马来西亚女性生殖器切割的医疗化：混合方法研究-PLoS博客

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抽象

背景

尽管联合国（UN）和其他国际机构在确保不由卫生专业人员进行女性生殖器切割（FGC）方面持明确立场，但医疗率并未降低。当前的研究旨在确定马来西亚医生中FGC的医疗化程度，医生的执业医师，执业方式和方式以及实施该研究的动机。

方法和发现

这项混合方法（定性和定量）研究是在2018年至2019年期间使用自我管理的问卷调查方法，对来自2个主要医学协会的穆斯林医生以及来自马来西亚各地的大量穆斯林成员参加的年度会议进行了问卷调查。对于那些未参加会议的医生，调查表已发布给他们。协会A有510名成员，64名男性穆斯林医生和333名女性穆斯林医生。协会B只有穆斯林医生；女性3,088，男性1,323。总共以手工或邮递方式分发了894份问卷，并收到了366份完整的问卷。对于研究的定性部分，使用了雪球采样方法，并使用半结构化问卷进行了24次深度访谈，直到数据达到饱和为止。使用SPSS 18版（IBM，Armonk，NY）分析定量数据。进行卡方检验和二进制逻辑回归。使用NVivo版本12手动记录，组织，编码和重新编码定性数据。聚集的编码被引为通用主题。大多数受访者是女性，拥有马来西亚的医学学位，并拥有家庭医学的研究生学位。中位年龄为42岁。大多数人在马来西亚卫生部（MoH）以及城市的诊所工作。实行FGC的穆斯林医生的患病率为20.5％（95％CI 16.6-24.9）。实行FGC的主要原因是宗教义务。定性研究结果还表明，除了文化和减少危害外，宗教是宗教习俗及其延续的强大动力。尽管大多数穆斯林医生进行了IV型FGC，但仍有相当多的人进行过I型FGC。被访者中的女性（调整后的优势比） [aOR] 4.4，95％CI 1.9–10.0。 P ≤0.001），拥有一家诊所（aOR 30.7，95％CI 12.0–78.4。 P ≤0.001）或共同拥有一家诊所（aOR 7.61，95％CI 3.2-18.1。 P ≤0.001），他认为FGC在马来西亚是合法的（aOR 2.09，95％CI 1.02-4.3。 P = 0.04），以及在宗教上受到鼓励的人（aOR 2.25，95％CI 3.2-18.1）。 P = 0.036），并认为FGC应该继续（aOR 3.54，95％CI 1.25-10.04。 P = 0.017）更有可能练习FGC。该研究的主要局限性是样本量小和响应率低。

结论

在这项研究中，我们发现许多穆斯林医生不知道反对FGC的法律和国际立场，许多人希望这种做法继续下去。令人担忧的是，传统助产士进行的IV型FGC可能会被医生实施的I型FGC所取代并加剧，这需要马来西亚医疗当局采取紧急行动。

作者摘要

为什么要进行这项研究？

  • 联合国（UN）和其他国际机构强烈反对医生进行女性生殖器切割术（FGC）。
  • 有报道说，在许多国家，越来越多的医生在进行FGC，但马来西亚的医生对此一无所知。
  • 目前的研究是为了确定马来西亚的医生从事FGC的程度，医生是谁进行了FGC的医生，实施的方式和方法以及实施这种方法的动机。

研究人员做了什么并发现了什么？

  • 我们从2018年至2019年从2个医学协会招募了366位医生，其中有大量穆斯林会员，他们通过回答自我管理的问卷调查参与其中。
  • 此外，我们与24位医生进行了深入访谈，以使调查表中回答的问题更加清晰。
  • 大约20％的医生进行了FGC。女医生，拥有或共同拥有诊所的医生，认为FGC合法的人以及在伊斯兰教中受到鼓舞并认为FGC应该继续的人更有可能从事FGC。
  • 大多数医生在阴蒂上方的皮肤上进行了FGC，但有些切除了阴蒂的一部分。
  • 这样做的主要原因是宗教义务，文化和阻止父母寻求传统助产士进行FGC。

这些发现是什么意思？

  • 一些医生开始进行更多有害形式的FGC，这是马来西亚传统助产士以前从未进行过的。
  • 马来西亚的医疗机构应禁止医生和其他卫生专业人员实行FGC。

引文： Rashid A，Iguchi Y，Afiqah SN（2020）马来西亚女性生殖器切割的医疗化：混合方法研究。 PLoS Med 17（10）：e1003303。 https://doi.org/10.1371/journal.pmed.1003303

