The medicalisation of female circumcision: Misguided policies that have handed doctors the scalpel instead of taking it away

“I’ll never forget how they stripped me and pinned me down.” Reem didn’t know she was about to be circumcised. Her mother took her to visit her grandmother, and there, her arms and legs were restrained, and a nurse—whose face still scares Reem—took out an implement resembling a scalpel and cut off a part of her body she had decided was not needed.

The medicalisation of female circumcision refers to the practicing of female genital mutilation by healthcare providers such as doctors and nurses. According to the 2021 health survey, 83% of women aged 0-19 who have been subjected to the practice were circumcised by a doctor or a nurse.

Among the 31 countries worldwide where female genital mutilation is common, Egypt leads the way in the medicalisation of the practice. According to UNICEF, the medicalisation of female circumcision gives parents a false sense of faith in the operation by virtue of its being performed by doctors, nurses or other health professionals.

Gynaecologist and obstetrician Maria Armia says that the culture and practice of female circumcision is no longer widespread, and that the families of young women seek out doctors and nurses to perform circumcision because they fear complications like infection and haemorrhage. She says the fact that a doctor has performed the procedure also relieves their consciences.

Healthcare providers who perform female genital mutilation are violating young women’s right to physical safety and health, as well as basic medical ethics as represented in the injunction to do no harm, according to the United Nations.

In most areas of Egypt where the practice is common, circumcision is referred to not by this name but by a proud epithet [tahara] meaning “purity” or “chastity,‫” thereby lending a veil of piety and broad social acceptability to this crime.

“I remember it like it happened yesterday”—Reem

Reem was a child of ten at the time. She didn’t understand what was happening to her body, and nobody bothered to explain to her. Her mother simply told her that “chastity” was necessary, and happened to all girls. Girls who weren’t circumcised would “grow up to be dirty and indecent.”

In Reem’s countryside village in Manufiyya governorate, in the Nile Delta, girls are still tied up and subjected to circumcision at the hands of doctors and nurses, though it is no longer publicly acknowledged, say Reem and her mother.

Reem’s mother, like others in the village, wanted a doctor or nurse to perform the circumcision rather than one of the traditional midwives who were relied on in earlier times, believing that as specialists, doctors would perform the circumcision correctly and ensure it didn’t cause the girl any problems.

Despite the consequences of circumcision, the damage it has caused, and the fact it has been criminalised, Reem’s mother still believes that what she did to her four daughters was necessary. She is trying to convince one of them to circumcise her own daughter, or at least have her seen by a doctor, and is highly disapproving of her daughter’s refusal.

Reem, meanwhile, suffers panic attacks if she has to pass close by the nurse’s house or bumps into her in the street, although fifteen years have passed since the day in question. “I remember it like it happened yesterday,” she says. “I’ll never forget how they stripped me and pinned me down. I’m still terrified of her.”

Reem says that all the girls were circumcised, and those who were not would be disparaged for being immoral, even by other girls.

Reem, who got married a few years ago, often feels like she doesn’t enjoy her sexual relationship with her husband and doesn’t want to continue. She believes circumcision is responsible, because she loves her husband and has no problems with him.

Dr Maria Armia says young women do not forget the experience of having their genitals exposed in front of a group of people, or of being restrained and having a piece of their body cut off. They suffer negative psychological repercussions which manifest in their relationships with their husbands and their self-confidence, and feel as if they’re missing something and as if their body is flawed—feelings which only worsen if they are subsequently criticised by husbands.

How did the circumcision scalpel end up in the hands of doctors and nurses?

In September 1994, while Egypt was hosting the Population Conference which was to discuss the issue of circumcision, CNN broadcast a chilling report about a young child called Naglaa whose father stripped her naked, tied her hands, and forced open her legs while a barber-surgeon circumcised her.

The girl was shaking, shrieking and screaming for help while a smiling group of people, mostly men, looked on, amid her mother’s ululations.

