Is de discussie over vrouwenbesnijdenis overdreven?

Recent verklaarden imams in Nederland zich tegenstander van de praktijk van vrouwenbesnijdenis. Ook recent is er een onderzoek uitgevoerd of in Nederlandse privé-klinieken deze initiatierite wordt uitgevoerd.

Meisjesbesnijdenis wordt soms getypeerd als een typisch islamitisch gebruik, maar het is socio-historisch beter te plaatsen als een cultureel-regionaal gebruik dat stamt uit de tijd voor de komst van de islam (dat geldt overigens ook voor jongensbesnijdenis). Meisjesbesnijdenis komt namelijk in diverse landen voor, onder moslims, christenen en animisten. Vooral in sub-Sahara landen en Noord-Oost-Afrika worden meisjes besneden als ze in de basisschoolleeftijd zijn, maar ook in het Midden-Oosten en Indonesië komt het voor. Soms krijgen vrouweneen klein sneetje in de clitoris (incisie), soms wordt de clitoris en een deel van de kleine schaamlippen verwijderd (clitoridectomie) en soms worden ook de grote schaamlippen weggesneden en wordt de wond dichtgenaaid op een kleine opening na voor urine en bloed (infibulatie). Nederland wordt sinds eind jaren tachtig geconfronteerd met meisjesbesnijdenis.

Veel discussie over vrouwenbesnijdenis en ook veel projecten om er iets tegen te doen. Des te opmerkelijker is het eigenlijk dat we er helemaal niet zoveel van weten. We weten niet precies wat de lichamelijke, seksuele en psychische gevolgen ervan zijn en in welke mate die optreden. Uit het rapport van Bartels en Van der Kwaak is wel een en ander bekend (p.16):

De meeste literatuur over de gevolgen van meisjesbesnijdenis betreft de gevolgen van infibulatie en circumcisie, de zwaarste varianten, zoals die plaatsvinden in Noord Oost Afrika en Mali. In een van de eerste Somalische studies schrijft Dirie (1985) hier uitgebreid over: shock, bloedingen, fistelvorming, in een latere fase genitale-urineweg en obstetrische complicaties als ook psychiatrische, psychosomatische en psychosociale effecten op het leven van jonge meisjes. Grassivaro Gallo (1998:248) beschrijft hoe vrouwenbesnijdenis het psychosociale leven van Somalische migrantenmeisjes in Italië beïnvloedt. Na de ingreep worden de meisjes introvert, stil, teruggetrokken en vertonen gedragstoornissen zoals eetstoornissen en angsten. Menage (1998:215) stelt dat circumcisie als een genitale medische procedure genoeg stressgevend is om te leiden tot een posttraumatische stress stoornis. Immers er is sprake van gevoelens van machteloosheid van het meisje, gebrek aan controle, gebrek aan instemming, gebrek aan kennis en intense pijnbelevenis Over de gevolgen van mildere vormen van meisjesbesnijdenis is minder bekend.

Opmerkelijk is dat de auteurs in dat rapport ook het volgende signaleren (p. 18):

Enkele maanden na deze studiedag eindigen de publieke reacties.7 Na 1992 is er nog wel literatuur (Bartels 1993a,b, Reyners 1992, 1993, Struijs 1995, Smith en van der Weide 1992, Smith 1995 Veerman e.a.1995) verschenen over dit onderwerp maar veel discussie heeft dat niet opgeleverd. Vrouwen die besnijdenis praktiseren komen niet aan bod. Ook pleidooien om tenminste naar hen te luisteren worden verkeerd begrepen (Van der Zwaard 1994, Bartels 1994). In een analyse van dit debat laat Suurmond (1998:90) ook deze eenzijdigheid zien. “Bij het debat over vrouwenbesnijdenis gaat het om het zoeken naar een concrete oplossing voor vrouwenbesnijdenis (namelijk het verbieden ervan) ten koste van een andere mogelijke uitkomst van het debat, namelijk het aan het woord laten van de verschillende deelnemers.” Met de verschillende deelnemers bedoelt Suurmond de belangrijkste gesprekspartners, de mensen die vrouwenbesnijdenis uitvoeren. “In het debat werd vooral gezocht naar een concrete oplossing voor het probleem. Daarnaast zien we dat niet alle betrokkenen hebben deelgenomen aan het debat. De constructie van ‘onbeschaafdheid’ die een rol speelt door het hele debat heen, leidde tot een buiten het debat houden en laten van een belangrijke groep van gesprekspartners, de Somaliërs.” (Suurmond 1998:90).8

