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Debating medicalization of Female Genital Mutilation/Cutting (FGM/C): learning from (policy) experiences across countries

• Els Leye   ORCID: orcid.org/0000-0002-1740-7814 1 ,
• Nina Van Eekert 2 ,
• Simukai Shamu 3 ,
• Tammary Esho 4 ,
• Hazel Barrett 5 &

Reproductive Health volume  16 , Article number:  158 ( 2019 ) Cite this article

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Although Female Genital Mutilation/Cutting (FGM/C) is internationally considered a harmful practice, it is increasingly being medicalized allegedly to reduce its negative health effects, and is thus suggested as a harm reduction strategy in response to these perceived health risks. In many countries where FGM/C is traditionally practiced, the prevalence rates of medicalization are increasing, and in countries of migration, such as the United Kingdom, the United States of America or Sweden, court cases or the repeated issuing of statements in favor of presumed minimal forms of FGM/C to replace more invasive forms, has raised the debate between the medical harm reduction arguments and the human rights approach.

The purpose of this paper is to discuss the arguments associated with the medicalization of FGM/C, a trend that could undermine the achievement of Sustainable Development Goal 5.3. The paper uses four country case studies, Egypt, Indonesia, Kenya and UK, to discuss the reasons for engaging in medicalized forms of FGM/C, or not, and explores the ongoing public discourse in those countries concerning harm reduction versus human rights, and the contradiction between medical ethics, national criminal justice systems and international conventions. The discussion is structured around four key hotly contested ethical dilemmas. Firstly, that the WHO definition of medicalized FGM/C is too narrow allowing medicalized FGM to be justified by many healthcare professionals as a form of harm reduction which contradicts the medical oath of do no harm. Secondly, that medicalized FGM/C is a human rights abuse with lifelong consequences, no matter who performs it. Thirdly, that health care professionals who perform medicalized FGM/C are sustaining cultural norms that they themselves support and are also gaining financially. Fourthly, the contradiction between protecting traditional cultural rights in legal constitutions versus human rights legislation, which criminalizes FGM/C.

More research needs to be done in order to understand the complexities that are facilitating the medicalization of FGM/C as well as how policy strategies can be strengthened to have a greater de-medicalization impact. Tackling medicalization of FGM/C will accelerate the achievement of the Sustainable Development Goal of ending FGM by 2030.

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Although Female Genital Mutilation/Cutting (FGM/C) is internationally considered a harmful practice, it is increasingly being medicalized allegedly to reduce its negative health effects, and is thus suggested as a harm reduction strategy in response to these perceived health risks.

The purpose of this paper is to discuss the arguments associated with the medicalization of FGM/C, a trend that could undermine the Sustainable Development Goal (5.3) to end FGM/C by 2030. The paper discusses the reasons for engaging in medicalized forms of FGM/C, or not, by exploring ongoing public discourses in four country case studies: Egypt, Indonesia, Kenya and UK. The discussion is structured around four key hotly contested ethical dilemmas. Firstly, that the WHO definition of medicalized FGM/C is too narrow allowing medicalized FGM to be justified by many healthcare professionals as a form of harm reduction which contradicts the medical oath of do no harm. Secondly, that medicalized FGM/C is a human rights abuse with lifelong consequences, no matter who performs it. Thirdly, that health care professionals who perform medicalized FGM/C are sustaining cultural norms that they themselves support and are also gaining financially. Fourthly, the contradiction between protecting traditional cultural rights in legal constitutions versus human rights legislation, which criminalizes FGM/C.

The paper concludes that more research needs to be done in order to understand the complexities that are facilitating the medicalization of FGM/C as well as how policy strategies can be strengthened to accelerate the achievement of the Sustainable Development Goal of ending FGM by 2030.

The trend towards medicalization of FGM/C

The World Health Organization defines the “medicalization” of FGM/C as situations in which FGM/C is practiced by any category of health professionals, whether in a public or a private clinic, at home or elsewhere, at any point in a female’s life (including reinfibulation Footnote 1 ) [ 2 ]. Health professionals involved in medicalization include physicians, assistant physicians, clinical officers, nurses, midwives, trained traditional birth attendants (TBAs), gynecologists/ obstetricians, plastic surgeons, and other personnel providing health care to the population, in both private and public sectors. They may be undergoing medical training, working in the medical sector or be retired [ 2 ].

Medicalization of FGM/C continues to rise in many countries despite increasing numbers of countries legislating against the practice. Based on self-reported Demographic and Health Survey (DHS) data in 25 countries, Shell-Duncan and colleagues estimated that 26% of the women in the age cohort 15–49, which equals to nearly 16 million women, report having been cut by a medical professional [ 3 ]. Medicalization rates, as the percent of FGM/C performed by a medical professional, are highest in the following five countries: Sudan (67%), Egypt (38%), Guinea (15%), Kenya (15%) and Nigeria (13%), and rates are rising in all of these countries, except Nigeria [ 3 ]. The performance of the procedure by skilled medical professionals in any setting is systematically documented through the inclusion of a question on who performs the cutting in the DHS module on FGM/C.

The increasing use of medical staff and equipment has also been noted in Somaliland [ 4 ]. Reinfibulation is estimated to affect 20 million women globally and between 10 and 16 million women are likely to experience medicalized reinfibulation. Reinfibulation, medicalized or not, is documented in many countries where infibulation is (highly) prevalent, e.g. in Sudan, Somalia, Djibouti and Eritrea [ 5 ] as well as in Europe and North America [ 6 , 7 ]. This paper will use evidence from four countries (Egypt, Indonesia, Kenya and UK) to explore current debates concerning the medicalization of FGM/C.

