Circumcision or mutilation?

The exam today began like any other routine postpartum exam: we talked about her birth, cooed over her baby, was she having any problems? Breastfeeding was going well? Bleeding had stopped? Had she started having sex again? What was she planning on using for birth control? Then, after all the listening and talking and note taking and question answering, we finally moved around to the exam, which also seemed routine enough until we got to the pelvic portion. It didn’t hit me immediately—I just kept staring at her vulva while a small voice in the back of my mind kept nudging me that something wasn’t quite right—and then I finally saw it: she had no clitoris. She had no labia minora. There wasn’t anything except her outer labia, and the introitus (opening) to her vagina, and a thin, white, well-healed scar running up the center of her vulva, from her vagina to where her clitoris should have been. You’d think this would have been glaringly obvious, except that I think some subconscious part of me was in denial, willfully trying to make me see something that wasn’t there.

And breathe.

“Oh,” I said, as calmly and casually as I could, “I see you’ve been circumsized.”

“Yes,” she said, “back in my country.”

And then I sat there for another few seconds, on my stool with her legs in stirrups on either side of me, wondering if I should say anything else. What should I say? Should I ask her how she feels about it? Should I ask her if it bothers her? Should I ask her if she’s planning on having her daughter circumsized? Was there anything I could do for her? Was there anything I should do for her? We’d learned about female genital mutilation (FGM) in school—the different types and degrees of mutilation, the different surgical procedures that can be done to de-infibulate women—but actually seeing it was like a slap of cold water to the face. And yet, at the same time, I was very hesitant to impose my judgements on her. Asking her if it bothered her implies that it should bother her; asking how she feels about it is a more neutral question, but she was definintely giving me signals which seemed to indicate that she didn’t really want to talk about it.

So what did I do? I didn’t say anything. I proceeded with the rest of the exam. It was a Type II mutilation, her introitus and vagina were perfectly normal, the laceration from her delivery had healed nicely, there wasn’t any infibulation present, and she was obviously able to give birth vaginally without complications from the FGM. I finished the exam, wrote my note, talked about it briefly with my preceptor, and then moved on to the next woman.

Except that now I can’t shake the feeling that I didn’t handle the situation correctly—in fact, the more I think about it, the more certain I am that I handled it very incorrectly. I’m not sure exactly what the correct way of handling it is, but I feel like I didn’t advocate or educate or do my job as well as I potentially could have. And I can’t get the image of her vulva out of my mind, either. It’s not something you ever want to see, and having seen it now, it’s not something I’m ever going to be able to unsee.

What’s the right balance to strike? We try so hard as midwives to be tolerant and respectful and non-judgemental of the cultural practices and beliefs of the women we serve that it’s too easy to look at FGM as a cultural practice, and avoid questioning it or challenging it for fear of stepping on any toes, or making a woman feel that we’re not being respectful of her beliefs and practices. I was scared of saying anything because I didn’t want to impose my own judgements of what’s right and wrong on her (i.e. my culture thinks clitoral hood piercing is cool, sexy and trendy, but I’m going to sit here and tell you that your cultural practice of FGM is actually violence against women?). How can you tell her that FGM is an act of violence when she might firmly believe that it is actually an act of love? When she might be grateful to her parents for insisting that she have it, so that she wouldn’t be unsightly and ugly in the eyes of her culture? Should I be the one to challenge her, or dissuade her of her long-held beliefs? And what if challenging this ends up throwing her entire worldview into chaos, and whereas before she was accepting of the FGM, afterwards she starts to think about it more and it begins to torture her? As if she hasn’t been injured enough. Is it my place to be the one to tell her that it’s wrong?

Was all of this floating around somewhere in my head when the word “circumcision” came out of my mouth? Probably. And that’s probably why I did say “circumcision” instead of “mutilation”. Mutilation is such a loaded word—such a terrible word! How horrible to tell someone that they’ve been mutilated! And yet calling it “circumcision” is like putting a thick veneer of acceptability onto a procedure that is unacceptable. Circumcising men doesn’t cause medical complications such as shock, homorrhage, possible death, long-term urinary incontinence, lifelong reproductive problems, cysts, keloid scars, absesses, not to mention permanently destroying their sexual function or ability to enjoy sex—or sometimes just their ability to walk without difficulty or pain.

Calling female genital mutilation “circumcision” is like calling genocide “ethnic cleansing” or calling rape a “forced sexual encounter”. It’s making something that’s violent and painful and oppressive and horrific into something that’s clinically palateable, something that can be politely discussed in the literature from a safe, removed distance, something you can say in a professional setting as if we were discussing a new haircut: “Oh, I see you’ve been circumsized. Yes, do you like it?” No! If beating women into a bloody pulp every Friday night was a specific cultural practice (and some days, it feels like it is), would we turn our heads and say: well, that’s just their cultural belief, and who are we to question it? If a man had no testicles and no penis, but just a thin white scar exactly where those organs should be, would we call that “circumcision”? I think not. FGM is a prevalent, worldwide form of descrimination and violence against women. Notes to self: it can’t be glossed over with antiseptic terms like “circumcision”, it can’t be tolerated as a cultural belief, and it can’t be ignored in the clinical setting.

So…that’s what happened today. I’ve been trying to wrap my head around it all night. I have no idea what I’ll say next time I’m in this situation, but I know for sure that I will definitely call it what it is: mutilation. And I will definitely say something, instead of just letting it slide. But what to say?????

Here are some great resources on FGM, most of them courtesy of Women’s Health News:

Female Genital Cutting — National Women’s Health Center
Female Genital Mutilation: Legal Prohibitions Worldwide — Center for Reproductive Rights
Female Genital Mutilation: A Human Rights Information Pack — Amnesty International
Female Genital Mutilation — Unicef
RAINBO — Research, Action and Information Network for the Bodily Integrity of Women
Prevalence of FGM — US Dept. of State
Female Genital Cutting — USAID
Female Genital Mutilation — AAP Bioethics Committee Policy Statement
Possessing The Secret of Joy — a novel by Alice Walker

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