学术编辑： 比利时根特大学Els Leye

收到： 2020年1月6日； 公认： 2020年9月25日； 发布时间： 2020年10月27日

版权： ©2020拉希德等人。这是根据以下条款分发的开放获取文章： 知识共享署名许可，只要注明原始作者和出处，就可以在任何媒体中不受限制地使用，分发和复制。

数据可用性： 所有相关数据都在手稿及其支持信息文件中。

资金： 这项研究是使用日本科学促进会的KAKENHI赠款（16KK0067）授予YI作为主要研究者进行的。资助者在研究设计，数据收集和分析，决定出版或撰写手稿中没有作用。

利益争夺： 作者宣称不存在任何竞争利益。

缩略语： aOR，调整后的优势比； FGC，切割女性生殖器； FIGO，国际妇产科联合会； MMC，马来西亚医学委员会；卫生部卫生部；非政府组织，非政府组织； STROBE，加强流行病学观察研究的报告；联合国，联合国；联合国儿童基金会，联合国儿童基金会；人口基金，联合国人口基金；美元，美元；世卫组织，世界卫生组织

背景

切割女性生殖器（FGC；也称为女性生殖器切割）一词是指所有涉及部分或全部切除外部女性生殖器或由于非医学原因对女性生殖器官造成任何其他伤害的程序[[1个， 2]。世界卫生组织（WHO）定义了几种类型[[1个]国家之间的实践。

I型：部分或全部切除阴蒂和/或包皮过长（蛛网膜下腔切除术）

II型：切除或不切除大阴唇（切除），部分或全部切除阴蒂和小阴唇（切除）

III型：通过切开和贴合小阴唇和/或大阴唇，在切除或不切除阴蒂的情况下缩小阴道口，形成覆盖密封。

类型IV：未分类；非医疗目的对女性生殖器的所有其他有害程序，例如刺，刺，切开，刮擦和烧灼

FGC有争议，并已被标记为有害的传统做法。医疗兄弟会称该程序对身心都有害，律师谴责该程序，因为它侵犯了儿童的人权，女权主义者认为这些程序是性别不平等的体现，并且有害于妇女的健康。[[3]。

FGC有许多报道的急性或慢性健康影响，可分为短期和长期身体健康。[[4]心理和社会[[5]问题。大多数身心健康问题与I，II和III型有关[[6]和从业者的技能以及仪器的状况[[7]。在许多非洲国家以及亚洲和中东的一些国家中都实行FGC，由于移民，现在甚至在历史上从未实行过FGC的国家中也报道了这种做法。[[8]。据估计，全世界每年约有360万女童被砍掉[[2]超过2亿女孩和妇女经历了某种形式的FGC[[9]。估计到2050年，尽管接​​受FGC的女孩比例可能会下降，但接受FGC的女孩人数将增加[[2]。由于FGC具有强烈的文化和宗教价值及信仰[[1个， 10–12]，尽管经过数十年的竞选甚至将FGC定为刑事犯罪，但患病率的下降速度仍然很慢[[13]。 FGC发生在社会经济阶层之间以及不同种族，文化和宗教之间[[14];然而，尽管在古兰经中并未提及FGC，并且许多宗教人士反对这种习俗，但许多实行这种习俗的社区还是穆斯林[[15]。

2012年，联合国大会通过了一项决议，呼吁全球为结束这一习俗而作出努力。已经实施了广泛的干预策略，旨在加速放弃FGC，包括减少切割程度，改变FGC的年龄以及促进其医疗化。[[13]。但是缺乏证据表明医学化是消除这种做法的第一步[[13， 16， 17]。世卫组织将医疗化定义为“任何类型的医疗保健提供者在公共或私人诊所，在家中或其他地方实践FGC的情况”[[1个， 18岁]。联合国在1997年发表的世界卫生组织/联合国儿童基金会（UNICEF）/联合国人口基金（UNFPA）联合政策声明中采用了该定义。[[19]并在2008年得到联合国10份机构间声明的重申[[20]。

传统上，大多数被割伤的人都是传统的治疗师，他们没有接受过医学培训，并且在没有麻醉或绝育的情况下进行手术[[4]。现在，更多的父母选择让他们的女儿接受医疗保健提供者的检查，最好是在诊所进行，以最大程度地减少痛苦和并发症[[21]。 FGC的医疗化趋势已引起全球严重关注[[18岁]。

据估计，在全球范围内，超过18％的FGC程序由医护人员执行，其中包括护士，训练有素的助产士和其他医护专业人员。各国之间的比率在1％到74％之间[[16]。据报道，大多数医疗工作都在非洲进行。医疗保健提供者的参与被标记为不专业，并且违反了医学道德规范，在某些国家甚至是非法的。医疗化会给人一种错误的印象，认为该程序有益于健康或无害，并有可能使这种做法具有合法性[[16]

假设对医疗服务提供者执行FGC的需求增加，是由于如果社区的传统医生使用未经消毒的器械，并且对解剖学和人体生理学，感染预防原则或治疗后果的培训[[1个]。从事FGC的医生列举的常见原因如下。

1.减少危害[[1个， 12， 16， 17]