Policies on medicalization of FGM/C

Initially, campaigns against FGM/C stressed the adverse health consequences of the practice, assuming that this would help to raise awareness of the health risks and in turn motivate people to abandon the practice [ 8 ]. However, it is speculated that the health approach taken in these campaigns has unintentionally motivated the medicalization of FGM/C, at both demand and supply side [ 2 ]. In 2009 the World Health Organisation (WHO), the United Nations Children’s Fund (UNICEF) and the United Nations Populations Fund (UNFPA) condemned the medicalization of FGM/C in any setting [ 9 ], however, WHO had already raised this issue 30 years earlier (1979) at an international conference, stating “it is unacceptable to suggest that performing less invasive forms of FGM/C within medical facilities will reduce health complications” [ 1 ]. The most recent guidance by WHO on the management of health complications from FGM/C states: “stopping medicalization of FGM/C is an essential component of a holistic, human-rights based approach towards the elimination of the practice” [ 1 ].

In December 2012, the United Nations General Assembly adopted the first ever Resolution to ban FGM/C worldwide.[ 10 ] Resolution A/RES/67/146 was co-sponsored by two thirds of all UN members and was adopted by consensus of all UN members. Its adoption reflected the universal agreement that FGM/C constitutes a violation of human rights, which all countries of the world should address through ‘all necessary measures, including enacting and enforcing legislations to prohibit FGM/C and to protect women and girls.’ More recently, in September 2015, the global community agreed a new set of development goals, the United Nations Sustainable Development Goals (SDGs), which includes Sustainable Development Goal 5: achieve gender equality and empower all women and girls [ 11 , 12 ]. This Goal includes a target to eliminate all harmful traditional practices, including FGM/C (SDG 5.3), by 2030, a signal of international political will to end the practice of FGM/C globally.

FGM/C whether traditionally performed or medicalized, is now recognized internationally as a violation of girls’ and women’s rights and as an expression of gendered violence, with a demonstrated impact on women’s sexual and reproductive health. Governments worldwide are thus obliged to take measures to prevent and eliminate FGM/C, including medicalized forms of the practice, and can be held accountable for failing to take steps to prohibit the practice of FGM/C through legislative and other measures. Some countries have increased the prison sentences when health professionals have been convicted of performing FGM/C, and some also provide for the revocation of licenses of health professionals if they perform FGM/C [ 13 ]. However, even if the legal framework is put in place, a number of challenges remain. This paper contributes to four current hotly contested debates on the medicalization of FGM/C, namely:

That the WHO definition of medicalized FGM/C is too narrow allowing medicalized FGM to be justified by many healthcare professionals as a form of harm reduction which contradicts the medical oath of do no harm.

That medicalized FGM/C is a human rights abuse with life long consequences, no matter who performs it.

That health care professionals who perform medicalized FGM/C are sustaining cultural norms that they themselves support and are also gaining financially.

The contradiction between protecting traditional cultural rights in legal constitutions versus human rights legislation, which criminalizes FGM/C.

Current debates on medicalization of FGM/C

When does fgm/c become defined as ‘medicalized fgm/c’ and is medicalized fgm/c an acceptable form of ‘harm reduction’.

Although not specifically addressed in the WHO definition, we argue that medicalization of FGM/C might also include performing less invasive forms of FGM/C, often promoted as ‘a harm reduction strategy’. This form of medicalization has been documented in African countries where FGM/C is prevalent, as well as in European countries and the USA. Indeed, in 2010 the American Academy of Pediatrics issued a position statement in which they suggested that ‘it might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick as a possible compromise to avoid greater harm”. Such a nick, or prick, would consist of pricking the prepuce of the clitoris, without removal of tissue. A study in Somaliland, for example, showed that there is a trend towards milder forms of FGM/C, with “pharaonic circumcision” (Type III or infibulation) being replaced by “sunna” cutting [ 14 ]. Moreover, the study showed that girls are more likely to undergo the procedure in a medical facility where staff has received at least some medical training. A recent study from Nigeria demonstrated that the campaign and legislation against FGM/C and the training of nurses concerning the health implications of FGM/C made them more cautious and because they knew the complications, they were more likely to only nick the clitoris enough to cause bleeding and thus satisfy parents that the procedure had been done, without removing much tissue [ 15 ].

Another complication with defining medicalized FGM/C is whether the use of medical instruments (such as sterile razor blades or surgical blades, forceps), antibiotics and/or anesthetics to carry out FGM/C, especially when used by traditional practitioners, should be considered as a form of medicalized FGM/C. Data on this are notably lacking, and only anecdotal evidence is available. In Guinea, the use of razor blades instead of traditional instruments is attributed to the increasing medicalization of the procedure and sensitization campaigns [ 16 ] A qualitative study conducted in four communities in the Nigerian States of Delta, Ekiti, Imo and Kaduna, showed that health workers used a range of essential supplies when carrying out FGM/C: antiseptic, artery forceps, surgical scissors or blades, cotton wool, and antibiotics. They described the steps of the procedure as: “using an antiseptic to clean the area, clamping the tissue with forceps, cutting the tissue with scissors or a surgical blade, applying pressure with cotton wool to control bleeding, cleaning the area again with an antiseptic, and applying an oil or Vaseline”. Some ‘health workers’ mentioned also administering pain relief and prescribing antibiotics [ 15 ].

Finally, we want to highlight the issue of medicalized reinfibulation, and how a recent court case in the UK demonstrates the difficulties in defining what constitutes medicalized FGM/C, especially in the context of re-stitching following the birth of a child (reinfibulation). The UK case study (see Table  1 ) is a demonstration of an unsuccessful legal case brought against a doctor who allegedly performed a reinfibulation and illustrates the difficulty of proving to a court that FGM/C has taken place. However, the huge publicity that occurred during and following the court case made it very clear that medicalized, as well as traditional FGM/C, was against the law and prosecutions would be brought. Since this case in 2015, two further unsuccessful cases have been brought in the UK against two different fathers of girls who have allegedly been subjected to FGM/C. Again, these showed a weakness in the law concerning the testimony of the victims and expert evidence from health professionals who could not agree whether FGM/C had taken place on the girls. However, in February 2019 the first successful case was prosecuted in the UK of a mother who performed FGM/C using traditional techniques, FGM/C on her three-year-old daughter.

