGC. They are liable to occur with any
referees and user comments. Firstly, I want to make it completely other type of female surgery, whether minor or major. Bleeding is
clear to all that I do not condone female circumcision. In retrospect, liable to occur with the tiniest injury to the body, not only genitalia,
the title of the first version was particularly misleading, and so I and death may occur if not dealt with. Pain during genital cutting
have now changed it to reflect the scientific opinion I am trying to
convey.
was attributed to non use of anesthesia or pain killers during the
procedure5, something which is expected with any other similar
Many believe that female circumcision helps personal cleanliness
of young girls, preserves virginity, and enhances sexual pleasure
situation. The procedure is illegal in most countries of the world
for the husband, while for others, it is a religious right. Because of and it is routinely performed at home using non-sterilized instru-
this, and despite the legal ban in most parts of the world, female ments. Infection is the normal sequel for any surgical interference
circumcision is still practiced illegally by unqualified personnel performed in such an environment. We should ask ourselves what
using non-sterilized instruments.
would be the percentages of these complications if FGC was per-
Female circumcision is rightly recognized as a harmful practice. formed in a well-equipped theatre by experienced personnel. They
However, there is no high-quality medical evidence to demonstrate
would probably not be different to any other surgical procedure.
this: only Level III evidence exists – described in evidence-based
medicine levels as the opinions of respected authorities, based
on clinical experience, descriptive studies, or reports of expert Late complications
committees. Even so, no single procedure in medicine would be The alleged late risks include a wide variety of complications.
banned based on this evidence alone and this poses a significant
Scars and keloid formation may occur6. It is well known that the
problem because it would be completely unethical to aim for a
higher level of evidence such as a randomised controlled trial. I type of scar depends on the mode of healing, whether by primary
believe that a total ban of the procedure is ineffective, and may lead or secondary intention. Healing with secondary intention and the
individuals to look for illegal and often incompetent practitioners, formation of ugly scars occurs if the wound is left to heal on its
thus exposing their daughters to possible catastrophes. The own without repair. This pattern of healing is expected because the
international efforts aiming to ban female circumcision should be
directed towards demonstrating that it is a surgical practice with no
procedure is usually performed by the traditional illiterate birth
known benefit, rather than illustrating the complications associated attendant (IBA) at home. Epidermoid cysts may form probably due
with it. Once people become convinced that it is of no value, they to cutting with non sharp instruments or imprecise cutting by the
will start to question their use of the practice; in this situation, the traditional IBA or un-experienced surgeon7. The occurrence of both
initiative to eliminate female circumcision will be theirs. I believe
complications can be minimized if the procedure is performed in
that a change of strategy from “complications awareness” to “no
benefit awareness” should be the first step in the long journey that a well-prepared theatre. Controversy exists as for sexual pleasure.
must be taken before the total elimination of female circumcision Although many researchers reported that female genital mutilation
can be a reality. Meanwhile, we should be able to respond to interferes negatively with women’s sexual pleasure, others provided
social calls for circumcision with the least possible damage. contradictory evidence and confirmed that women with types I and
See referee reports II cuttings were able to enjoy their sex lives8,9. Lightfoot-Klein10
conducted a study on infibulated females “type III cutting” in
Sudan and, based on her findings, she stated that nearly 90% of all
Introduction women said that they experienced orgasm or had experienced it at
Female genital cutting/mutilation (FGC/M), or circumcision as it various periods in their marriage. Thabet et al. showed that women
was previously described1, is held responsible for a multitude of with type II cutting complain of defective sexuality compared to
health risks. According to WHO, FGC/M is defined as “all proce- non circumcised women, while women with the more extensive
dures that involve partial or total removal of the external female type III cutting are not different to controls11. This is not logical. If
genitalia, or other injury to the female genital organs for non- FGC is responsible for defective sexuality, those with type III cut-
medical reasons”2. ting should have the maximum suffering. The explanation for this
contradiction is because sexual arousal is not only dependent upon
The legislations enacted in most countries to ban FGC had minimal clitoral stimulation. It involves the stimulation of nerve endings in
effect on its prevalence3. In the most recent estimate carried out and around the vagina, vulva, cervix, uterus and clitoris, with psy-
by the WHO in 2008, an average of between 100 and 140 million chological response and mindset also playing a role12,13.