Het gebrek aan feitelijke kennis en het niet horen van de stemmen van de praktiserende vrouwen, is aanleiding voor een interessante discussie in The New York Times. De discussie over vrouwenbesnijdenis zou bewust overdreven worden, de gevolgen de negatief afgeschilderd en vrouwen die het praktiseren zou de mond gesnoerd worden. John Tierney stelt daarbij het volgende:

Should African women be allowed to engage in the practice sometimes called female circumcision? Are critics of this practice, who call it female genital mutilation, justified in trying to outlaw it, or are they guilty of ignorance and cultural imperialism?

Those questions will be debated Saturday morning in Washington at the American Anthropological Association’s annual meeting. Representatives of international groups opposed to this procedure will be debating anthropologists with somewhat different views, including African anthropologists who have undergone the procedure themselves.

[…]

Dr. Ahmadu, a post-doctoral fellow at the University of Chicago, was raised in America and then went back to Sierra Leone as an adult to undergo the procedure along with fellow members of the Kono ethnic group. She has argued that the critics of the procedure exaggerate the medical dangers, misunderstand the effect on sexual pleasure, and mistakenly view the removal of parts of the clitoris as a practice that oppresses women. She has lamented that her Westernized “feminist sisters insist on denying us this critical aspect of becoming a woman in accordance with our unique and powerful cultural heritage.” In another essay, she writes:

It is difficult for me — considering the number of ceremonies I have observed, including my own — to accept that what appears to be expressions of joy and ecstatic celebrations of womanhood in actuality disguise hidden experiences of coercion and subjugation. Indeed, I offer that the bulk of Kono women who uphold these rituals do so because they want to — they relish the supernatural powers of their ritual leaders over against men in society, and they embrace the legitimacy of female authority and particularly the authority of their mothers and grandmothers.

[…]

Dr. Shweder says that many Westerners trying to impose a “zero tolerance” policy don’t realize that these initiation rites are generally controlled not by men but by women who believe it is a cosmetic procedure with aesthetic benefits. He criticizes Americans and Europeans for outlawing it at the same they endorse their own forms of genital modification, like the circumcision of boys or the cosmetic surgery for women called “vaginal rejuvenation.” After surveying studies of female circumcision and comparing the data with the rhetoric about its harmfulness, Dr. Shweder concludes that “‘First World’ feminist issues and political correctness and activism have triumphed over the critical assessment of evidence.”

If I were asked to make a decision about my own daughter, I wouldn’t choose circumcision for her. But what about the question raised by these anthropologists: Should outsiders be telling African women what initiation practices are acceptable?

Daar kwamen nogal wat reacties op en dus kwam Tierney met een tweede post over dit onderwerp.

My post about a debate over a female initiation rite in Africa prompted lots of angry reactions, some quite thoughtful ones, much misinformation and one entirely reasonable request from Charles:

Having read dozens of passionate comments, are there any dispassionate factual examinations of the subject addressing (a) the health risks, (b) the health benefits, and (c) the actual effect of the procedure on the lives of those subject to it, all categorizing by the varieties of practice? It would be nice to have some granular facts rather than summary conclusions.

I’m not sure it’s possible to find anyone dispassionate on this subject. The experts, like Lab readers, can’t even even agree on what to call this procedure. (In my post I used several of the terms: circumcision, female genital mutilation, female genital cutting, genital modification.) But I would like to give Lab readers a sense of the research results and range of expert opinion. I’ve asked several researchers to respond to Charles’ question and to other concerns raised by Lab readers. The first response (others will follow) is from Richard Shweder, a cultural anthropologist at the University of Chicago and one of the organizers of Saturday’s debate on this topic at the American Anthropological Association’s annual meeting. Here’s Dr. Shweder’s response:

“Female genital mutilation” is an invidious and essentially debate-subverting label. The preemptive use of that expression is just as invidious as starting a conversation about a women’s right to choose by describing abortion as the “murder of innocent life.” Pro-choice advocates rightly object to the presumptive disparagement implied by that label; many African women similarly object to naming a practice which they describe in local terms as “the celebration” or the “purification” or the “cleansing” or the “beautification” as “the mutilation”. Notably in most ethnic groups where female genital surgeries are customary, male genital surgeries are customary as well and are named with the same terms.