A few weeks after the TV report was broadcast, provoking criticism, the minister for health announced a decision that aimed to take the circumcision scalpel out of the hands of the barber-surgeon. It was placed instead in the hands of doctors and nurses, and so far nobody has managed to wrest it away, despite numerous decisions and increasing sanctions.

Timeline of ministerial decisions

1. Decision by minister of health Ali Abd al-Fattah no. 3/10754 of 19/10/1994 prohibiting the performance of circumcisions by anyone other than doctors and anywhere other than locations intended for the purpose in general and central hospitals; implementing the medical professions law; and stipulating that any teaching, general or central hospital must set aside two days of the week for male circumcision procedures and one day to receive families wishing to have their daughter circumcised.

2. Decision by minister of health Ismail Sallam no. 261 of 1996 which stated: “female circumcision procedures shall not be performed, whether in hospitals or in public or private clinics, and must not be carried out other than in medical cases which shall be decided by the head of the hospital’s gynaecology and obstetrics department based upon the recommendation of the consulting physician.”

3. Decision by minister of health Hatim al-Gabali no. 271 of 2007 which prohibited doctors, nursing staff and others from performing any incision, adjustment or alteration to any natural part of the female genitals “circumcision” [sic], whether in a state or private hospital or any other location.

Unicef believes that ministerial decisions made in the 1990s which restricted the performance of circumcision to specific medical institutions and facilities, and to cases where it was a medical necessity—a decision which was left to medical practitioners—were among the factors which contributed to the medicalisation of female circumcision.

Likewise, campaigns against female circumcision which focused exclusively on the health risks of the procedure helped ensure it became seen as a medical issue.

“I haven’t forgiven her. I feel like I’ve been naked ever since”—Iman

Iman is a young woman from Cairo. Her mother, an educated woman employed at the Ministry of Health, has heard many awareness-raising campaigns about female circumcision and its dangers, and herself suffers from the after-effects of her own circumcision, but that wasn’t enough to save her three daughters from the scalpel or from invasive examinations.

One day, Iman’s mother asked her to take a shower so they could go out together and buy some hair accessories and nail varnish. But this outing, which the young Iman was excited about, ended up in a hospital which at the time was run by an Islamic group—specifically, in the gynaecology and obstetrics clinic.

The doctor told her to remove her trousers so he could examine her, and when she refused and tried to leave the room, crying and screaming, her mother slapped her, dragged her to the bed and undressed her.

“I knew then that he was going to circumcise me, and I was terrified and humiliated,” continues Iman. But the doctor said “The girl doesn’t need it now.” “Are you sure she doesn’t? Check again, Doctor,” insisted Iman’s mother. He examined her again and replied, “Right now, she doesn’t. You can bring her back in a few years and we’ll see.”

Iman escaped the scalpel, but her relationship with her mother was never the same. “I haven’t forgiven her,” says Iman. “I feel like I’ve been naked ever since.”

Tadwein: Half of medical students believe some women require circumcision

A survey by Tadwein Center for Gender Studies published in December 2020 into the awareness, opinions and practices of college students of medicine around female circumcision revealed that 10% planned to perform circumcisions in future while 8% had not yet decided.

Half of the students who participated in the survey believed that certain cases required female circumcision, with 82% of these supporting circumcision in cases where the appearance or shape of the vulva was “inappropriate.”

Dr Amal Fahmi, director of Tadwein Center and the researcher behind the study, said its aim was to understand medical students’ attitudes towards circumcision, the extent to which they support the practice, and whether or not they intend to perform female circumcisions in future.

She believes that the increasing medicalisation of the practice is connected to awareness-raising messaging, which initially focused on the health risks of circumcision—such as haemorrhaging, infection, sterility, and so on—and led citizens to seek out doctors to perform circumcisions in order to avoid medical complications.

Amal says that some doctors accept the practice of circumcision because they are deeply rooted in the societal culture which links it to the control of women’s behaviour. Others consider it a religious obligation, while some perform it to make money; others wish to earn social acceptance and avoid stigma.