医生认为，他们正在防止传统从业者进行FGC带来的风险，如果他们不提供服务，社区将恢复为传统从业者。减少伤害的论点甚至得到了比利时和美国等并非FGC并非“社会规范”的国家的医生的支持，甚至得到了一些非政府组织（NGOs）的支持。[[12， 22， 23]。事实证明，医疗化作为减少伤害的策略在实行更严重形式的FGC的地区是有效的[[16， 24]。但是，以减少伤害为由来实践FGC是有争议的。减少危害的目标是通过提供一组务实的和文化上可接受的替代方案来减少各种行为对个人和所居住社区的健康后果[[25]。大多数减少伤害的策略通常是在可以给予知情同意并涉及可逆策略的个人中进行的。但是由于儿童无法表示同意并且FGC不可逆，因此减少伤害的原则不适用于FGC的医疗[[23]，并通过将其宣传为无害且卫生的方式被解释为促进医学化。

2.宗教[[1个， 12， 16， 23]和支持父母的社会文化信仰[[1个， 12， 13， 16， 26]

大多数执行FGC的医疗服务提供者都是FGC执业社区的一部分，他们在该社区中服务并且通常与要求FGC的动机相同。

3.财务收益是FGC的动力[[1个， 5， 16， 23]

据报道，如果从业者不练习FGC，他们会担心受到社会制裁，特别是在农村社区，那里的社区成员可能抵制他们的做法，导致患者人数减少，收入减少[[27]。

全球可持续发展目标的目标5.3和阻止卫生保健提供者履行FGC的机构间联合全球战略中阐明了在2030年前消除所有形式的FGC的全球承诺。[[18岁]。世界卫生大会通过了一项决议，成员国同意致力于消除FGC，并确保该程序不由卫生专业人员执行。世界医学协会与国际妇产科联合会（FIGO），联合国条约监督机构以及许多非政府组织一起谴责了FGC的医疗化，并呼吁各国取消医疗化[[1个]。尽管如此，全世界，尤其是非洲的卫生专业人员越来越多地使用FGC[[16， 23， 28]，但对于FGC也在东南亚地区开展的国家/地区的FGC实施知之甚少。

在马来西亚，没有关于FGC的全国代表性数据[[2]。很少有关于FGC的实践的文章，除了对医疗的简要介绍外，马来西亚没有关于FGC的医疗数据。根据2010年的最新人口普查，马来西亚位于东南亚，人口约为2600万，其中54.6％为马来穆斯林，其中27.1％为马来穆斯林妇女。[[29]。马来西亚由14个州组成，分为西马来西亚和东马来西亚。研究表明，约有99％的马来穆斯林妇女接受了FGC，主要是因为他们认为这在伊斯兰教中是强制性的。 FGC通常由练习IV型FGC的传统助产士进行。助产士通常坚持滴血，作为实践的必要条件。但是，医疗化的趋势是，越来越多的年轻女性被医生割伤，并且更倾向于医生对女儿进行FGC，这主要是由于其清洁和专业知识。社区自我报告的医疗率约为28％[[30–32];但是，没有医生从事FGC的数据。马来西亚的医生必须拥有或共同拥有一个诊所或一组诊所，才能在马来西亚卫生部（MoH）完成4年的强制性服务。一些医生可能选择不担任执业医生，而是选择担任临时医生的诊所之间的自由职业者。该法律未对马来西亚实行FGC实行沉默，马来西亚医学委员会（MMC）尚未在医生中阐明其对FGC实行的正式立场。但是，FGC不是马来西亚卫生部提供的服务。国家宗教部门在2009年发布了一项“ fatwa”（不具约束力的宗教法令），规定FGC对马来西亚的穆斯林妇女是强制性的。但是，宗教是每个州（而不是联邦政府）的管辖范围，各州可以发布自己的宗教信仰。

当前的研究旨在确定马来西亚医生的医疗程度，执业医生，执业方式和执业方式以及执业动机。

方法

已准备了一个简短的协议，并作为支持信息随附于此（S1协议）。

学习规划

这是在马来西亚两个主要医学协会的会员中注册的穆斯林医生之间进行的混合方法（定性和定量）研究。

工具

创建了一份自我管理的问卷以收集数据（S1问卷）。医生获得了调查问卷以及客户信息表和邮资已付的信封，上面贴有调查人员的地址。有关研究的定量组成部分的问题包括年龄，性别，医学学位，毕业年份，任何研究生学历和诊所的位置。关于实践的问题包括以下内容：实践年限，被访者是否接受过FGC培训，被访者是否接受过FGC培训（如果适用），进行过的FGC数量，局部麻醉的使用，手术导致的出血，并发症，与筛查患者的出血性疾病有关的问题，与感染疾病相关的问题以及手术前的其他与健康有关的问题，手术的解剖位置以及确切进行的操作，使用的仪器，患者的年龄，费用，进行FGC的原因，和同意。在定性方面，使用半结构化访谈指南对从事FGC的医生进行了深入访谈。访谈的重点是从业人员接受实践和培训的原因，以及程序的细节，包括医生如何，在何处以及何时进行FGC。