Medicalized FGM/C: harm reduction or human rights abuse?

One of the most important reasons given by health care professionals who perform FGM/C is their belief that when it is done by skilled professionals, it reduces the immediate health risks and pain, especially when antiseptic techniques, anesthetic and analgesic medication are used [ 9 ]. Health professionals doing FGM/C might indeed be able to control the immediate physical consequences of cutting the genitals, such as the severe pain, bleeding and infections. However, many health professionals who perform FGM/C have limited knowledge of long-term health consequences of the procedure, in particular the mental health implications. Even if women do not report physical after-effects of FGM/C, research suggests that the majority of women subjected to FGM/C have reported mental health problems and emotional disorders with living with the effects of FGM/C [ 22 ]. A study by Knipscheer indicated a high level of reporting of severe depression, anxiety and Post Traumatic Stress Disorder (PTSD) by FGM/C survivors [ 23 ]. Eisold found that FGM/C can affect the emotional well-being of women throughout their lives [ 24 ].

Whilst medicalized FGM/C might minimize – but not avoid - some of the long-term physical consequences of FGM/C, the fact remains that there are no perceived health benefits of the practice itself. It is therefore considered to be against good medical practice and a violation of the medical code of ethics, as even “do less harm” is contradictory to the Oath of Hippocrates ‘do no harm’.

Still, the harm reduction approach dominates the discourse, as is demonstrated by the high numbers and increasing rates of health professionals that engage in performing FGM/C. Health professionals performing FGM/C in order to provide a safer setting for the procedure are ignoring the human rights issues associated with FGM/C, including the right to freedom from violence and discrimination, amongst others. The trend to medicalize FGM/C is worrying, given that its impact on the global campaign and efforts to end FGM/C is still not clear. How the promotion of medicalized ‘safe’ or ‘light’ versions of cutting girls’ and women’s genitals influences these efforts is difficult to assess, but it is commonly believed that promoting medicalized forms of FGM/C communicates the message to practicing communities that FGM/C is acceptable when done by health professionals, and thus is a legitimation of the practice [ 1 ]. This harm-reduction approach contrasts with the human rights approach, which states that health professionals performing FGM/C in order to provide a safer setting for the procedure, are ignoring the human rights aspects associated with FGM/C.

Furthermore, the assumption that medicalization reduces harm is not empirically proven. Moreover, in the Indonesian case described in Table  2 there is anecdotal evidence to the contrary, namely that midwives perform more severe forms of FGM/C than traditional practitioners. The case of Indonesia also shows that the government has been oscillating between the human rights approach and the harm reduction strategy. Government policy has played a crucial key role in medicalizing FGM/C in Indonesia, together with strong religious/social norms that underpinned this medicalization.

Medicalized FGM/C: reflecting the social norm or used to justify financial gain?

One aspect that plays a key role in health care professionals deciding to do FGM/C is that they commonly share the same social norms regarding cutting the genitals of girls and women, hence resisting the pressure or the demand to do FGM/C from the community is challenging. A study from Nigeria for example, demonstrated that most health workers that engage in FGM/C do so because they share the same FGM/C beliefs as the community they serve, and this was evidenced by the fact that four out of five health workers with daughters had also cut their own daughters [ 15 ]. Another study, from Sudan, concluded that medicalization is primarily driven by the demand motivated by social norms [ 31 ].

The patriarchal nature of FGM/C underpins many of the arguments to continue FGM/C, whether it is medicalized or not, and parallels between FGM/C, patriarchy and female genital surgeries have been discussed elsewhere by various scholars (see for example Pedwell C [ 32 ], Ogbe E et al. [ 33 ]).

However, the financial gains to perform FGM/C for both health professionals and parents should not be underestimated, as FGM/C can bring in additional income to health professionals and for parents it can mean a higher bride price/dowry can be expected when their daughter is married. Health professionals’ motivation to perform FGM/C is reinforced by the fact that many health systems in countries where FGM/C is prevalent are weak, and so extra financial income is attractive. Serour suggests that medicalization of FGM/C is a major source of income for those who perform it. Fees are high, especially in countries where FGM/C is illegal [ 9 , 34 ].

This is demonstrated by the case study that looks at Egypt, where medical doctors have taken the lead in the medicalization of FGM/C, often arguing that as FGM/C is a strong social norm and will happen whatever, that it is better that it is performed by a medical doctor than a traditional practitioner (Table  3 ). It has also been argued that many of these doctors support the practice for cultural and religious reasons and in addition make a good livelihood from performing the procedure. Despite cases where girls have died following medicalized FGM/C, few successful prosecutions have taken place against a medical professional in Egypt [ 42 ]; a country where medicalized FGM/C is highly prevalent and numbers rising. The Egyptian case study shows us the importance of the context in which FGM/C arises.

FGM/C: cultural rights versus human rights?

Both the Egyptian case discussed above and the Kenyan case discussed hereafter (Table  4 ) demonstrate how the law has limited influence in contradiction with culture and tradition. It shows how FGM/C is embedded in cultural and traditional norms and rights that are considered by proponents to prevail over the law of the country.

As alluded to in the Kenyan case of a medical doctor supporting the medicalization of FGM/C, there may be gaps in the law that proponents of FGM/C might use to push their agenda. This case indicates that some medical practitioners themselves do not only medicalize, or support it, but do so by exploiting gaps in the judicial system hence derailing progress made towards abandonment of FGM/C.

Tackling the medicalization of FGM/C needs to consider the contested issues surrounding the debate of medicalized FGM/C. In the current paper we discussed four important issues and dilemmas that should be taken into account: the trouble with defining FGM/C, the need to contextualize FGM/C, the debate of harm-reduction versus social norm and the difficulty of applying a law when it contradicts cultural values and social norms. In conclusion to this paper we want to translate the discussions above to some suggestions for the way forward.