women have undergone FGC in the world and every year, 3 million
female children are mutilated in Africa4. There are claims that women who have undergone genital cutting
may have a feeling of inferiority14. This is apparent when these
Female genital cutting in medical literature women immigrate to western societies which do not practice FGC.
I searched the English literature in Medline/Pubmed and Google This psychological burden probably stems from the fact that their
Scholar for female genital cutting/mutilation and circumcision in new societies consider FGC as abnormal contradicting the tradi-
the period from January 1980 until January 2012. The available tions and beliefs they have grown up with. There are other claims
studies showed that FGC may result in either physical and/or psy- that infertility may also complicate FGC. Reasons are anatomic
chological injuries, immediate and/or late. disfigurement due to excessive scarring after infibulation “type III”
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F1000Research 2012, 1:23 Last updated: 16 MAY 2019
probably resulting from healing by secondary intention. Another the ban of FGM takes place in most countries. In fact, the design
cause is the associated infection; that might arise after FGC, to the and implementation of a RCT to address the effects of FGC cannot
internal genitalia causing inflammation and scarring and subse- be justified and seems to be unethical. In light of this fact and in the
quent tubal block15. Infection again is due to the improper environ- absence of any scientific evidence to support the practice of female
ment where the procedure was performed. circumcision, the available level III evidence, derived from retro-
spective studies and studies depended on self-reported FGC and its
The WHO reported that obstetric complications are more likely health consequences, should be taken into consideration in spite of
to occur with genital cuttings and the risk increases with more their imprecision and low reliability19,20.
advanced cutting16. This conclusion was based on a WHO collabora-
tive prospective study which included 28,393 women attending for Religious and cultural views
singleton delivery at 28 obstetric centers in Burkina Faso, Ghana, In Islam and Judaism, male circumcision is a must while female is
Kenya, Nigeria, Senegal, and Sudan. The WHO study and few not. In Islam, if female circumcision is desired by parents, it should
others also showed that a higher percentage of cut women deliver not go beyond type I FGC (Ia is removal of the prepuce and Ib is
by Cesarean section compared to uncut women due to an increased removal of the prepuce and clitoris) according to hadith “Sunna
number of obstructed labors. There is a higher incidence of infant type of circumcision”. This type of female genital surgery is equated
resuscitation, stillbirth, or neonatal death in mothers with FGC16–18. with male genital surgery21. In support of hadith, many studies
One of the major drawbacks of the WHO study is that the popula- showed that women with clitoridectomy “type I cutting” are less
tion studied is not representative for the whole population in the likely to develop gynecologic or obstetric complications compared
selected countries. In poor societies, only high-risk and complicated to infibulated women “type III”6. Considering that the number of
pregnancies are referred to hospitals. Such cases are more liable for Moslems in the world ranks second, it seems logical to reconsider
adverse obstetric outcomes. This may have overestimated the rate the legal attitude towards female circumcision and probably avoids
of complications in women with FGC who attended hospitals to the ban directed towards Sunna circumcision.
deliver. Claims for increased Cesarean deliveries in cut women were
attributed to obstructed labor most likely due to excessive scarring It therefore seems that the prohibition of FGC for those who strong-
at the pelvic outlet probably resulting from the imperfect healing ly believe in circumcision in the absence of solid scientific evidence
of the genital cutting and possible associated infection. However, does not respect their traditions and cultural beliefs. Women in socie-
the high Cesarean rate in this population cannot be attributed ties which practice FGC and the practicing immigrant minorities
solely to obstruction due to excessive outlet scarring; obstructed living in the west consider that strength and identity partly come
labor may occur due to a variety of reasons. In fact, excessive scar- from the pain and difficulty which FGC causes, making them
ring at the pelvic outlet is the easiest reason to deal with, using ‘strong’ and ‘desirable’ women22,23.