人口

研究人员与马来西亚最大的医学协会取得了联系，该协会拥有约11,500名会员，其中2,905名是穆斯林（男性1,426名，女性1,379名女性），但是由于以下原因，该协会未批准协助其穆斯林会员参加研究的请求：研究的敏感性。考虑到FGC与马来西亚的伊斯兰教有关[[32]，调查人员从该国2个主要医学协会招募了穆斯林医生，这些协会的会员来自马来西亚各地，其中有大量穆斯林医生。协会A有510名成员，其中穆斯林64名，女性333名。协会B只有穆斯林成员。女性3,088，男性1323。在这些协会的帮助下，在协会举行的年度会议期间分发了调查表，并将调查表发给注册但未参加的穆斯林成员。由于其中一个会议中有非穆斯林参加者，因此研究小组的一名成员（在分发调查表之前在会议期间有机会谈论该研究）已宣布仅要求穆斯林成员填写问卷。除包含调查表的信封外，还包括参与者信息表，其中详细列出了参与者的研究目标和权利以及参与标准（其中提到穆斯林医生有资格参加）。因为有可能（即使是遥远的）医生也可能是这两个协会的成员，并且参加彼此在一个月之内举行的两次会议，所以与会者被告知，如果他们应该收到2个问卷，则只能填写一份问卷问卷仅发布给该协会的穆斯林成员。总共以手工或邮寄方式分发了894份问卷。总共在会议A和B分发了300份问卷；其中，分别从各会议退回了111和154份完整的调查表。总共发布了294份问卷，并收到了101份完整的问卷。会议期间，有兴趣参加深度访谈的人应将名字提交调查人员。这些医生进一步推荐了从事FGC的同事的名字，然后与他们联系并邀请他们参加研究。

采样。

研究人员在马来西亚的医生中找不到任何与FGC相关的已发表研究，并且迄今为止，还没有关于FGC实践的官方统计数据。但是，调查人员认为，在大量的穆斯林医生中，有相当多的医生从事FGC。由于研究的主要目的是描述患病率，因此根据Agresti-Coull二项式置信区间计算了样本量。 384名穆斯林医生的样本量将使该研究能够以±5％的置信区间和50％的患病率确定从事FGC的人的患病率。

对于研究的定性部分，研究人员打算采访医生，直到数据达到饱和为止。为了确保对接受采访的医生进行公平的抽样调查，他们选自东部北部和西部沿海州以及马来西亚半岛中部。由于资金和时间的限制，在南部和东部马来西亚的医生中没有进行任何采访。参与调查的医生不在参与定量研究的医生之列。

分析。

使用SPSS 18版对定量数据进行分析，并在表格和图形中描述性地显示。为了评估与实行FGC相关的因素，对年龄，性别，毕业国家，毕业年份，毕业资格，诊所拥有权，诊所位置，法塔瓦意识，对FGC的信念等因素进行了卡方检验。在伊斯兰教中是强制性的，在伊斯兰教中对FGC是否合法表示信任，对所有穆斯林是否都进行FGC的信念，在马来西亚进行FGC的原因，对FGC是否应继续进行的信念，以及对谁应该进行FGC以及为何在诊所进行FGC的信念。来自与 p 二进制Logistic回归中包括<0.2。数据（S1数据 和 S1 数据字典）可在支持信息中找到。根据《加强流行病学观察性研究报告（STROBE）指南》（S1频闪 清单）。

使用半结构化问卷收集定性数据，该问卷在未包含在最终数据收集中的3位医生中进行了先导测试。通过试点测试，对半结构化访谈进行了一些小的添加。由于试点研究中的医生自愿提供了有关FGC的未来以及助产士的作用的信息，因此还包括了有关助产士在FGC实践中的作用的其他问题。与医生联系并任命后，由两名熟悉定性数据收集的研究人员进行了访谈，他们在医生的工作地点进行了面对面的访谈。采访以英语进行；但是，给出的答案是英语和马来语的混合体。收集数据直到信息饱和。当没有从受访者那里获得新信息时，数据已经达到饱和。利用现有文献，扎根理论被用来分析数据。数据被一名研究人员使用Nviv版本12手动转录，组织，编码和重新编码。研究小组将聚类的编码作为常见主题。

伦理

这项研究是从道德上进行的，所有参与者均应提供书面知情同意书。将调查表以及参与者信息表发送给参与者，然后要求参与者在签署知情同意书之前将其退还给调查人员。对于定性访谈，应从医生那里读出信息表，并要求他们在访谈开始之前签署知情同意书。确保参与者的匿名性；研究人员之一为每位参与者分配了唯一的代码，后者还负责键入数据。问卷被存储在调查人员之一的办公室的带锁橱柜中，只有他才能访问。该研究获得了立命馆亚太大学研究伦理委员会的伦理批准（2018-01）。