Policy emphasizing the human rights approach

As demonstrated there is a tension between a pragmatic harm reduction approach maintained by some health professionals and the human rights approach that seeks to safeguard girls and women’s bodily integrity. Social and religious norms supporting the practice of FGM/C pose serious challenges to the implementation of legislation that aims to protect the human rights of women and girls.

In both Egypt and Indonesia the governments have at various times supported the medicalization of FGM/C as a harm reduction strategy, often under great pressure from religious leaders, resulting in a confused response to FGM/C and its medicalization which undermined efforts to end the practice in line with international agreements. In Kenya, Egypt and Indonesia, FGM/C practicing communities and the health profession have been very vocal and at times militant in advocating against national legislation banning FGM/C. Very often these groups have used constitutional arguments such as the preservation of cultural and traditional rights, to support their case. These three case studies reveal that at various times over the last 20 years the harm reduction approach to FGM/C has taken policy precedence over the human rights approach to FGM/C.

FGM/C is a strong social norm that makes it difficult for individuals to challenge, as the practice often occurs in societies where norms of collectivity are predominant. The impact of these different settings on social norm change and human rights is not in the scope of this paper and has been discussed elsewhere by various authors (see for example Diabate et al. [ 45 ], UNICEF [ 46 ], Leye et al. [ 47 ]).

There is now a growing momentum in many high FGM/C prevalence countries and others, to tackle FGM/C from a human rights perspective, 25 years after the World Conference on Human Rights held in Vienna, Austria in 1993 accepted that FGM/C was a violation of human rights. In 2008 the United Nations Special Report on Torture stated that violence against women, including FGM/C can be considered a violation of the Convention Against Torture.[ 51 ] Regionally several treaties and consensus documents call for the protection of the rights of women and girls through the abandonment of FGM/C. These include the African Charter on Human and People’s Rights (The Banjul Charter) and the Protocol on the Rights of Women in Africa (Maputo Protocol), the African Charter on the Rights and Welfare of the Child, and the European Convention for the Protection of Human Rights and Fundamental Freedoms [ 30 ]. More recently, in September 2017 at a meeting in Egypt jointly organized by UNFPA and the League of Arab States, public statements were made by National Doctors’ Syndicates and Medical Councils as well as the National Midwives Associations in the Arab Region to end the medicalization of FGM/C.

Educating health professionals on FGM/C and its consequences

Awareness raising on the sexual and reproductive health consequences of FGM/C and the human rights violations, as well as building capacities through inclusion of FGM/C in curricula or postgraduate training of professionals likely to deal with FGM/C are some of the most commonly used strategies to involve health professionals in countering medicalization. From the case studies discussed above the importance of having a clear definition of medicalized FGM/C, such that it’s clear to health professionals when they are performing FGM/C, and thus breaking the law, is highlighted. Moreover, they should be aware of the negative psychological and physical consequences of performing FGM/C.

Training of health care professionals on FGM/C can vary across and between countries and can take different forms, such as the provision of specific training workshops on medicalization or general training on FGM/C, the inclusion of FGM/C in medical curricula, or the development of e-learning modules or other tools on FGM/C. It should be noted however, that very few of these training and capacity building efforts, especially regarding medicalization, are evaluated, hence it remains unclear what the most effective methods of awareness raising amongst health professionals might be. Moreover, a recent analysis of the evidence on knowledge, experiences and attitudes of health professionals towards FGM/C showed that there are six areas for improvement for health care providers. These areas are: knowledge of FGM/C and its consequences, adherence to FGM/C protocols and guidelines, socially constructed acceptance of FGM/C, knowledge of legislation and legal status of FGM/C, condoning, sanctioning or supporting FGM/C and information and training to work with women and girls living with FGM/C [ 48 ]. This list indicates that much work still needs to be done.

It is commonly assumed that the reproductive and sexual health consequences, the legal repercussions as well as the human rights dimension should be part of any FGM/C module in the curricula of health professionals. The WHO Guidelines (2016) on the management of health complications from FGM/C, are useful for designing pre- and in-service professional training curricula for health care providers, and include the above-mentioned aspects. However, too often, FGM/C is not included in curricula on a systematic basis, and/or medicalization and the preventive role of health professional is not addressed at all. Moreover, capacity-building on how to resist pressures from the community, as well as communication techniques for social norm change are rare. A study from Nigeria showed that health workers should be educated and empowered to advocate for the abandonment among patients but also among fellow health workers [ 15 ]. Studies from The Gambia showed that training programmes should be modeled to fit the specific characteristics of the trainees in terms of sex and ethnicity [ 49 ].

Detangling professional norms from social norms

The above demonstrates that any effort to deal with medicalized FGM/C should take into account the context in which it occurs. Health care providers’ understanding about FGM/C and how their opinions are shaped by social norms should be unpacked. Many health professionals are not aware of the long-term health implications of FGM/C and the fact that it is a violation of human rights and a breach of medical ethics, despite many regional and global protocols cited above condemning it. Moreover, health professionals often share the social norms of FGM/C being an important cultural tradition. Additionally, the financial reward for performing FGM/C is attractive to health professionals, especially in a weak health system.

We are therefore advocating that health professionals receive training to raise their knowledge of the issues surrounding FGM/C and the awareness that performing FGM/C is in contradiction with the Oath of Hippocrates ‘you should do not harm’. In particular, medicalization of FGM/C and how to tackle it should be part of any curriculum of health professionals (pre and postgraduate training). The legal interpretations of what constitutes a crime with regards to medicalization of FGM/C need to be made clear among health professionals.

Codes of conduct or position statements by professional organizations have been issued both in Western countries as well as in countries where FGM/C is most prevalent. Some of these position statements have caused controversy, such as the 2010 Statement by the American Association of Pediatrics that promoted the performance of a ‘ritual nick’. This statement was revised after outrage and fierce opposition by WHO and others. The European Academy of Pediatricians on the other hand, clearly states: “It also calls upon all physicians to help to stop this practice. The practice of offering a “clitoral nick”, a minimal pinprick, must also be condemned as an unnecessary and extremely painful procedure [ 50 ]”.

