Crippling operations: 6 questions about clitorectomy
At the beginning of the week it became knownthat the Moscow Medical Center "Best Clinic" offers clitorectomy - female genital mutilation, which involves the removal of the clitoris; a report on this published "Medusa". First, the clinic's website changed the description of the procedure - the phrase “the circumcision of the clitoris is performed on girls before the onset of puberty, usually between the ages of 5 and 12 years,” was removed from it. Later, the message was removed from the site altogether, but on the remaining screenshots there remained information about three types of clitorectomy: removal of the clitoris hood, removal of the clitoris head along with the hood and labia and infibulation, that is, procedures for creating penetrating vaginal sex. The description indicated that there was no medical indication for this service, so "the intervention is for religious or ritual reasons."
Already after the information disappeared from the Best Clinics website, users of social networks found that other medical institutions are located at the request of "clitorectomy Moscow" - they are issued by aggregators that help find out where they have this or that service. Representatives of several of them immediately stated that the clinics not only did not offer this kind of intervention, but also came out sharply against him - for example, Pavel Brand, the director of the "Family" clinic, did so.
In many countries, such mutilated operations are prohibited by law, for example, in several African countries, as well as in Australia, Austria, Norway and the United Kingdom. Nevertheless, there are many places around the world where they are still being carried out, both illegally and “legally” - according to the UN Population Fund, one of the five female genital mutilation is performed by a medical professional. We are examining how the procedure of clitorectomy turns out to be in the arsenal of clinics, whether it can be legal and whether there is a difference between it and genital mutilation.
alexander savina
Is it possible to compare this intervention with male circumcision?
Female genital mutilation is often referred to as "female circumcision", but this wording is gradually being rejected in the world. This is due primarily to the fact that the phrase "female circumcision" leads to an incorrect comparison with male circumcision - a completely legal and common medical procedure. In contrast to female genital mutilation, male circumcision can be beneficial - as long as the only argument against it is the risk of complications. The rest of the research is more likely to favor the procedure: male circumcision reduces the risk of many sexually transmitted infections, including HIV and HPV, as well as urinary tract infections - cystitis and urethritis.
For female genital mutilation, on the contrary, there are no medical prerequisites - and the consequences are very serious. There are several types of female genital mutilation. Type I (actually, clitorectomy) implies the complete or partial removal of the clitoris head (in some cases, make a cut or remove only the hood of the clitoris). Type II involves the removal of the outer part of the clitoris and the labia minora (sometimes they also remove the labia minora). With type III (infibulation, or "pharaoh circumcision"), small or large labia are removed, and then the tissue is sutured, leaving only a small hole. Type IV involves all other mutilating operations: punctures, cuts, cauterization, or incisions in the vagina. Procedures can leave the consequences of varying severity: bring pain and discomfort (both during intercourse and permanent), infections, cause bleeding and blood loss, leave injuries (physical and psychological), lead to depression, difficulties in pregnancy and childbirth, infertility. In type III operations, a woman may have problems with the removal of menstrual blood from the body; sometimes the tissue is cut and stitched back several times - for intercourse and childbirth. All this shows that it is impossible to compare the two procedures: “female circumcision” is more logical to equate to torture.
Are there any medical indications for clitorectomy?
The term "clitorectomy" exists in medical practice. "Ectomy" means the removal (partial or complete) of an organ or some part of the body - in theory, this could also mean the head of the clitoris. In medical practice, clitorectomy really exists - but rather not as a separate action, but as part of a more complex operation. Karina Bondarenko, MD, gynecologist at the Rassvet clinic, says she has never met women with indications for isolated clitorectomy in her practice. According to the doctor, part of the clitoris can be removed as part of vulvectomy in the treatment of vulvar cancer. The National Health Service of the United Kingdom also notes the removal of the head of the clitoris as one of the possible operations for vulvar cancer - although not the most common.
There are no medical prerequisites for female genital mutilation.
Medical procedures with a protruding part of the clitoris are also possible as part of an operation within a transgender transition. True, they do not mean removal: with metoidioplasty from the clitoris head, enlarged due to hormonal therapy, the patient is given a penis - in this case, the organ will be capable of independent erection. In a phalloplasty, an implant is inserted into the patient to form a penis; Vulvar tissues can be stitched together to form a testicle (again with the help of implant implants) - in theory, this is similar to what is called “female circumcision”, but is carried out with completely different goals and results. In addition, the stitching of the tissues of the vulva is not considered an obligatory part of the operation - it is performed only at the request of the patient and with the consent of the doctors.
The only medical manipulation of the clitoris head, technically comparable to male circumcision, is associated with clitoral phimosis. Researchers at the Boston University School of Medicine note that it was found in almost a quarter of patients who addressed them about problems in the sexual sphere. They describe clitoral phimosis as a condition in which the hood of the clitoris is too tight to the head or its stimulation is difficult due to the nature of the structure - so that the woman experiences discomfort. Nevertheless, the phenomenon has been little studied and there is no standard protocol for working with it - in some cases an operation is performed to dissect the hood of the clitoris (as described, this is close to type I "female circumcision"), but we are not talking about removing it.
Why do I need clitoroplasty?
There are plastic surgeries affecting the head of the clitoris - the so-called clitoroplasty. Most often we are talking about it in the framework of the so-called vaginal rejuvenation - procedures aimed at changing the shape of the genital organs, which may also include reducing the hood of the clitoris. At the same time, a serious “gray zone” is hidden in the discussion of such operations. They can be carried out both for medical reasons (for example, if the patient experiences discomfort during sexual intercourse and in ordinary life), and for aesthetic reasons - but the necessity and relevance of such an operation in the second case remains a big question. There may be undesirable consequences of such operations - for example, a decrease in sensitivity.