a generous episiotomy. The reason for increased stillbirth and/or
neonatal death in mothers with FGC is probably related to the Conclusions
obstructed labor; whatever the reason is, it is not a direct compli- To conclude, law makers all around the globe are invited to review
cation of FGC. the legal situation of female circumcision. Parents, especially
immigrants to the western world from the practicing societies, should
Comments be properly counselled for the possible complications, but should
The decline in FGC practice is not proportionate to the efforts also be informed that these data were not derived from randomized
exerted3. It is not easy to give up your traditions and cultural beliefs controlled trials. Those who insist on circumcising their daughters
for what is considered, by many, to be an attempt to westernize should be allowed to do so, but advised not to exceed type I cutting;
societies in the third world. Many believe that national and interna- otherwise, they will go for it secretly and illegally by inexperienced
tional feminist organizations and child rights’ advocates have prop- personnel in a poorly hygienic environment with the possibility of
agated misleading or unproven information through the media in complications.
order to force governments to prohibit the procedure. In fact, all the
above-mentioned health hazards were concluded from studies that
showed inconsistent findings. Some of them confirmed the hazards Competing interests
of FGC while others failed to prove them. In the era of evidence No competing interests were disclosed.
based medicine, level I evidence, derived from either systematic
reviews or randomized controlled trials (RCTs), to support the ban Grant information
against FGC is not available. Such studies were never considered The author(s) declared that no grants were involved in supporting
by the WHO or any other international health organization before this work.
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F1000Research 2012, 1:23 Last updated: 16 MAY 2019
References
1. Rahman A, Toubia N: Female Genital Mutilation: A practical Guide to worldwide 13. Mah K, Binik YM: Are orgasms in the mind of the body? Psychosocial versus
Laws and Policies Worldwide. Published by Zed Books 2000. physiological correlates of orgasmic pleasure and satisfaction. J Sex Marital
Reference Source Ther. 2005; 31(3): 187–200.
2. Female genital mutilation. World Health Organization. Fact sheet No 241, Geneva. PubMed Abstract | Publisher Full Text
February 2010. Last accessed 9 December 2011. 14. Utz-Billing I, Kentenich H: Female genital mutilation: an injury, physical and
Reference Source mental harm. J Psychosom Obstet Gynaecol. 2008; 29(4): 225–29. Last accessed:
3. Cottingham J, Kismodi E: Protecting girls and women from harmful practices 9 December 2011.
affecting their health: Are we making progress? Int J Gynecol Obstet. 2009; PubMed Abstract | Publisher Full Text
106(2): 128–31. 15. Almroth L, Elmusharaf S, El Hadi N, et al.: Primary infertility after genital
PubMed Abstract | Publisher Full Text mutilation in girlhood in Sudan: a case-control study. Lancet. 2005; 366(9483):
4. Eliminating Female genital mutilation – An interagency statement (OHCHR, 385–91.
UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCR, UNICEF, UNIFEM, WHO), PubMed Abstract | Publisher Full Text
World Health Organization, 2008; pp.4, 22–28. 16. WHO study group on female genital mutilation and obstetric outcome. Banks E,
Reference Source Meirik O, Farley T, et al.: Female genital mutilation and obstetric outcome:
5. Female genital mutilation. World Health Organization (2008). Last accessed date WHO collaborative prospective study in six African countries. Lancet. 2006;
27 November 2011. 367(9525): 1835–41.
Reference Source PubMed Abstract | Publisher Full Text
6. Kelly E, Hillard PJ: Female genital mutilation. Curr Opin Obstet Gynecol. 2005; 17. Larsen U, Okonofua FE: Female circumcision and obstetric complications. Int J
17(5): 490–4. Gynecol Obstet. 2002; 77(3): 255–65.