Motivate health care providers as agents of change for ending FGM/C

Even though health professionals are at the core of the medicalization issue, they can and are targeted as part of the solution to reverse the medicalization of FGM/C. Given that they are important role models in societies, they are often key in becoming agents of change regarding FGM/C. However, a scoping survey would need to be conducted in each country where medicalized FGM/C is performed to assess the knowledge, attitudes and practices of health professionals in the practicing of medicalized FGM/C.

From our discussion above, it is clear that more attention should go to how health care professionals can be used as agents of change for ending FGM/C. This can be done through: 

Including, more systematically, the human rights framework and the ethics of medicalization of FGM/C in curricula of health professionals’ education and training.

Building bridges between sectors: linkages between health professionals and legal stakeholders should be explored and reinforced in order to make the implementation of laws banning FGM/C more effective.

Establishing collaborations between health professionals and religious leaders to agree that FGM/C is not a religious requirement and to communicate this to FGM/C practicing communities.

Developing strategies on how health professionals can deal with social pressures from the community wanting to continue with FGM/C and to challenge the social norms perpetuating the practice.

Urging Professional Medical Associations to reinforce the unethical nature of the medicalization of FGM/C and produce public statements and protocols advocating for the ending of FGM/C whether performed in traditional or medicalized settings, including reinfibulation.

This paper has discussed the complex ethical debates that accompany the medicalization of FGM/C, and the contradictions between the social and cultural norms supporting the continuation of FGM/C and the human rights of women and girls. It is clear that more attention should go to how health care professionals can be used as agents of change for ending FGM/C. It is also clear that more research needs to be done in order to decipher the code that will facilitate the detangling of these social norms from health professional norms and human rights. It is essential that we have a deeper understanding of the issue and the process of medicalization of FGM/C if the United Nations SDG 5.3 of ending FGM by 2030 is to be achieved.

Availability of data and materials

Not applicable

Reinfibulation is the procedure to narrow the vaginal opening in a woman after she has been deinfibulated (i.e. after childbirth); also known as re-suturing [ 1 ]

Abbreviations

Academic Network for Sexual and Reproductive Health and Rights Policy

Demographic and health survey

Egyptian Demographic and Health Survey

Female genital mutilation

Female genital mutilation/cutting

Kenyan Demographic and Health Surve

National Health Service

Post traumatic stress disorder

Sustainable development goal

Traditional birth attendant

United Kingdom

United Nations Populations Fund

United Nations Children’s Fund

World Health Organization

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Leye, E., Van Eekert, N., Shamu, S. et al. Debating medicalization of Female Genital Mutilation/Cutting (FGM/C): learning from (policy) experiences across countries. Reprod Health 16 , 158 (2019). https://doi.org/10.1186/s12978-019-0817-3

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Krishnan, Ashwina --- "Reframing The Discussion On Female Genital Cutting: An Analysis Of The Arguments For And Against The Abolishment Of Femital Genital Cutting" [2021] UNSWLawJlStuS 17; (2021) UNSWLJ Student Series No 21-17

REFRAMING THE DISCUSSION ON FEMALE GENITAL CUTTING: AN ANALYSIS OF THE ARGUMENTS FOR AND AGAINST THE ABOLISHMENT OF FEMITAL GENITAL CUTTING

ASHWINA KRISHNAN

I INTRODUCTION

Female genital cutting (FGC), often times referred to as female genital mutilation (FGM), is a practice that is highly contentious. While some believe it to be an abhorrent practice that violates women and children’s rights and by virtue of this should be abolished, others consider the practice to be an integral part of their culture. The reasons for the continuation of this practice are varied and often dependent on the contexts within which FGC is practiced. For instance, some believe that FGC is prescribed by their religious scriptures whilst others consider it to be a coming of age ritual. Whether or not this practice is a cultural or religious phenomenon continues to be a point of contention. Nevertheless, many in the international community have called for this practice to be abolished deeming it a human rights violation due to the purported negative impact it has for young women and children. The debates that have ensued in relation to whether FGC is a human rights violation or an acceptable cultural practice have often occurred within the context of the controversies between universalism and cultural relativism, [1] with many arguing against the concept of cultural relativism on the basis that FGC is so barbaric that it should not be permitted, in spite of the justifications that may arise from viewing this issue from a culturally relativist standpoint. This paper examines the arguments made for and against the abolishment of FGC and seeks to answer the question: is the move to abolish FGC a form of cultural imperialism or a statement of a universal human rights norm? It does so by reviewing the impact of both the practice of FGC and its abolishment on women and children and by juxtaposing the attitudes expressed in relation to other similar practices that are accepted in Western societies. The essay ultimately argues that the debate should in fact be reframed and analysed from a children and women’s rights focused perspective.

II TERMINOLOGY

This paper will firstly address the various terms that signifies the practice of female genital cutting. Initially, the practice was referred to universally as female circumcision, including in medical literature. [2] However, in 1979, the term “female genital mutilation” or FGM was coined which imbued the practice with negative connotations and distinguished the practice from male circumcision. [3] The coining of the term FGM was intended to ‘aptly capture the gruesome and harmful nature of the procedure’ and also to effectively designate the practice as a human rights violation, [4] thus making the distinction between circumcision as it is practised on males and on females. [5] The terms FGM itself is a point of great contention [6] as many who have undergone the procedure themselves may consider it to be demeaning. [7] However, the alternative of utilising the term female circumcision can be considered to many as a means to trivialise or normalise the practice. [8] The term female genital surgery was also used interchangeably; however, this term remained unpopular due to its implication that the practice is ‘medical in nature.’ [9] This paper will refer to the practice in its most literal sense, that is, female genital cutting or FGC.