Amal continues: “Some doctors told us that they’d tried to raise awareness of the dangers of the practice and were then smeared as being “indecent” people. In some cases patients stopped seeking them out; in others, they felt obliged to perform the circumcision, or to cut off a small part or pretend they’d performed the circumcision, so as to maintain their status.”

Amal stresses that the medicalisation of circumcision must be halted, because doctors possess knowledge of its risks and harms and because they are violating their professional oath by performing it. They also enjoy social prestige, and thus the fact they perform circumcision lends it legitimacy and social acceptance, and hinders campaigns to combat it.

“We do reductions not circumcisions”—a doctor who performs circumcisions

M, a doctor based in a city in the Delta who refused to give his name for fear of legal repercussions, defends his choice to practice circumcision on the grounds it is called “reduction.” “Of course circumcision is wrong for the girl,” he says confidently, “but we don’t do circumcisions, we do reductions which are beneficial for the girl, and protect her, which is what the Prophet commanded us to do.”

He believes that circumcisions will take place regardless of whether the doctor consents or refuses, because of the wishes of girls’ families, and that it is preferable for him, as a doctor, to perform the procedure, in order to reduce the chance of infection and haemorrhage and so that he can remove only a small part. He adds that in the past, doctors were permitted to perform circumcisions.

In response to the legal criminalisation of circumcision, and the religious prohibition issued by Dar Al-Ifta, the doctor says that “they decide what to ban and what to permit based on the position of the state and pressure from the West.” The same position was expressed by a nurse at the Ministry of Health, who refused to give her name, and who works with doctors to arrange for the circumcision of girls from her home town in one of the governorates of Upper Egypt.

“In Upper Egypt, if you don’t ‘purify’ your daughter it’s a ‘disgrace’”—Hiba

Hiba was a little girl of around six when a razor snapped in two was put to her and her younger sister’s bodies. On that long-ago day, she didn’t know that she was going to be subjected to circumcision, where it was going to take place or what it was for.

“I was tiny and I didn’t understand anything,” continues Hiba, “but I knew that ‘purity’ was done to all the girls, so obviously they were going to do it to us too.”

In the village where Hiba lives, in Qina governorate in Upper Egypt, campaigns still take place where girls are circumcised en masse, mostly by doctors and nurses, but in private homes rather than clinics and hospitals.

Hiba recounts one such recent mass circumcision event, when over ten girls—including her sisters, other relatives, and neighbours—were gathered together, and an agreement made with a doctor who then visited the home of one of them and performed circumcision on them all.

Gynaecologist Maria Armia, who works in Sohag governorate in Upper Egypt, confirms that mass circumcisions of girls take place in her governorate and in Upper Egypt more generally, and are performed by healthcare workers such as doctors and nurses. She says the practice of mass circumcision makes any escape from circumcision very difficult for girls, yielding to sociocultural pressure and collective mobilisation, and fearing stigma [sic]‫.

Twenty years after she was put into the hands of a nurse who snapped shaving razors in two to violate the bodies of young girls, Hiba, now a young mother with a university degree, is thinking about the future of a daughter she might one day have, and isn’t yet sure what she will do when it comes to whether or not her daughter should undergo circumcision.

Hiba knows well what lies in store for a woman in her town who is considering not circumcising her daughter. “Her husband and his family will object, and the news will spread, and people will say ‘she hasn’t purified her daughter,’ and that’s a disgrace here—so often the mother agrees against her will.”

Hiba, like others in her village, has seen awareness-raising campaigns about the risks of circumcision and the fact it has been criminalised, but she thinks they’re ineffective. “People think it’s a disgrace if a girl isn’t ‘purified,’” she says, “and if doctors do it, it can’t be dangerous. There was one woman who got married and wasn’t circumcised, and her husband criticised her and told her family.”

According to the United Nations Population Fund, female genital mutilation can never be safe, even when performed by a healthcare specialist in a sterile environment, and the medicalisation of circumcision gives a false sense of security while involving major risks.

By agreeing to perform circumcision, healthcare workers are wrongfully legitimising the practice as medically sound or healthy for women and girls—all the more so given the social authority and respect they command.