Charles calls for a dispassionate factual examination of the risks and consequences of female genital surgeries. Fact checking has not been the strong suit of anti-“FGM” advocacy groups or of the American press. Indeed, the press in general has served as an effective outlet for the advocacy groups and has kept itself innocent of available sources of information that run counter to the received horror arousing story-line about barbaric or ignorant or victimized Africans who maim, murder, and disfigure their daughters and deprive them of a capacity to experience sexual pleasure. With rare exceptions, the only African women who have been given a direct voice and allowed to speak for themselves in our media are those who oppose the practice.

For example, in recent years there have been two major scientific reviews of the medical literature and an exemplary Gambia-based research study, which have raised serious doubts about the supposed effects on mortality, morbidity and sexuality that are so often attributed to these customary surgeries; yet, as far as I know, there has been absolutely no mention of these reviews and studies in any American newspaper or on NPR, although one might have thought they were sufficiently eye-opening and significant to warrant media coverage.

Any reasonably objective assessment of the risks and consequences of female genital surgeries should begin with the epidemiologist and medical anthropologist Carla Obermeyer’s comprehensive and critical reviews of the medical and demographic evidence on the topic (published in the journal Medical Anthropology Quarterly). Her first publication reviews and critiques the available literature on female genital surgeries through 1996; her second publication reviews the subsequent literature from 1997-2002. The third key source is a research report by Linda Morison and her Medical Research Council team published in 2001 in the journal Tropical Medicine and International Health. That research, conducted in the Gambia, is the most systematic, comprehensive and controlled investigation of the health consequences of female genital modifications yet to be conducted.

This is what Carla Obermeyer says in her first comprehensive review. “On the basis of the vast literature on the harmful effects of genital surgeries, one might have anticipated finding a wealth of studies that document considerable increases in mortality and morbidity. This review could find no incontrovertible evidence on mortality, and the rate of medical complications suggest that they are the exception rather than the rule.” …“In fact, studies that systematically investigate the sexual feelings of women and men in societies where genital surgeries are found are rare, and the scant information that is available calls into question the assertion that female genital surgeries are fundamentally antithetical to women’s sexuality and incompatible with sexual enjoyment.”

Perhaps the most scientifically rigorous and large-scale study of the medical consequences of female genital surgeries in Africa is the Morison et al Gambia study. In the Gambia a customary genital surgery typically involves an excision of the visible or protruding part of the clitoris and either a partial or complete excision of the labia minora. (It is important to note that the visible part of the clitoris, which many African women view as an unbidden, unwanted, ugly and vestigial male-like element that should be removed for the sake of gender appropriate bodily integrity and a sense of mental well-being, is not the entire tissue structure of the clitoris and much of that tissue structure, a good deal of which is not visible and protruding but is rather subcutaneous, remains even after the surgery, which may explain why “circumcised” women remain sexual and have orgasms.)

The Morison et al study systematically compared “circumcised” with “uncircumcised” women. More than 1,100 women (ages fifteen to fifty-four) from three ethnic groups (Mandinka, Wolof, and Fula) were interviewed and also given gynecological examinations and laboratory tests. This is rare data in the annals of the literature on the consequences of female genital surgeries.

Overall, very few differences were discovered in the reproductive health status of “circumcised” versus “uncircumcised” women. Forty-three percent of women who were “uncircumcised” reported menstrual problems compared to 33% for “circumcised” women but the difference was not statistically significant. Fifty-six percent of women who were “uncircumcised” had a damaged perineum compared to 62% for “circumcised” women, but again the difference was not statistically significant. There were a small number of statistically significant differences – for example, more syphilis (although not a lot of syphilis) among “uncircumcised” women, and a higher level of herpes and one particular kind of bacterial infection among women who were “circumcised.”

But in general, from the point of view of reproductive health consequences there was not much to write home about. As noted in the research report, the supposed morbidities (such as infertility, painful sex, vulval tumors, menstrual problems, incontinence and most endogenous infections) often cited by anti-“fgm” advocacy groups as common long-term problems of “fgm” did not distinguish women who had the surgery from those who had not. Yes, 10% of circumcised Gambian women in the study were infertile, but the level of infertility was exactly the same for the “uncircumcised” Gambian women in the study. The authors caution anti-“FGM” activists against exaggerating the morbidity and mortality risks of the practice. In addition, circumcised Gambian women expressed high levels of support for the practice; and the authors of the study write: “When women in our study were asked about the most recent circumcision operation undergone by a daughter, none reported any problems.”