III CONTEXT

According to UNICEF, ‘at least 200 million girls and women have undergone FGM’/C globally. [10] While the prevalence of the practice itself varies geographically, [11] According to the World Health Organisation (WHO), a majority of those who have undergone female genital cutting go through it prior to turning fifteen years old. [12] The common view held in most Western societies is that FGC not only embodies a severe human rights violation, but is also a means to ‘suppress women’ and to make women more subservient to their ‘future husbands.’ [13] This view is widely accepted by the international community as seen by the various calls to end female genital cutting. [14] [15] The UN has further regarded the elimination of female genital mutilation as a means to achieve gender equality and empower all women and girls, as per its sustainable development goal five. [16] This view is expounded on the premise that FGC ‘violates the right to physical integrity of the person’ [17] and constitutes a form of violence against women and children. [18] Many have come out to criticise this view stating that it is in fact primarily underpinned by ‘cultural bias’ rather than objective facts. [19] Accordingly, accusations of Western ethnocentrism clouding the judgement of those calling for the abolishment of FGC have been meted. [20] This line of argument is further justified by the fact that the ‘”zero-tolerance” stance on FGM...[has not been] applied consistently to analogous practices that happen to be more popular in Western countries,’ such as elective cosmetic genital surgeries, intersex genital “normalisation” surgeries, male circumcision [21] and genital piercings. It is posited that these practices are presumed to be ‘permissible’ on the basis that it is ‘more familiar to a Western mindset’ and is therefore not held to the same standard as that of FGC. [22] While this view may be criticised for minimising the impact of FGC, a careful analysis into these practices deemed “acceptable” and the potential harmful impact they may have to those who undergo them shows that they share many comparable features with FGC, [23] thus labelling the calls for abolishment of FGC a form of cultural imperialism. The challenge this argument poses to the universality of the norms proscribing FGC cannot be overlooked and will be examined further in this paper.

IV WHO’S DEFINITION OF FGC

The most widely accepted definition of FGC is put forth by WHO, as follows:

‘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.’ [24]

WHO has also categorised the practice into the following types:

• ‘Type 1: this is the partial or total removal of the clitoral glans (the external and visible part of the clitoris, which is a sensitive part of the female genitals), and/or the prepuce/ clitoral hood (the fold of skin surrounding the clitoral glans).

• Type 2: this is the partial or total removal of the clitoral glans and the labia minora (the inner folds of the vulva), with or without removal of the labia majora (the outer folds of skin of the vulva).

• Type 3: Also known as infibulation, this is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoral prepuce/clitoral hood and glans (Type I FGM).

• Type 4: This includes all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.’ [25]

This definition and categorisation of FGC practices has drawn various criticisms. The main criticism of WHO’s classifications is that the lumping together of the various and disparate practices makes generalisations of the practice of FGC and conflates the issue insofar that it does not acknowledge that the impact for each categories of FGC would differ. [26] The “catch-all” definition of Type 4 is also criticised for being too broad and for its specific application only to cultural practices in non-Western countries, in spite of its definition encapsulating other analogous Western practices. In categorising FGC in this manner, WHO allows for all types of FGC to be regarded as ‘ipso facto condemnable. ’ [27] The common factor of these practices, no matter how wide-ranging and disparate thus becomes that it is performed on women and girls, which leads to the false presumption that girls are ‘always harmed by genital surgery.’ [28] WHO’s classification is therefore, at best ‘inaccurate’ and at worst ‘intolerant’ and ‘intellectually lazy and misleading.’ [29]

Another area of contention is the origins and reasons for continuing the practice of FGC. While the notion that the practice is undertaken to curb women’s promiscuity and to ensure fidelity is widely accepted and often advanced by WHO, [30] in some cases, the motivation for cutting has little to do with curbing sexuality. [31] This is again seen as an over-simplification, on the part of WHO, of a complex and multifaceted practice. There are a wide variety of reasons cited as to why FGC is undertaken including religious beliefs, ritual purity/chastity, hygiene and even cosmetic purposes. [32] While it is conceded that in some cases FGC may be practiced as a means of protection of virginity and purported control of lust, it is important to note that FGC is not solely undertaken for this purpose. This a particularly important point to consider given that the calls for abolishment are generally prefaced on the basis that FGC is a practice utilised as a means to control women’s sexuality and to establish women as subjugate to men.

Attributing every practice of FGC to gender inequality is a gross over-simplification of its social and cultural functions within the societies that it is performed in. [33] It is further integral to understand the various reasons for why FGC is undertaken within different cultures as these disparate reasons result in the variety of ways that the procedure itself is carried out, particularly, variations in the ages ‘of girls or women that undergo the procedure, the accompanying rituals, the surroundings in terms of hygiene, the skills, qualifications and gender of the circumciser.’ [34] While WHO estimates that majority of the procedure are carried out on children under the age of fifteen, FGC may in fact be carried out ‘at infancy, before puberty, at puberty, with or without initiation rites, upon contracting marriage, in the seventh month of the first pregnancy, [or] after the birth of the first child.’ [35] To conflate these varying reasons and origins of the practice thus negates the myriad health consequences [36] as well as psychological impact each FGC procedure has on women and children. For instance, some cultures consider the ‘external clitoris’ to be a sign of ‘androgyny’ rather than a symbol of ‘female sexuality’ as it is perceived in the West. As such, removal of the clitoris is viewed within some cultural contexts as both ‘feminizing and an affirmation of “matriarchal power”’ [37] thus holding a different psychological impact altogether.

While the validity of claims that FGC is rooted in religious belief is still debated, it is important to note that if FGC is sanctioned by religion and/or is part of one’s religious practices, then it can be presumed that ‘there is a prima facie case of right to religion.’ [38] This of course does not negate that religious beliefs cannot be utilised as a shield against practices that are intrinsically harmful, however, whether all “types” of FGC are in fact intrinsically harmful remains a point of contention.