Doctor says circumcision crimes aren’t usually reported

At the hospital where she works, Maria treats girls who have undergone circumcision and have usually been left to bleed for a long time in the hope the bleeding will stop by itself, meaning many arrive in a critical state. Most have undergone type 1 or 2 circumcision.

Maria says that in such cases, the hospital treats the patient, which typically involves stitching the wound and administering a blood transfusion, then informs the hospital administration, which should then call the child safety line or report the child’s family to the police, but that this usually doesn’t happen, especially in rural areas.

Maria explains that police officers often come from the same village, and will try to settle the issue without a formal report. Doctors also fear that if they insist on making a crime report, they may become the object of attacks by the girls’ families.

Everyone enjoys their peace of mind while girls pay the price. Maria believes that medical professionals who perform circumcisions safe in the knowledge they will not be reported for performing it at the families’ request have simply become more guarded about revealing what they do, out of fear both parties will face legal consequences, not because it’s not happening [sic].

Heavier penalties with suspended sentences

In April 2021, the official gazette published law 10 of 2021 which addresses the problem of the medicalisation of circumcision, and punishes anybody who performs circumcision or requests it to be performed, with tougher sentences for doctors and nursing practitioners who perform circumcision.

The UN praised the law, saying that it was a historical moment in which Egypt was continuing to tighten its legislation to outlaw female circumcision, and that the new amendments would have grave consequences for those practicing or promoting circumcision such that its implementation would contribute to combating the medicalisation of female circumcision.

Maria believes that the tightening-up of the law criminalising the medicalisation of circumcision is important but not enough to get a grip on the problem, and has led to its transformation into a secret operation. She says cultural change is more important, because ultimately, healthcare workers are products of their environment and culture.

To investigate to what extent the newly-tightened law has been implemented, we searched an archive of news articles relating to circumcision published from the time the new law was issued in April 2021 until August 2023. We found just one court ruling, dating to September 2021, that referred to the new law, sentencing a father and male nurse in absentia to three years with labour and rigorous imprisonment for ten years respectively, for carrying out a circumcision on the daughter of the first defendant and causing her permanent damage.

Asmaa’s years of terror waiting for the scalpel

Asmaa, who lived with her family in a European country, always knew very well that she would undergo circumcision just like her older sister did, and that it would take place during one of their summer visits to the family in a neighbourhood of Cairo.

For years, Asmaa felt sick whenever their annual visit to Egypt approached, eavesdropping on her parents’ conversations to find out if they were planning something. It was seven years of waiting for, expecting, and fearing the scalpel.

On the visit that Asmaa curses, a female doctor came to her family home in Cairo, and began with two of her female relatives, while she listened to the girls’ screams and the clattering sounds of scissors and scalpels being sterilised in readiness for her.

When her turn came, her mother told her to take off her trousers so the doctor could examine her, and then she, a shy and terrified girl, was placed on a plastic sheet which she had seen her grandmother spreading on the floor for the sacrificial slaughtering that took place at Eid al-Adha. This time the blood would be hers, and there was no Eid.

Two female relatives helped her mother strip her and hold her down, while the terrifying woman began to “chop off her flesh,” as Asmaa describes it today.

The girl says, I think everyone in the neighbourhood must have heard my screams, but the strange thing was that afterwards, despite the excruciating pain and the sense of shame, I felt relief for the first time in years. My ordeal of waiting was over, even if it ended in my flesh being chopped off. I’d been terrified for years. [sic, no speechmarks]

We tried to obtain a comment from Dr Amr Hasan, advisor to the Minister of Health and Population for population and family development affairs, regarding the measures the ministry is taking to combat the medicalisation of circumcision, but did not receive a response by the time of publication.

The World Health Organisation says Egypt must redouble its efforts to outlaw all forms of the “medicalisation of circumcision,” based on the ethical principles that underpin healthcare.

Female genital mutilation cannot be permitted to take place in any form, anywhere, because circumcision in all types and degrees of severity is harmful to women and girls, and for it to be conducted by medical professionals does not prevent harm but helps ensure the persistence of the practice.