结果

受访者基准

总共从马来西亚所有州的参与者那里收到366份完整的问卷。如图所示 表格1，大多数受访者是女性（73.8％），拥有马来西亚医学学位（69.7％），并拥有家庭医学的研究生学位（61.5％）。中位年龄为42岁，毕业后的年龄范围为1至51岁（平均= 18.0）。大多数人在马来西亚卫生部（55.0％）和市区的诊所工作（79.8％）。

表2 深入显示接受采访的医生的背景；医生的平均年龄为49岁；大多数是妇女（95.8％），已经从马来西亚机构毕业（79.2％），自己经营诊所（79.1％），没有研究生学位（75.0％）。

FGC实践的细节

表3 在75名（20.5％）穆斯林受访者中报告了他们实践FGC的详细情况。医生练习FGC的平均年数为11.7（范围为1到33）。略高于一半（53.3％）的人声称已经接受了如何进行FGC的培训，其中大部分来自同事（75％）。

在深度访谈中，高级同事是他们从中学习程序的人，尽管其中有些人确实提到传统的助产士是培训的来源，但他们最多。

“向做过此事的其他医生学习…” （受访者10）

“…我从朋友那里学到了东西，甚至去看了传统的治疗师来学习 [to] 做到这一点……但我会稍作调整” （受访者14）

每月平均进行6.6次FGC（范围1至50）。大多数受访者报告未使用局部麻醉（86.7％），并报告有出血（69.3％），但只有一滴血（98.1％）。绝大多数报告无并发症（98.7％）。在开始使用FGC之前，大多数（62.7％）的患者没有筛查出血性疾病或感染性疾病。对患者进行筛查的医生对他们进行了出血性疾病（20.0％）和传染病（17.3％）筛查，主要是根据病史（26.7％）进行筛查。大多数医生使用器械划痕（29.3％）和刺穿阴蒂包皮（25.3％），最常见的是使用手术剪刀（36.0％），并使用了防腐剂（56.0％）。

在深入访谈中，刺穿阴蒂包皮是医生描述的常见程序。

“我们刺破包皮…只是尼克…只是刺” （受访者9）

“有人教 [taught] 我只是用针刺，但我认为这不合适。” （受访者16）

但是，大量的受访者对阴蒂本身进行了手术。

“没有什么可以删除的[d] 除了阴蒂……你喜欢aaa……你去除了很小的一部分，但实际上不是很小的一部分……” （受访者11）

“……阴蒂的尖端， 我用剪刀剪了” （受访者20）

“我们削减了…我们试图得到阴蒂的一小部分。 [asked again whether the clitoris is cut and not the prepuce over the clitoris]…没有， 没有…亚 [yes] 阴蒂被切掉” （受访者17）

“ …然后我切了一个很小的， 阴蒂很小” （受访者16）

最常见的手术年龄为7至12个月（32.0％），但大多数医生更喜欢在4至6个月的年龄（34.7％）进行手术。平均收费为RM31.80（1美元 [USD] = 4令吉），并获得最多的口头同意（74.7％）。

与FGC实践相关的因素

如图所示 表4，年龄（p <0.001），距毕业（p <0.001），不具有研究生学位，诊所拥有权（p <0.001）和诊所位置（p = 0.02）与FGC的实践显着相关。

实行FGC的理由

医生从事FGC的主要原因是宗教信仰（76％）和健康（16％），而未执业FGC的原因没有接受过培训以进行FGC（87％），这与他们的信念背道而驰（6％） ，认为FGC违反伊斯兰教（5％），并认为FGC违反法律（2％）。

深入的采访还显示，宗教是大多数医生提到的最普遍的原因。

“成为穆斯林， 我相信这是一项宗教义务， 但我不确定是否是wajib [mandatory]…但是我相信自己的信仰和内心深处，我相信我们必须这样做。 因为有些事情你看不到， 你听不懂……你只是跟随” （受访者21）

“…是， 基本上是因为宗教，…你知道那里 [a] 由于宗教需求， 我必须做， 我是医学专家， 但我仍然必须做，没有其他原因。 如果病人想要[s]， 我们就做…” （受访者6）

人们也经常提到文化。

“我认为……嗯……这与文化有关……因为文化 [reemphasises]， 我认为很难改变……如果医生停止这样做并且文化要求做到这一点， 他们会在哪里 [parents] 去，会发生什么？” （受访者12）