PubMed Abstract PubMed Abstract | Publisher Full Text
7. Kroll GL, Miller L: Vulvar epithelial inclusion cyst as a late complication of 18. Hakim LY: Impact of female genital mutilation on maternal and neonatal
childhood female traditional genital surgery. Am J Obstet Gynecol. 2000; 183(2): outcomes during parturition. East Afr Med J. 2001; 78(5): 255–8.
509–10. PubMed Abstract | Publisher Full Text
PubMed Abstract | Publisher Full Text 19. Geneletti S, Richardson S, Best N: Adjusting for selection bias in retrospective,
8. Catania L, Abdulcadir O, Puppo V, et al.: Pleasure and Orgasm in Women with case-control studies. Biostatistics. 2009 Jan; 10(1): 17–31.
Female Genital Mutilation/Cutting (FGM/C). J Sex Med. 2007; 4(6): PubMed Abstract | Publisher Full Text
1666–78. 20. Elmusharaf S, Elhadi N, Almroth L: Reliability of self reported form of female
PubMed Abstract | Publisher Full Text genital mutilation and WHO classification: cross sectional study. BMJ. 2006;
9. Nussbaum MC: Judging Other Cultures: The Case of Genital Mutilation. Sex and 333(7559): 124–27.
Soc Justice. Oxford University Press 1999; pp.119–20. PubMed Abstract | Publisher Full Text | Free Full Text
Reference Source 21. Richards D: Male Circumcision: Medical or Ritual? 3 JLM at 372; Parekh, op cit n
10. Lightfoot-Klein H: The Sexual Experience and Marital Adjustment of Genitally 63, at 268; United Nations Centre for Human Rights, Harmful Traditional Practices
Circumcised and Infibulated Females in the Sudan. J Sex Res. 1989; 26(3): Affecting the Health of Women and Children 1996; Fact Sheet No 23 (Geneva,
375–392. 1995), p. 8; (1996).
Publisher Full Text Reference Source
11. Thabet SM, Thabet AS: Defective sexuality and female circumcision: the cause 22. Dirie MA, Lindmark G: The risk of medical complications after female
and the possible management. J Obstet Gynaecol Res. 2003; 29(1): 12–9. circumcision. East Afr Med J. 1992; 69(9): 479–482.
PubMed Abstract | Publisher Full Text PubMed Abstract
12. Komisaruk B, Carlos BF, Beverly W, et al.: The Science of Orgasm. JHU Press, 23. El Saadawi N: The Hidden Face of Eve: Women in Arab World Women of Arab
2006. For an interview with two of the researchers, see Exploring the Mind-Body World, Translated and edited by Sherif Hetata. Published by Zed Books, London,
Orgasm. Last accessed 26 Nov. 2011. 1980; pp. 7–11.
Publisher Full Text Reference Source
Page 4 of 8
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Open Peer Review
Current Peer Review Status:
Version 2
Reviewer Report 19 November 2012
https://doi.org/10.5256/f1000research.600.r500
© 2012 Akoum A. This is an open access peer review report distributed under the terms of the Creative Commons
Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.
Ali Akoum
Laval University, Quebec, Canada
I personally think that the study is well performed. The author made a fair presentation of the literature and
outlined the various studies and statistics on this subject, which, the least we can say is delicate and
controversial.
The author presents a point of view that advocates a change in legislation in order to make this practice
legal and carried out by professionals in an appropriate and sterile environment, so that to reduce the risk
of infection and sequelae. That being said, I think it would have been appropriate to make sense of things
and take into account the traditions and cultures of the peoples who perpetuate and believe traditionally
and/or religiously in the virtues of this practice and other peoples who do not share this point of view and
condemn such practices for equally valid social and cultural reasons.