VI RELEVANT INTERNATIONAL INSTRUMENTS ON FGC

Many international instruments, even if they do not explicitly forbid FGC, have articles that can be interpreted to do so. For instance, Article 2 of the Convention on the Elimination of Discrimination Against Women (CEDAW) stipulates that State Parties should eliminate discrimination against women by taking all ‘appropriate measures, including legislation, to modify or abolish existing laws, regulations, customs and practice which constitute discrimination against women.’ [39] Article 5 similarly states that all state parties should take any necessary steps to eliminate ‘practices that are based on the idea of the inferiority or the superiority of either sexes.’ [40] Some argue that FGC should fall under these practices that should be abolished on the basis that it is ‘exclusively performed on women,’ and is thus ‘prima facie discriminatory.’ [41] However, if the view that FGC and male circumcision is both similar in nature, the argument that FGC is discriminatory would not stand. Relevant regional instruments on the other hand are more explicit in their prohibition of FGC. For instance, the Protocol to the African Charter on Human and Peoples' Rights on the Rights of Women in Africa (Maputo Protocol) prohibits all forms of FGC under Article 5, including medicalisation. [42] Article 38 of the Council of Europe Convention on preventing and combating violence against women and domestic violence (Istanbul Convention) on the other hand, explicitly criminalises a range of practices including ‘excising, infibulating or performing any other mutilation to the whole or any part of a woman’s labia majora, labia minora or clitoris,’ rather than utilising the umbrella term of FGM/C. [43] The positions put forth in these instruments are unambiguous.

Bearing in mind that a majority of the procedure is undergone by children, the Convention on the Rights of the Child (CRC) is also a very important instrument. Article 24(3) of the CRC requires state parties to ‘take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.’ [44] Article 19(1) also imposes a positive obligation on State Parties to protect children ‘from all forms of physical or mental violence, injury or abuse.’ [45] These articles again do not explicitly outlaw FGC but it is widely accepted that these articles implicitly prohibit the practice of FGC on the basis that it is a violation of children’s rights. [46] Similarly, the African Charter on the Rights and Welfare of the Child (ACRWC) does not explicitly prohibit FGC but does prohibit ‘any custom, tradition, cultural or religious practice that is inconsistent with the rights, duties and obligations contained in the present Charter’ which includes that all actions concerning children be undertaken with primary consideration being given to the ‘best interests of the child.’ [47] While some may argue that this in turn implies that as FGC is ‘harmful to children,’ the practice runs afoul of the “best interest of the child” principle, [48] however, what constitutes the “best interests of the child” remains subjective.

VII IMPACT OF FGC ON WOMEN AND CHILDREN

The criticisms of FGC often come under three broad categories, that the ritual violates women and children’s rights to ‘bodily integrity,’ that it ‘perpetuates gender inequality’ and that FGC has serious ramifications on women and children’s health and mental wellbeing. [49] Being that the health impact FGC has on women and children can be objectively observed, it poses the ‘strongest “case” against’ the continuation of the practice. [50] As per WHO’s fact sheet, the health consequences of FGC can range from menstrual problems to death.’ [51] Some of the causes named by WHO can also be attributed to the way in which the procedure is performed in certain contexts. According to Muteshi et al, a ‘vast majority of girls’ undergo the procedure with no ‘anaesthesia or analgesia using non-sterile instruments such as scissors, razor blades or broken glass’ with the minority of these procedures having been medicalised to minimise any health risks. [52] Muteshi et al further states that the consequences are both similar for the various types of FGC, as defined by WHO, but differ in severity. [53] There is thus some consensus that particular types of FGC results in more harmful health consequences and accordingly, other types of FGC lead to lesser health consequences. In light of this, the call to abolish FGC is often criticised on the basis that this view does not differentiate between the various types of FGC and instead calls for the eradication of all types, which does not take into account the lesser health consequences of more moderate forms of FGC. For instances, the procedure for FGC in many Muslim communities, particularly in parts of Indonesia and Malaysia, involves ‘nicking the clitoris [or clitoral hood] with a sharp instrument to cause bleeding but no permanent alteration of the external genitalia’ and as a result when a hospital based study was conducted in Malaysia, the findings where that there were ‘no clinical evidence of injury to the clitoris or the labia and no physical sign of excised tissue.’ [54] This thus undermines the call for eradication, at least, while it encapsulates all types of FGC.

In spite of the above, all forms of FGC continue to be viewed as impermissible by the international community. [55] This view can perhaps be justified by the pain and trauma associated with the procedure, or the psychological impact of FGC. This justification is not fool proof as more superficial types of FGC (such as pricking), particularly if undertaken under anaesthesia, can negate the pain and traumatic side-effects of the procedure. [56] On the other hand, in the context of when FGC is consented to by an adult woman who is choosing to undergo it upon her own free will, pain can be an important and necessary part of the cultural ritual. For instance, Earp notes in his paper that the ‘Rendille [women] of Kenya...reject the idea of using anaesthesia when being excised’ as a means of demonstrating their ability to withstand pain. FGC in this context is viewed as a demonstration of ‘maturity’ as being able to tolerate undergoing FGC without anaesthesia would in turn be viewed as a woman’s ability to undergo the pain of childbirth. [57] This is not unlike many women in the West who choose to undergo the pain of childbirth sans epidural. In the context of FGC carried out on adult women, there is thus a juxtaposition of who can consent to pain and who cannot, on the basis of cultural lines.

The medical arguments against FGC are also weakened by the comparison of less invasive types of FGC to the practice of male circumcision (MC). Many justify MC and oppose FGC on the basis that the former may have health benefits while the latter has none. However, this view neglects that the foreskin can play an important role in the health of young boys and men, including that it serves a ‘protective function’ for the penis ‘to irritants from the environment, such as urine and feces in the diapers of the youngest of boys, and to rubbing against clothing thereafter.’ [58] There are also a range of ‘complications that could arise from male circumcision’ that are not dissimilar to that of FGC which is again ignored, [59] thus begging the question why should FGC be abolished MC continues to take place?