这可能是因为大多数受访者将文化与宗教联系在一起。

“我认为可能对双方 [religion and culture]…好， 人们将文化和宗教视为同一……平等。” （受访者4）

大多数医生也让他们的女儿接受了这一程序，而宗教再次是这样做的原因。

“是瓦吉卜 [mandatory]，。 。 。 。 我给所有女儿割礼了” （受访者22）

仅顺便提及了健康和医学适应症，但大多数提及与检查异常的机会有关。

“[医疗福利[Medicalbenefit？]我不能告诉你…我认为我找不到一个， 但是也许我们可以看到类似的异常……那也是我试图寻找的……”（受访者3）

有关FGC实践的知识

如图所示 表5，大多数受访者并未意识到马来西亚宗教事务部（JAKIM）在2009年提出的Fatwa（伊斯兰法律法令不具有法律约束力），认为FGC因女性原因是女性的“ wajib”（强制性）（61.5％ ）。

在深度访谈中，还提到了Fatwa作为练习和继续练习FGC的原因。但是，几乎所有受访者都没有意识到法特瓦的细节。

“我认为2009年， 如果我没有记错的话， 对我们来说这是必须的， 如果带来伤害，那就不用做，…否则wajib [mandatory]” （受访者22）

“I have read somewhere, and I know there is a fatwa but I don’t know how to read [explain it] exactly to you。 Fatwa said [stated] you have to do it for a Muslim, baby, women…” (Respondent 21)

“Yes…but I really forgot…but there is fatwa, I read it somewhere” (Respondent 21)

Most doctors did not think FGC is mandatory in Islam, and they didn’t think all Muslims perform FGC (61.5%) or that it reduces libido.

“Religiously yes, because there is [a] fatwa on it…the fatwa…supposedly circumcision reduces the libido but…I have my doubts [about FGC reducing libido]…yeaaa” (Respondent 23)

But the majority assumed that it was legal (68.3%) in Malaysia.

During in-depth interviews, legality of the practice was an area that most of the respondents were unsure about, but most agreed that they would not conduct FGC if there were clear instructions from the medical council or if it was declared illegal.

“…Against the law？…I hope no… I am not aware of it, [of] any law against it” (Respondent 20)

“Hmm…I think it’s legal…because there is no law stated that it is illegal…so far, 他们 [the MMC] allow it…they didn’t say we cannot do…”(Respondent 14)

“It is not in black and white…basically…ermmm…I know it is a grey area, it is not documented, cannot do or must do…if there is any new regulation we just follow” (Respondent 5)

“I don’t know if [the] MMC allow us or not, but they never stopped us from practising it。 Nothing that said [stated] we cannot practice it。 If they stop us from doing it, we won’t do it。 But there is no such act…I don’t know…whether legal or what, the mother brought the baby to me so the consent is there already…and I got their verbal consent。 The parents brought, it is not that we go search for the patients…they come to us” (Respondent 21)

Most were of the opinion that medical doctors commonly perform FGC (69.9%).

Regarding the differences in the reasons for FGC, religion (χ2 = 6.405, p = 0.01), health (χ2 = 4.295, p = 0.02), hygiene (χ2 = 7.437, p = 0.006), and increased libido (χ2 = 4.201, p = 0.04) were statistically significant; regarding differences in who usually performs FGC, traditional midwives (χ2 = 8.92, p = 0.003) and medical doctors (χ2 = 14.63, p < 0.001) were statistically significant.

Attitudes toward continuation of FGC practice

As shown in Table 6, the majority of doctors were of the opinion that FGC should continue (85.4%) and that medical doctors should be the ones to conduct FGC (63.9%).

Religion was the main motivating factor behind the doctors’ belief that the practice should continue besides considering it to be a harmless procedure.

“Yes…I would (continue to) do…in terms of religion I will do。 Because there is not much harm, because it just a small prick and baby just cry like aah [expresses suggesting for a while] after we [are] 完成, it is okay。 。 。 。Although I can’t think of any benefit for now, maybe when I am older, I will understand。 Just like before this, 一世 [didn’t] understand what fasting is for, what solat [prayer] is for, over time I understand [understood] it is good…。maybe it’s something that I have not discover[ed] yet, maybe my knowledge is still [gestures shallow]…If I don’t do, it is like a big sin。” (Respondent 13)

There were doctors who suggested cosmetic reasons for the continuation of the practice.

“It should be continue[d]…It should be because as I told you the shape of the labia is different from one person to another person…some babies just a bit exposed…(in others) there is a pouch but not as big…it depends [on the genitalia]…” (Respondent 8)

During the in-depth interviews, no matter what the reasons were for practising, they all preferred the practice be conducted in a clinic by a health professional primarily as a harm reduction measure for the prevention of infections.

