Despite the international human rights principles stating that every girl’s security, health and life should be protected [4, 12, 13] and the WHO statement against the medicalization of FGM , an increasingly alarming proportion of health-care providers continue to maintain the FGM tradition . For example, in Egypt, the percentage of girls that had FGM performed by a health-care provider was 55% in 1995, and increased to 77% in 2008. An increase in the medicalization of FGM was also found in Kenya where it increased from 34–41% in one decade, i.e., between 1998 and 2008–2009. This integrative review illustrates that health-care providers have several motivations to perform FGM and re-infibulation.
The “harm reduction” rationale seems to be the main reason why some health-care providers are in favour of being involved in the medicalization of FGM. Indeed, those that subscribe to that belief feel the girls would benefit from undergoing FGM with a health-care provider, who would use aseptic techniques for the operation, as opposed to a traditional practitioner. Moreover, some argue that girls could be spared from the pain of the procedure by having access to anaesthetic and analgesic medication (where it is available), and also that health-care providers are trained to intervene in case of severe bleeding or infection. However, every provider should know that cutting and/or removing healthy body parts without medical indication is not without risks and violates medical ethics, even if done under optimal sanitary conditions. Unfortunately, it was shown that many health-care providers have poor knowledge about the health risks associated with FGM, either in countries where FGM is more frequent [37–42, 46] as well as in countries hosting immigrants [43, 45]. Therefore, this finding suggests that information and training about the risks of FGM should be given to all health-care providers caring for girls and women, including in western countries receiving immigrants.
Furthermore, the strategies aimed at eliminating the practice of FGM have largely focussed on warning about its risks for girls’ and women’s health . This approach seems to have failed to reduce the prevalence of FGM, and to rather lead to an increase of its medicalization to reduce harm for girls [2, 3, 23]: more families and communities request medicalized FGM, and more health-care providers offer the service . Although the population needs to be aware of the immediate and long term risks associated with FGM, this angle alone “is not sufficient to undermine a practice based on cultural beliefs and a perceived need to control women’s sexuality and fertility” . Consequently, public health approaches and policies targeting FGM should be redesigned to be more comprehensive, taking into consideration the sociocultural factors related to this practice as well as the human rights principles, in addition to the health issues.
Cultural reasons were also often reported in studies, showing that many health-care providers do perform FGM for non-scientific and non-health-related reasons, such as beliefs about the preference of husbands, cultural identity and beauty criteria. Most of the studies constituting this review were assessing the motivation of providers from countries where FGM is prevalent. It is therefore not surprising that despite their professional training, they would be influenced by their own cultural group’s convictions. The fact that some of the providers either have a positive attitude towards FGM, have undergone FGM themselves or have maintained the tradition for their daughters [35, 38–41, 46, 48] indicates that it is not always obvious for them to make a distinction between their personal beliefs and their professional obligations. On the other hand, health-care providers working in countries in which FGM is not part of the culture generally seemed to have negative attitudes towards this tradition . However, several researchers assumed that providers working in countries where FGM is not the norm would be against the practice. This is an important shortcoming, since some seem to show cultural relativism and therefore tolerance for practices such as FGM . Future studies should then take into account the cultural beliefs of health-care providers about FGM, no matter the country where they work or come from. Health-care providers should receive appropriate training based on the content and guiding principles of the United Nations interagency statement on ending medicalization of FGM , in order to understand the implications of FGM for girls and women’s health and sexuality. This would ensure their professional practice adheres to the Hippocratic oath of not doing harm, which is an ethical imperative that every health-care provider should uphold.
The consideration of the financial incentive for health-care providers to perform FGM and/or re-infibulation also emerged in this review. As Toubia & Sharief reported in their review, one Egyptian doctor stated: “It [FGM] is one of those high gain low risk operations that are too lucrative to forgo unless your license is at stake” . Moreover, bearing in mind that most of the FGM procedures are undertaken in low income countries, this is an important motivating factor for providers, and in particular for nurses and nurse-midwifes known to have lower salaries than medical doctors. The financial motivation should not be overlooked in high-income countries as well, and this should be explored more in-depth in future researches, particularly as it relates to cosmetic surgeries. Also, any strategy aimed at ending medicalization of FGM should take the financial aspect into consideration.
Trying to meet with the community’s expectations, and even dealing with the social pressure put upon them, are other key issues in understanding the reasons for which health-care providers perform FGM and re-infibulation. Providers need to be taught skills and given support for dealing with such requests, in order to refuse to contribute to this tradition. Likewise, professional associations should take a public stand against the practice of FGM and re-infibulation, and should disseminate their consensus statement to their members and to society at large to help reduce the community pressure on providers. For example, such statements were issued by the International Federation of Gynecology and Obstetrics , the Society of Obstetricians and Gynaecologists of Canada  and the Royal College of Obstetricians & Gynaecologists of United Kingdom .