My conclusion from reading those three publications is that the harmful practice claim has been highly exaggerated and that many of the representations in the advocacy literature and the popular press are nearly as fanciful as they are nightmarish. A close and critical reading of the much publicized 2006 Lancet publication of the “WHO Study Group on Female Genital Mutilation,” which received widespread, immediate and sensationalize coverage in the press because of its purported claims about infant and maternal mortality during the hospital birth process, suggests to me that again there is not very much to write home about.

In that WHO study, not a single statistically significant difference was found between those who had a “type 1” genital surgery versus no surgery; no statistically significant differences were found between those who had no genital surgeries and those who had type 1, 2 or 3 genital surgeries for the best predictor of infant health, namely birth weight; the perinatal death rate for the actual women in the sample who had a “type 3” surgery was in fact lower (193 infant deaths out of 6595 births) than those who had no surgery at all (296 deaths out of 7171 births) and only became statistically significant in a negative direction through non-transparent statistical manipulation of the data; the study collected data on women across six nations but never displayed the within nation results; there was no direct control for the quality of health care available for “circumcised” versus “uncircumcised” women; the sample was unrepresentative of the whole population; and in general any reported increased risk for genital surgery was astonishingly small and hardly a mandate for an eradication rather than a public health program.

The best evidence available at the moment suggests to me that the anthropologist Robert Edgerton basically had it right when he wrote about the Kenyan practice in the 1920s and 1930s as a crucible in which it is not just the courage of males but also the courage of females that gets tested: “…most girls bore it bravely and few suffered serious infection or injury as a result. Circumcised women did not lose their ability to enjoy sexual relations, nor was their child-bearing capacity diminished. Nevertheless the practice offended Christian sensibilities”. As Charles put it in his comment: “Personal revulsion is not a good basis for making general policy.”

It is noteworthy, perhaps even astonishing, that in the community of typically liberal, skeptical and critical readers of the Times there has been such a ready acceptance of the anti-FGM advocacy groups’ representations of family and social life in Africa as dark, brutal, primitive, barbaric, and unquestionably beyond the pale. Many commentators are confident that when it comes to this topic no debate is necessary.

One witnesses the ready assumption that any deliberate modification of the female (and even the male) anatomy is an example of oppression or torture (as though we should begin describing the Jewish practice as “male genital mutilation”) and that these coming-of-age and gender identity or group identity ceremonies of African mothers should be placed on the list of absolute evils along with cannibalism and slavery. At the panel on “Zero Tolerance” policies held on Saturday at the American Anthropological Association meeting, one of the participants Zeinab Eyega, who runs an NGO concerned with the welfare of African immigrants in the USA, noted that these days in New York “the pain of hearing yourself described is more painful than being cut.”
[…]

De informatie die er is, is dus gebrekkig want eenzijdig. Eenzijdig omdat voorstanders (en vrouwen zelf) nauwelijks aan bod komen en omdat het is gebaseerd op de meest vergaande vormen van besnijdenis en nauwelijks op de lichtste vorm die het meeste voorkomt (80% van de gevallen). Dat het overdreven is, lijkt mij overigens een premature conclusie als we niet genoeg weten. Termen als ‘beautification’ en ‘celebration’ maken een vergelijking met schoonheidsmaakbaarheid in westen ook nog wel voor de hand liggend. Ervan uitgaande dat de negatieve gevolgen dus overdreven zijn, zoals wordt gesteld, staan we vrouwenbesnijdenis dan wel toe?  Of is er toch meer aan de hand? Of mag toch eenzijdig worden bepaald wat vrouwen zich wel of niet mogen aandoen in naam van de schoonheid, reinheid en vrouw-zijn? Een tricky punt lijkt wellicht nog de besnijdenis van minderjarige meisjes te zijn. Maar als de gevolgen dus inderdaad mee vallen (en ervan uitgaande dat dit zo is) en jongensbesnijdenis of plastische chirurgie bij minderjarigen worden ook toegestaan, wie zijn wij dan om ouders te verbieden hun dochters te besnijden? Of is dat toch echt wat anders?