“I think there is a need la [for doctors to perform]…because we do it in [a] sterile way compared to those ‘bidans’ [traditional midwives]…。 Risk of infection is there and then risk of transferring infectious disease is there…。 They are using blade…from what I understand, same blade from one person to another person…so I think the risk of infection is there” (Respondent 2)

“I don’t think they [traditional midwives] should continue doing。 Because sometimes I hear from other’s experience…very bad practice。 Very dirty…sometimes [they] use the same blade for one week…and the ‘kain’ [cloth] used to wrap [the tools] change colour [are stained]。 …when we do, even if no SOP [standard operating procedure] we do in septic technique。” (Respondent 13)

“Some people [parents] who came here, they claimed [say] themselves they don’t want to go to the midwife because of hygienic reasons, the midwife[s] [are] already old and their eyesight not really clear [good]…。 They [parents] think that it is not proper for the midwife to do [FGC] to their child” (Respondent 17)

“If we don’t do, 他们 [parents] will do it outside。 It is better to do in clinic。” (Respondent 1)

Regarding the differences of opinion about whether the practice should continue (χ2 = 11.841, p = 0.001) and reasons why it should be performed in a clinic, there being no complications (χ2 = 4.319, p = 0.04), hygiene (χ2 = 9.779, p = 0.002), and safety (χ2 = 5.374, p = 0.02) were statistically significant.

Fig 1 depicts the wish list of the doctors who want the practice to continue: wish that FGC be taught in medical schools (222), that religious experts define the confines of the practice (201), that there be regular updates on FGC (220), that the MMC officially declare FGC legal (183), and that law be enacted to make FGC legal (169).

Fig 2 shows the reasons why FGC should not continue: there are no health benefits (56), it is not compulsory in Islam (48), it contravenes human rights (37), it is not proven to reduce libido (36), it is not taught in medical school (33), it is against international law (13), and it is against Malaysian law (3).

Regression analysis showing factors associated with conducting FGC

Table 7 shows the result of a binary logistic regression that was conducted to determine the significant factors associated with conducting FGC, which included age, sex, clinic ownership, knowledge about JAKIM fatwa, thinking that FGC mandatory in Islam, thinking that FGC is legal in Malaysia, thinking that FGC is encouraged in religion, thinking that FGC increases libido, and thinking that FGC should continue. The model had an overall correct predicted percentage of 88.5% and Nagelkerke R2 of 0.457. Being a woman (adjusted odds ratio [aOR] 4.4, 95% CI 1.9–10.0, p < 0.001), owning a clinic (aOR 30.7, 95% CI 12.0–78.4, p < 0.001) or jointly owning a clinic (aOR 7.61, 95% CI 3.2–18.1, p < 0.001), thinking that FGC is legal in Malaysia (aOR 2.09, 95% CI 1.02–4.3, p = 0.04), thinking that FGC is encouraged in religion (aOR 2.25, 95% CI 3.2–18.1, p = 0.04), and thinking that FGC should continue (aOR 3.54, 95% CI 1.25–10.04, p = 0.01) increased likelihood of practicing FGC.

讨论区

The findings of this study show that the prevalence of FGC practice among doctors in Malaysia was 20.5%. The practice was conducted by mostly female doctors who were trained by senior colleagues on girls less than 1 year of age in their clinics. Most doctors practiced type IV FGC, but there were a substantial number conducting type I. The reasons cited for the practice included harm reduction, religion and culture, and even cosmetic reasons was mentioned. Money, however, was not a motivating factor for the practice. Most doctors wanted the practice to continue.

On average, 26% of women have been cut by medical professionals; the rates vary between 1% and 74% among countries[[16]。 The 5 highest medicalization rates are reported in Egypt (38%), Sudan (67%), Guinea (15%), Kenya (15%), and Nigeria (13%), and the rates of medicalization are increasing[[17]。 In the current study, 20.5% of doctors who responded practiced FGC; however, due to grey areas concerning the legality of the practice, there is a possibility of underreporting, making the numbers reported conservative compared to the actual medicalization rate. This underreporting is also noted in Egypt[[33], Nigeria[[26], and Indonesia[[34]。

There is no official training on FGC in the medical curriculum. Like most other health practitioners who perform FGC elsewhere, such as in Nigeria, Egypt, and Indonesia[[26, 27, 34, 35], the doctors in this study learned the skills from colleagues who themselves had no formal training. Unfortunately, parents who prefer their daughters be cut by healthcare professionals are unaware of the healthcare providers’ lack of knowledge and training related to FGC[[32]。

Most of the doctors in this study were female, just like reported by studies in Kenya[[5]and Nigeria[[33]。 This could be because most mothers think it is a woman’s duty to perform FGC on girls[[5]probably because FGC has been traditionally conducted by female midwives[[32]。 Unlike in parts of Africa where FGC is performed by medical personnel in homes or makeshift clinics[[5], all FGC in the current study was conducted on girls of a very young age in the clinics owned or co-owned by the doctors—just like in other parts of South East Asia—to avoid embarrassment and the difficulty of restraining a bigger child[[31, 36–38]。