Additionally, the fact that FGM is being legally banned in many countries seems to influence some health-care providers’ decisions about not to perform the intervention, whereas some others seem to allow themselves to practice FGM because no law forbids them to do so, or because the law is not enforced. It is noteworthy that the majority of governments of high prevalence countries recognise that FGM is a violation of human rights . Nearly all countries where the studies included in this review took place, had legislation to prohibit the practice of FGM before the studies were undertaken: this is the case for all the Western countries, as well as most countries where FGM is commonly practiced (Egypt (2008); Sudan (2008–2009); Kenya (2001, 2011) and Nigeria (1999–2006) [2, 51]). The only exception is The Gambia, where FGM was recently outlawed (2015) . Interestingly, in the other study undertaken in Sudan, as well as the studies done in Egypt, Kenya and Nigeria, the legal issue did not come up in the findings, which is another demonstration that banning the practice is insufficient in itself to end the medicalization of FGM . Indeed, some health-care providers are involved in the practice despite existing laws [35, 40] and choose to take the risk of being caught, since other motivations are important for them. For example, some providers admitted to discretely performing the act within the walls of the public health-care centre where they work. And “as most of the midwives and some of the physicians seemed to be involved in and aware of the procedures taking place”, this practice seems to be hidden or even tolerated . Likewise, some providers prefer to practice FGM underground, for example in their own home. Health-care providers should receive the proper information to better appropriate the law. Moreover, laws banning the practice of FGM should be reinforced by sanctioning health-care providers, either by the suspension or withdrawal of their professional licence, or by civil punitive measures (i.e., fine or imprisonment). Health institutions (hospitals and clinics) allowing or condoning the practice of FGM or re-infibulation inside their walls should also be held accountable.
Since some inconsistencies were found in categorizing some types of health-care professionals, defining what type of providers to include should be considered when studying the phenomenon of medicalization of FGM. Indeed, in some contexts such as low income countries where a shortage of adequately skilled health professionals is common , the distinction between a professional trained in a university and an apprentice or self-educated provider might not always be clear. Recognizing that there are different cadres of health care providers, some of whom may lack professional training or competencies, a standard definition of “medicalization” is proposed. Medicalization of FGM should refer to “health-care providers” who are professionals who have received formal training allowing them to develop adequate skills and competencies, and who are recognized by the local ministry of health as having the right to provide health care.
The studies included in this review help elucidate the medicalization phenomenon – 9 of them were undertaken in countries with not only a high proportion of girls and women having undergone FGM, but also with a high prevalence of medicalization of FGM, including Egypt (77%), Sudan (55%), Kenya (42%), and Nigeria (28%) . The Gambia is an exception since despite the high prevalence of FGM , medicalization is not widely practiced in this country . However, the study done there showed that 42.5% of the 468 nurses surveyed embraced the continuation of FGM, and 42.9% of them think that medicalization of FGM is safer than when it is performed by a traditional practitioner . These findings are of great concern and show that an increasing number of health-care providers could eventually perform FGM in this context. Moreover, no studies were found from countries where the medicalization phenomenon is present, such as in Guinea, where the prevalence of FGM is as high as 97% , and where 27% of FGM is reported to be done by health-care providers . Since communities maintain or adopt the practice of FGM mainly for sociocultural reasons , more research is needed in different regions where health-care providers perform FGM, in order to tailor strategies to end medicalization of FGM to each context. As 4 studies were undertaken in countries hosting immigrants from practicing nations (United Kingdom, Belgium, Australia, United-States of America) and revealed that a number of health-care providers do perform some form of FGM in these parts of the world also, it is clear that the phenomenon of medicalization of FGM is a global problem. Therefore, it should be recognized that medicalization can be practiced by health-care providers throughout the world.
Limitations of the review
Our findings have several limitations. First, the results of this review were limited by the fact that most of the available studies were descriptive, in the form of quantitative surveys with pre-determined answer choices. Therefore, this suggests the pressing need to develop robust, in-depth qualitative studies, as well as quantitative studies that specifically focus on this topic rather than embedding questions on medicalization in surveys related to other topics.
Also, this review identified a relatively small number of studies (n = 14), with methodological limitations in nearly all the studies. Furthermore, although the “STROBE Statement” is a useful tool to improve the reporting of observational studies, it was not designed to assess quality. Therefore, a checklist for quality assessment of survey studies is needed.
Because of the paucity of studies that could be included in this review, the findings were not analysed by the type of health-care providers, nor by the sex of the providers. Additionally, the lack of information in many studies made it difficult, and even virtually impossible, to specifically distinguish the motivations of the providers according to the different types of FGM (i.e., types 1–4 and re-infibulation) they perform. This should be taken into account in future studies, since this exploration could reveal different viewpoints about the medicalization of FGM. The rising trend of “symbolic circumcision” should also be accounted for, since it is increasingly considered as an “alternative to more severe forms of cutting”  (but it is nonetheless a form of mutilation as per WHO). The findings of this review were not distinguished according to the types of settings in which health-care providers perform FGM or re-infibulation. Different contexts might show different motivating factors for the practice. Also, because the tradition of FGM has different meanings among diverse sociocultural groups, future studies should consider these nuances .
Searches for studies were carried out in the main pertinent databases as well as in the grey literature. However, unpublished research findings were not looked for, which would have allowed to complete this systematic review of the literature. Finally, since the main literature can be found in English, a keyword search in other languages was not undertaken. However, a search in languages such as in Arabic (which is a major language spoken in East Africa) and French (which is a major language spoken in West Africa and in some Western countries) would have potentially generated some additional articles. Nevertheless, no study was rejected because of the language.