The size of the clitoris head in women can vary greatly, there is no single “standard” and “norm” of appearance. Nevertheless, experts identify a condition called clitoromegaly - a significant increase in the outer part of the clitoris, which may be due to hormonal imbalance or be caused by the use of steroids. Increasing the size of the clitoris while taking hormonal drugs in transgender men is also considered clitoromegaly. There are situations when people with such a diagnosis reduce the external part of the clitoris surgically - most often this happens with intersex people who are subjected to so-called normalizing operations in infancy in order to bring them "into line" with the male or female. The intersex community opposes the "normalizing" operations: most often they are performed back in infancy, when the child cannot give informed consent to the procedure. In addition, if a person does not experience discomfort, there are no medical indications for the procedure - it is carried out only for social and aesthetic reasons, with which not everyone agrees.
What do UN and WHO think about this?
International organizations - the UN and WHO - strongly condemn genital mutilation and consider them a serious violation of the rights of women and girls. In 2012, the UN General Assembly unanimously adopted a resolution against mutilation. The United Nations Population Fund actively advocates not only against the practice itself, but also against its medicalization, that is, situations where the practice is carried out by medical specialists. According to experts, this normalizes an unacceptable procedure, creating a false sense of security. Even if a crippled operation is performed by a person with a medical education, it does not become less severe from this, and the sterile conditions do not guarantee that in the future the girl or woman will not face difficulties, psychological trauma or health problems.
Why is crippling surgery unacceptable for adults?
According to the UN, today in the world there are about two hundred million women and girls who have undergone crippling operations. Most often, the intervention is carried out by underage girls, but there are other situations, for example, in Kenya, the rite is traditionally held on the wedding day.
It is often found that female genital mutilation is more acceptable, as an adult woman herself is responsible for herself. Nevertheless, it is difficult to talk about completely free choice in this case: practices and customs are deeply rooted at the cultural level. Many are not ready to give up the tradition, even knowing about all the risks, as they are sure that the benefits of the practice outweigh the danger. Often, crippling operations become a kind of initiation rite and part of the cultural heritage, which is why women cannot give up on them: the family can be reproached, and a girl who rejects mutilated practices can be considered "unworthy" of marriage and ostracized.
At the same time, crippling operations are inextricably linked with gender inequality - they violate the right of women to physical integrity, deprive them of the ability to freely manage their body, have sex without pain, give birth comfortably and can cause menstruation difficulties. Therefore, even if a woman is sure that she is doing the right thing by agreeing to an operation, this does not negate all the possible consequences for the health and dangers of the procedure.
What do laws say about crippling operations?
According to the UN, laws against crippling operations are in place in more than twenty countries in Africa (for example, in Egypt, Ghana, South Africa, Kenya and Sudan) and on other continents - for example, in the United Kingdom, Australia, Colombia, Italy and Portugal. In the United States, a law prohibiting female genital mutilation was adopted in 1996. Recently, however, the ban was declared unconstitutional when the question of the admissibility of such procedures was raised at the trial in the case of the doctor and the owner of the clinic that provided this service.
In Russia there is no separate law aimed specifically at female genital mutilation. Nevertheless, there are ways to hold accountable those who deal with them. Victor Lurie, a lawyer at Human Rights Postcards, notes that article 14.4 of the Administrative Code assumes responsibility for providing services that do not meet the requirements of regulatory legal acts. Female genital mutilation is contrary to the laws on the protection of public health - which means that in this case, anyone, regardless of whether he has been intervened or not, has the right to write to the Rospotrebnadzor, which should bring the clinic to justice. True, the article implies only an administrative fine of up to 30 thousand rubles.
Many are not ready to abandon the tradition, even knowing about all the risks, as we are sure that the benefits outweigh the danger.
According to Lurie, if the operation led to serious consequences (for example, inability to become pregnant), the actions of the doctors and the clinic management should be qualified under article 118 of the Criminal Code of the Russian Federation (its second paragraph implies responsibility for causing serious injury to health due to negligent performance of professional duties) or article 293 of the Criminal Code (negligence). "In this case, you should write a statement to the police, even if you are not directly affected by these consequences," the lawyer said. According to Lurie, having learned that the medical institution provides such a service, one should contact the territorial health authority, Roszdravraznadzor and the prosecutor's office in order to organize an inspection of the legality of the clinic's actions.
There is an opportunity to punish parents who are subjecting children to female genital mutilation. Viktor Lurye notes that article 156 of the Criminal Code of the Russian Federation criminalizes the parent or guardian for improperly performing the duties of raising a minor in combination with cruel treatment: "Inflicting irreversible damages on a child is nothing but child abuse." It is possible to attract parents who are abusing the child and other types of responsibility. “The possibility of collecting compensation for the child’s benefit for causing moral or property damage is not directly provided for by family law, but follows from the provisions of Article 151, 1064, 1099 of the Civil Code of the Russian Federation,” says Victor Lurie. The law enforcement agency or the prosecutor’s office may file a lawsuit with such a lawsuit based on the results of the audit - it can be carried out on the basis of the application of any person.
Finally, the responsibility for parents includes the Family Code of the Russian Federation. "In accordance with article 69 of the Family Code of the Russian Federation, parents can be deprived of parental rights if they, for example, abuse their parental rights, abuse children (this also implies physical or mental violence or an attempt on their sexual integrity), committed an intentional crime against the life or health of their children, "- says Victor Lurie. According to him, crippling operations are covered by all the above reasons for deprivation of parental rights - and anyone who knows about the actions of the child’s parent can initiate a check.
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