Perhaps it is better to firstly encourage change, possibly via the WHO, humanitarian organizations,
diplomatic channels, etc., and make every effort to ensure that the authorities of the countries concerned
put an end to conditions often atrocious, unacceptable and condemnable in which these interventions are
made, and the way one treat and mutilate young girls who despite the strong traditions and cultures have
fundamental rights that must be respected. If we admit that we cannot change traditions and habits and
must avoid to “westernize” the way of life of other peoples and if genital cutting in girls is “mandatory” by
the force of tradition and culture in some countries, one must ensure that such interventions are carried
out in an environment that allows these girls not to suffer and experience significant physical and
psychological distresses. On the other hand, we do not have as a society to change our laws and go
against our values to legalize or allow such practice to any group of our fellow citizens, especially as there
is no scientific evidence that it improves in anything the wellbeing of women and brings an advantage that
they cannot do without. Rather, we should ensure that our laws protecting human rights and the physical,
moral and psychological integrity of a person are respected.
Competing Interests: No competing interests were disclosed.
I have read this submission. I believe that I have an appropriate level of expertise to confirm that
Page 5 of 8
F1000Research 2012, 1:23 Last updated: 16 MAY 2019
I have read this submission. I believe that I have an appropriate level of expertise to confirm that
it is of an acceptable scientific standard, however I have significant reservations, as outlined
above.
Version 1
Reviewer Report 16 October 2012
https://doi.org/10.5256/f1000research.122.r314
© 2012 Kandil H. This is an open access peer review report distributed under the terms of the Creative Commons
Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.
Hisham Kandil
Department of Obstetrics and Gynecology, Cairo University, Cairi, Egypt
I approve the validity of this opinion article with some minor remarks.
I personally do not approve of female genital cutting as a general routine, however it is commonly
practiced in rural areas of third world countries. Due to this, it is important to study how to best deal with
the problem rather than totally deny it. The first degree procedure may be a first step towards avoiding
further damage.
I think that the final section ‘final remarks’ should be replaced with the title ‘conclusions’.
Competing Interests: No competing interests were disclosed.
I have read this submission. I believe that I have an appropriate level of expertise to confirm that
it is of an acceptable scientific standard.
Reviewer Report 11 October 2012
https://doi.org/10.5256/f1000research.122.r312
© 2012 Fetouh A. This is an open access peer review report distributed under the terms of the Creative Commons
Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.
Ahmed Fetouh
Faculty of Medicine, Al-Azhar University for Girls, Cairo, Egypt
My own personal stand is against female genital cutting except as a plastic surgery procedure for
restricted indications.
Competing Interests: No competing interests were disclosed.
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F1000Research 2012, 1:23 Last updated: 16 MAY 2019
Competing Interests: No competing interests were disclosed.
I have read this submission. I believe that I have an appropriate level of expertise to confirm that
it is of an acceptable scientific standard.
Comments on this article
Version 2
Author Response 24 Dec 2012
Mohamed Kandil, Department of Obstetrics and Gynecology, Faculty of Medicine-Menofyia University,
Shibin Elkom, Egypt
In reply to Malcolm Griffiths
Thank you for your comment.
In fact these 2 statements are not contradictory if you consider the title “limiting the harm”. It is true that I
said in my conclusion that parents who INSIST should be allowed to do so. This is applicable to poor and
illiterate societies where the traditions cannot be overcome by law. In such societies, when doctors refuse
to perform the procedure, the child is usually taken to a barber who performs the procedure with
unsterilized razors with possible catastrophes to the young girls. In this situation and only in this situation,
which is better? To allow medical professionals to perform the procedure with the mildest possible degree
(“type 1” ) or leave it to a barber to perform it? That is the message I am trying to convey.
I agree with you that a civilized mother or father would not agree to perform the procedure for his/her
daughter but an illiterate parent would, especially in areas where illiteracy rates exceed 60% and together
especially when extreme poverty and social traditions prevail.
Competing Interests: No competing interests were disclosed.
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