Unlike the traditional midwives in Malaysia, Thailand, Singapore, and Indonesia who practice type IV FGC[[30–32, 34, 36, 38], a number of doctors in this study practiced more invasive forms of FGC by cutting parts of the clitoris (type I). Similar findings have been reported in Indonesia[[34, 37]。 Traditional practitioners usually tend to cut minimally for fear of bleeding and pain, but having anaesthetics and having an understanding of anatomy and physiology may result in doctors using deeper and more extensive cuts. And because the prepuce of the clitoris is small, there is a risk of injuring the clitoris or the surrounding area[[20]。 However, in some parts of Sudan, it is reported that medicalization has resulted in less severe forms of FGC[[24]。

The finding in this study that some doctors claimed harm reduction as their reason for practising FGC concurs with the findings of a review by Doucet and colleagues[[12]and studies in Nigeria[[26]and Egypt[[27], where doctors practice FGC to prevent parents seeking traditional practitioners[[16]。 Religion and culture were motivations for the doctors in this study to conduct FGC just as in studies conducted in Nigeria[[26, 35]and Egypt[[33]。 This finding also concurs with a review of literature by Doucet and colleagues[[12]that found that FGC was justified for cultural reasons. Doctors who practiced FGC in this study were Malay Muslims who themselves were part of the community that they served, therefore some of them may have had the same religious, social, and cultural motivations as those who requested the service[[27]。 Some may have undergone FGC themselves or have maintained the tradition for their daughters[[28]。 Some doctors in this study cited cosmetics as a reason for doing FGC as found in studies in Egypt[[27]and Indonesia[[34]。 Money was not the primary motivation to conduct FGC in the current study, as opposed to a literature review[[12]and studies in Nigeria[[26], Egypt[[33], and Indonesia[[39]that showed FGC to be a lucrative practice. In general, parents are not very concerned about the cost because they prefer and trust health providers and the formal health system[[26]。

Judging from the large number of doctors who wanted FGC to continue and their wish lists, it can be assumed that these doctors were unaware of the Sustainable Development Goal target 5.3 to eliminate all forms of FGC by 2030[[18岁]and the stand taken by the World Medical Association against doctors practising FGC[[1个]。 A systematic literature review of health professionals’ knowledge, attitudes, and clinical practice toward FGC found that, although most doctors in the UK understood that FGC is illegal, the awareness of the UK FGC act ranged from 40% to 79%. In Belgium, only 45.5% of gynaecologists knew that FGC was illegal in the country. In the US, 56% of midwives knew that FGC was against the law, and less than half of Italian health professionals knew about the law prohibiting FGC in Italy. These figures, however, are higher than the 25% and 17% reported in Sudan and Egypt, respectively[[40]。

Strengths and limitations

The main limitation of this study is the sampling. The sample size of the study was small, casting doubt on the representativeness of the sample. The representativeness of the sample (as opposed to its precision) is always an issue with survey research, and nonresponse may have influenced the results to an unknown extent and in unknown directions. The unfortunate problem is that this bias could only be measured by surveying the nonresponders. Low response rate is another limitation of the study, but considering the religious, cultural, and ethical sensitivities around the topic of FGC, a low response rate is not unexpected. The degree, and even the direction, of resulting bias can only be guessed at. We suggest future that research use survey methods more suited to sensitive issues such as respondent-driven sampling or snowball sampling[[41], whereby the survey is propagated through networks of peers rather than directly administered. However, the strength of this study is that many interviews were conducted using snowball sampling, which helped in explaining some of the findings of this study. We recommend a large-scale study involving a bigger sample size and in-depth interviews among doctors who are from parts of Malaysia that this study did not include.

Implications of the study

The information garnered by this study can be used to persuade MoH Malaysia and the Malaysian Medical Council to issue a statement against the practice. This will clarify the confusion of the doctors in Malaysia concerning the legality of the practice in the country. Fear of losing their medical licence may compel doctors to abide by the sanctions imposed. Because of the trust parents have toward doctors, they should be roped into the fight against FGC by training them on how to counsel parents who approach them for FGC. Having FGC integrated into the medical curriculum will help future doctors understand the ethical and legal position of the national and international medical community against the practice.

结论

There is a possibility that the prevalence of FGC reported in this study could be lower than the actual rate. The high rates of respondents who wanted the practice to continue is a cause of concern. The doctors in this study were beginning to practice type I FGC, which was unheard of among the traditional midwives, who only practiced type IV. It is imperative for MoH Malaysia and the MMC to take a clear stand against the medicalization of FGC.

Supporting information

Acknowledgments

The authors would like to thank Professor Ronan M. Conroy from the Royal College of Surgeons for his help in checking and making sense of the statistics in this paper. The authors would also like to thank Dr Wan Namaziah Azahari and Dr Muhammad Nasir Salleh for their input as well as the immense help rendered in locating and convincing doctors to participate in our in-depth interviews.

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