**2. Literature review**

*Psycho-Social Aspects of Human Sexuality and Ethics*

for other forms of the practice, see [12, 13]).

girls from countries that practice FGM/C [15, 16].

The World Health Organisation (WHO) classifies FGM/C into four categories: Type I, Type II, Type III and Type IV. Type III is described as the most severe, whilst Type IV is described as only symbolic and not a ritual [3]. There are two forms of Type I. Type Ia involves the intentional removal of the hood of the clitoris and seldomly occurs on its own [4, 5]. Type Ib results in clitoridectomy—a procedure requiring the removal of the clitoral hood. Type Ib is more common and may also include the partial or complete removal of the clitoris together with that of the prepuce [6]. In Type II (excision), the clitoris and labia minora are partially removed with sharp objects, although some cultures partially cut out the labia majora and may apply ashes or herbs to stop the ensuing bleeding [5, 7]. FGM/C Type III (infibulation) involves the removal of all external genitalia, after which the wound is fused with cat gut, thorns or surgical threads (see [8, 9]). The clitoris may be pricked, pierced and scrapped to let blood in FGM/C Type IV. The practice represents the ritual of FGM/C in communities where FGM/C is outlawed ([10, 11];

An estimated 200 million women and girls globally have undergone the FGM/C

The prevalence of FGM/C in Australia is difficult to determine, although some speculate that it has been around since 1994 [17]. Whilst there appears to be a lack of research and literature around FGM/C in Australia, the increase of migrants into the country from nations where FGM/C is practised may be an indication that FGM/C prevalence is increasing in Australia [18]. It is believed that women who have experienced FGM/C arrive in Australia after the procedure has been done [19]. Tellingly, statistical analysis shows that Australia received 38,299 migrants from 11 African countries where FGM/C is highly prevalent such as Sudan (24,082), Egypt (6258), Somalia (2736) and Ethiopia (5223), with the remainder from other African nations, as reported by Bourke [20, 21]. In 2010, the Melbourne Royal Hospital reported that it had seen 600–700 women living with FGM/C [20, 21]. Mathews [18] argues that the challenge of accurately establishing the prevalence and occurrence of FGM/C in Australia also stems from secrecy of the practice when compared to how it is symbolically portrayed in public ceremonies in countries that observe

A 2010 US survey revealed that sexual and reproductive healthcare professionals (SRHPs) may have knowledge about the presentation of FGM/C amongst migrants, but lacked culturally competent skills and adequate information to provide competent healthcare for women living with FGM/C [22]. Hess et al. [22] also found that negative attitudes and cultural insensitivity in SRHPs reinforce stigmatisation and isolation, resulting in poor sexual health amongst migrant women. Further, Berggren et al. [23] conducted a study in Sweden revealing that midwives attending to women living with FGM/C did not have adequate knowledge, which was evident during labour of women with infibulation. They also revealed that cultural insensitivity by healthcare professionals, poor cross-cultural communication and poor management of the labour process resulted in caesarean sections in women with

Zaidi et al. [24] found that there is a need for healthcare professionals working with women living with FGM/C to be aware of their own cultural prejudices that may affect the wellbeing of their patients. Other researchers investigating healthcare professionals' knowledge and management of FGM/C revealed that cross-cultural training of healthcare professionals working with migrant women is imperative to

procedure, with populations with the highest percentages residing in Africa, including 1% in Cameroon, 4% in Ghana and Togo, and above 91% in Egypt and 98% in Somalia UNICEF [5]. In Europe, it is estimated that half a million women and girls are living with FGM/C [14], mostly due to the mobility of women and

**32**

FGM/C (see also [16]).

FGM/C more often than was necessary.

The WHO defines FGM/C to include 'all procedures that involve partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons' ([3], p. 3). FGM/C is performed on children between 0 and 15 years [28]. Traditionally, it is performed at 8 years of age on average but can occur at any age. Kolawole [29] argued that FGM/C is infused with cultural, legal and medical implications, making it difficult to adequately define. Debates regarding terminology and definitions continue across all societies, social groups and cultures. Almroth et al. [30, 31] pointed to concerns amongst scholars regarding the use of terminology and the ritual of FGM/C; in particular, some scholars consider 'mutilation' (p. 457) a medically acceptable term for the practice, as it involves the removal of healthy tissue and organs without medical indication, whilst others have argued that this term denotes negative connotations and attitudes towards the procedure, and may be offensive to some cultural groups [31, 32].

