Personal View: A question of medical ethics from Somalia
Authors: Robert T A Scott
Journal: BMJ (2004)

“Absolute morality is the regulation of conduct in such a way that pain shall not be inflicted”

Herbert Spencer, Essay on Prison Ethics

We were about to turn back from our evening walk when a nurse pushing a wheelbarrow hailed us. In it was a bundle of rags. Closer examination showed they were covering a girl curled like a sleeping dog. Two terrified eyes looked up in despair. The nurse snapped out the problem: “Bleeding for four days after circumcision!”

Wordlessly I followed the small, tragic procession into the hospital. The wheelbarrow, with its tiny pathetic passenger, led the way into the treatment room, where a lamp sat in a puddle on a wooden bench. In the oppressive heat I could taste the nauseating fumes of paraffin. The barrow came to a stop and was abruptly bumped down.


Why does such barbarity continue?


The nurse scooped the girl into her arms and dropped her on to the couch. She barked out a command for her to bend her knees. There being no response, she roughly grabbed the child's ankles and thrust them towards her bottom. She tugged at the girl's dress and slapped her skinny legs, forcing them apart. Instinctively the girl drew her knees back together, provoking a further bout of slapping from the nurse. Mercifully, the girl finally submitted and opened her legs.

She had been genitally mutilated. The remains of her labia had been sewn together with six neat, evenly spaced stitches. From the suture line a trickle of dark blood ran down over her buttocks. The raw edges of the wound were swollen and inflamed, while the vaginal opening was little bigger than a pencil. Her lower abdomen bulged forwards. Either she was about 20 weeks pregnant or her bladder was grossly distended.

The doctor stepped forward and dabbed at the blood with a swab. He seemed embarrassed at my being afforded this most intimate of insights into his culture.

“We do not carry out any female circumcisions in the hospital,” he said. He laid deliberate emphasis on the word circumcision; using the term mutilation was not something he could bring himself to do. The realities of living in present day Somalia dictate that anyone who flaunts tradition does so at their own considerable risk. He had decided to go with the flow. It was tempting to condemn him for his attitude and his behaviour towards the girl. Yet is medical morality absolute or only relative to the practitioner's culture? What gives a foreigner any right to judgment? By referring to my own values was I appointing myself the guardian of medical ethics in Somalia?

Female genital mutilation is deeply rooted in the culture of the country. The United Nations estimates that 98 out of 100 girls in rural areas are savaged in this manner. In the whole of Africa it is reckoned that each year perhaps as many as two million youngsters are genitally mutilated. The procedure typically takes place between the ages of 7 and 10 years and consists of the removal of virtually all the external genitalia, including the clitoris and labia. Thereafter the vaginal opening is tightly sewn up. Most often the operation is carried out by the village's traditional birth attendant, with a razor blade.

The horrendous nature of female genital mutilation cries out for its cessation. Why does such barbarity continue? The process may be associated with Islamic countries but is not justified under sharia law. Indeed research has shown that it was in operation before the arrival of Islam. Various reasons have been put forward to justify the practice, though none can withstand careful scrutiny. It may be based on a male engendered desire to reduce female sexual sensitivity and consequently, at least in theory, illicit erotic encounters. Whatever justification might once have been given, it is now impossible to defend the practice. Yet it is clear that they are not going to stop, just because the World Health Organization or anyone else says they should. The practice still goes on and, judging from the sutures, the traditional birth attendant had been the operator on our patient. She is regularly supplied with a limited amount of surgical material. In the days before thread became available thorns were used to close the wounds.

What is the appropriate medical response? Should we just deal with the complications and go on throwing up our ethical hands in horror? Should we demonise those who carry out the procedure and hope that communities will ultimately respond to the disapproval of others?

There are uncomfortable reminders here with the abortion debate in the United Kingdom in the 1950s and the need to save the lives of women who were dying as a result of illegal abortions undertaken in unsanitary conditions. Maybe, just like then, we now need to think imaginatively. Would it be better to deal with the problem on the pragmatic basis of reducing harm, rather than at the idealistic level of trying to abolish the process? Perhaps the Somali doctor's boast should be that his hospital carries out less extensive, token circumcisions, that no woman has ever died or suffered any serious complications, and that the risky practice of unclean, agonising mutilations has ceased for ever?