Seeking guidance for clinicians facing a question of human rights

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June 1, 2016 – A team of Georgetown experts — a physician, a lawyer and an ethicist — are taking on an issue that occasionally confounds clinicians in the delivery room: should a physician, after helping deliver a child to a women whose genitals had been cut and vulva stitched together — an outlawed procedure generally called female genital mutilation or FGM — close her up again?

Ranit Mishori, MD, MHS, FAAFP, a family medicine professor at Georgetown University School of Medicine, wrote practice guidelines last year that cautioned against this procedure, known as re-infibulation.

“But as I was writing the recommendations for the American Academy of Family Physicians , I realized I did not know the legal backstory and that the ethics of the issue needed exploring.”

“Complex Moral Problem”

So Mishori, a longtime expert on FGM, enlisted two colleagues to explore the issues — Rebecca Reingold, JD, an institute associate at Georgetown Law’s O’Neill Institute for National and Global Health Law, and Kevin FitzGerald, SJ, PhD, the Dr. David Lauler Chair of Catholic Health Care Ethics in the Center for Clinical Bioethics at Georgetown University Medical Center. They have  obtained a Georgetown “complex moral problem” grant to conduct what is the first broad look at a physician’s responsibility to women who have undergone female infibulation.

Female infibulation is the most extensive form of female cutting. It involves  removing all external genitalia then sewing up the edges, leaving a small opening for urination and the passing of menses. It occurs mostly commonly in Somalia and Sudan, among several other eastern African countries, and accounts for 10 percent of FGM practices.

In order to deliver their babies, physicians must de-infibulate — cut open the vulva.  But then, post delivery, some women ask their doctors to sew them up again.

Human rights violation?

Mishori says they claim they are not coerced; they want to be restitched. Part of the reason may be that because some women were cut as young as age 2, an altered anatomy is all they know, explains Mishori.

“They are often making an informed decision” she says, and asks “how is the practice different than physicians honoring requests by some women for genital plastic surgery”?  

“But if the procedure being requested is considered a human rights violation, aren’t you then perpetuating those violations?” Mishori asks

FGM in the U.S.

FGM is common around the world. In a report issued in May, the World Health Organization estimated that more than 300 million girls and women worldwide are living with FGM.

Conducting the three different forms of FGM is illegal in many countries, including the U.S., which also outlaws “vacation cutting” — sending a girl out of the country for FGM.

The U.S. Centers for Disease Control and Prevention estimates that in this country, more than 500,000 women or girls, primarily immigrants or former refugees, have either had or are at risk for FGM and its medical complications.

D.C. is listed as the city with the second highest number of local women at risk, ahead of Minneapolis, Los Angeles and Seattle, Mishori says. Women most at risk live in New York.

“Medicalized FGM”

The issue Mishori, Reingold and FitzGerald are investigating is reinfibulation, which is estimated to have been done in up to 10 million women worldwide.

Mishori has been asked by a new mother to reinfibulate her — which she did not do after having a conversation with the woman — and she says colleagues nationwide have reported encountering similar requests.

“The issue is that not only is this medically unnecessary, it may also constitute FGM,” she says. “Some clinicians view reinfibulation as ‘medicalized FGM,’ as well as a violation of the medical code of ethics, if not the law.”

But it is uncertain whether reinfibulation is against the law, and that leaves physicians without clarity as to how they should practice, says Reingold. Clinicians also don’t know what to do when they discover their minor patient has undergone vacation cutting. “Do the mandatory reporting requirements for child abuse apply?”  she asks.

Facilitate alternatives to FGM

Reingold’s first step is to examine the direction other countries have taken on these issues. She knows, for example, that the U.K. has outlawed reinfibulation, and that an obstetrician was recently prosecuted for performing the procedure. He was subsequently acquitted.

Reingold, who has a background in women’s reproductive rights, says this project is exciting “because it brings in a lot of different disciplines — religion, culture, law, and public health.”

In his examination of the ethical issues regarding reinfibulation, FitzGerald hopes to find ways to facilitate constructive alternatives to FGM.

“All cultures evolve, and the current global attention to the issue of FGM may be an excellent opportunity to facilitate an evolution within the communities that practice FGM to develop practices that foster and facilitate the constructive goals these communities wish to pursue in ways that will not physically or psychologically harm their members–especially their female members, but also their male members,” he says.

Mishori can’t say what they will find. “The law and patient autonomy and ethical concerns may conflict,” she says. “I am hoping we can come up with a consensus and more guidance but I can’t say that we will.”

Renee Twombly
GUMC Communications