We have argued elsewhere [33] that the term 'female circumcision' implies an analogy with male circumcision, which is misleading from an anatomical aspect as male circumcision only involves the removal of the glans, which by no means corresponds to the cutting of female genitalia (see also [31, 34])—FGM/C could only be compared with male circumcision if the penis were completely amputated and the surrounding tissue removed, as the cutting experienced by girls is severe, with irreversible effects that inhibit both sexual and reproductive capacities [29].

According to Bibbings [35], 'female genital mutilation' (p. 139–149) suggests torture and violent bodily injury forced on children and unwilling women by men and women from their cultural groups for the benefit of men and their communities or groups. This study shares this viewpoint, and both the term female genital mutilation and cutting (FGM/C) have been used concurrently to take a strong stand against the procedure, whilst acknowledging the theoretical debates on the definition of FGM/C as well as cultural, social and health implications of the procedure (see [36]).

Several scholars have argued that FGM/C is a strategy that exploits female sexuality for the sexual pleasures of men [37–39]. Some authors have postulated different reasons for the occurrence of FGM/C, including marriage [39], religion [26], cultural reasons [40], ethnicity [41], maternalism [23], patriarchy, and social pressures [37]. Additionally, community attitudes towards the continuance of the practice are reported to slow and frustrate measures designed to address and potentially end the practice [11, 42].

According to Almroth et al. [30, 31], there seems to be no known clinical studies that have documented the consequences of FGM/C, and the body of available literature only documents results of survey-based studies [30]. Anecdotal evidence and accounts of the consequences of FGM/C report a correlation between the procedure and adverse sexual and reproductive health outcomes [43]. Immediate and longterm sexual and reproductive health conditions have been reported in women living with FGM/C, although the severity of these conditions is believed to be dependent on the extent or the type of the procedure performed.

Diouf and Nour [44] argued that the adverse effects of Type I, Type II and Type III FGM/C can be short and long term, and possibly increase the risk factors for an HIV transmission due to the use of non-sterile instruments during the procedure. Wakabi [45] documented how surgical equipment is traditionally used numerous times on more than one initiate during the FGM/C procedure without being sterilised, increasing the risk of HIV and other blood-borne viruses (BBVs) being transmitted. Additionally, [46] argued that excessive bleeding is a complication of the FGM/C procedure, which can increase the need for medical attention (i.e., a blood transfusion); this may again increase the risk of potential HIV transmission. Although untraditional, it is based on adverse medical complications of FGM/C that the procedure came to into existence by emulating western medical practices of male genital cutting/ circumcision (MGC/M).

The medicalisation of FGM/C refers to any form of FGM/C being performed by healthcare providers, whether in private or public facilities, in the home or any other place where it may occur, in contrast to the traditional circumcision ceremony, which is usually ritualised and surrounded by public celebrations of the procedure [47]. In Kenya, for example, the medicalisation of FGM/C has become common amongst holidaymakers living in Western countries who originate from this country. Therefore, it is common amongst the Bagusii and the Kuria in the west of the country, where FGM/C is highly prevalent, and Njue and Askew [48, 49] reported that it has become common amongst nurses, midwives and even medical doctors to perform the procedure after consultations with a child's parents.

However, we opine that the medicalisation of FGM/C raises moral questions pertaining to whether it is a measure to protect the sexual and reproductive health of girls and women or an imperialistic promotion of a dangerous practice [50, 51]. Furthermore, the minimisation of complications during and after the procedure raises questions as to whether the medicalisation of FGM/C reduces harm or perpetuates an extremely dangerous practice [38].

A decade ago, the WHO delivered a joint statement against the medicalisation of FGM/C on the basis that it excuses and perpetuates a harmful practice, and further stated that the medicalisation of FGM/C is a dangerous and criminal practice, requiring strategies to stop healthcare providers from carrying out the procedure [52].