Another common reason cited for eradicating FGC is on the basis that FGC ‘violates women's rights to sexual fulfillment’ due to its interference with the clitoris. [60] This can again be compared to MC which ‘(eliminates) all sexual functions and related erotic activities that involve manipulation of the foreskin itself.’ [61] Furthermore, there are many studies that counter the argument that FGC impedes on a woman’s ability to achieve orgasm or hinders their libido. [62] On the flip side, some studies have found that FGC instead leads to increased promiscuity [63] and that some types of FGC, particularly those involving the removal of the clitoral hood actually lead to ‘maximum exposure of the clitoris’ thus allowing women the experience of ‘multiple, quicker, and more intense orgasms.’ [64] It is thus important to note that less invasive forms of FGC do not in fact eliminate a woman’s ‘capacity for orgasm.’ [65] Even with FGC procedures involving the removal of the clitoris, there is no consensus that such procedures can impede on a woman’s ability to achieve orgasm in every case as the psychosexual aspects of sexual enjoyment plays an important function in climax, even more so than the clitoris. [66] [67]

It follows from the above that where FGC is undertaken with the informed consent of an adult wishing to undergo the procedure, that the psychological impact can also be mitigated. This is not to say that for women and children who have undergone forced FGC, the experience would not have had a traumatic impact. In fact, many report experiencing ‘psychological and psychosomatic disorders such as disordered eating and sleeping habits’ as well as posttraumatic stress disorder, anxiety, depression, and memory loss associated with FGM/C. [68] However, on the other hand, the calls for abolishing FGC can have similarly ‘adverse psychological effects’ on women who have already underwent FGC. [69] There should thus be a clear line established distinguishing consensual and forced FGC.

VIII IMPACT OF THE INTERNATIONAL STANCE ON FGM

In analysing the merits of arguments for and against the eradication of FGC, it is also essential to understand the many potential consequences of the anti-FGC stance. While, not undergoing FGC in itself could have particular consequences for girls and women in certain contexts, such as social ostracism, [70] [71] the consequences of the stance adopted by the international community that has led to a variety of prohibitions, both legislative and political, are far more insidious. For instance, due to the hard line, no tolerance for any type of FGC view adopted, there is also a prohibition on medicalisation of the practice on the basis that medicalisation would legitimise it. [72] [73] This poses a serious issue to women and children who do undergo FGC as medicalisation would inevitably mitigate some of the harmful effects of FGC and/or may alleviate the pain of the experience itself. [74] Particularly, in a context where women and children may be subjected to FGC without their consent, medicalisation could at least lessen the ramifications of the procedure. Furthermore, engaging a medical practitioner may also lead to more informed consent from the person undergoing FGC as they would be advised of the risks of the procedure. This would also allow for a safer regime for FGC procedures given that medicalised procedures are generally regulated and accountability for “botched” procedures can be established. Non-medicalisation of FGC, in contrast, ‘drives [FGC] underground’ rather than eliminates the practice. [75] However, WHO and the international community remain firm on the stance of medicalisation considering it to just be another form of violation of ‘girls’ and women’s right to life, right to physical integrity, and right to health.’ [76] This has led some to criticise that the attitudes on medication of the practice is ‘not formulated on health concerns’ but on a reasoning based on ‘political and other extraneous factors,’ as the arguments against FGC on the basis of unqualified practitioners [77] and unhygienic and dangerous conditions of the procedure could easily be overcome through medicalisation. [78] While some have argued that even with medicalisation, there are cases of ‘girls bleeding to death after physicians performed the procedure,’ [79] this neglects the fact that in most cases, with health professionals performing FGC some of the more ‘immediate physical consequences’ such as ‘severe pain, bleeding and infections,’ can be controlled through the use of ‘antiseptic techniques, anaesthetic and analgesic medication.’ [80] In spite of this, the Western medical world continues to reject the practice of medicalisation, with many claiming, with no real justification, that the risks associated with FGC is only ‘slightly mitigated’ when performed by a medical professional. [81]

The hard line stance against medicalisation was adopted in an incident that took place at the Harbourview Medical Centre, Seattle, Washington in 1996, where a number of Somali immigrants demanded that infibulations be performed on their daughters. When the hospital refused to perform infibulations, the immigrants expressed that they would ‘transport their girls back to Somalia where infibulations would be done.’ In order to prevent the girls from being subjected to infibulation, the hospital proposed performing a procedure that would involve a ritual nicking of the prepuce (clitoral hood) with no excision of the tissue, under local anaesthetic for children who were mature enough to comprehend the procedure and give their consent. This came to be known as the “Seattle Compromise.” The Seattle Compromise, however, provoked a strong outcry of objection which eventually led to the Attorney General of the United States declaring the compromise illegal under ‘American anti-FGM laws.’ The arguments underpinning the objections are similar to those expressed by others against medicalisation in general as discussed above, as well as, that performing the procedure would have ‘sanctioned medically-unnecessary physical injury to children.’ [82] The ethics of FGC, whether performed on adult or children, are often questioned on the basis that it would be ‘unethical to injure a healthy body; although carried out in sterile conditions,’ [83] however, these ethics seem to be applied unequally, as other analogous practices, such as clitoral piercings, are seen as permissible. Though unpopular, the view that some form of medicalisation and compromise may be effective in negating the harmful impact of FGC is advanced by some qualified bodies, as reflected in the American Academy of Paediatrics’ statement issued in 2010 which suggested that legislative changes allowing paediatricians to offer a ritual nick as a compromise to mitigate FGC related harm may be more effective than laws banning the practice outright. [84]

Criminalisation is another adverse consequence of the no tolerance stance on FGC as it drives the practice underground exposing young women and girls to further health risks. [85] For instance, under the “Edo law” in Nigeria, punitive measures are not only specified for those who practice it, but also for ‘any person who offers herself’ for circumcision. As such, women consenting to undergo the procedure may be found guilty of an offence and can be liable to pay a fine of ‘one thousand naira or imprisonment for not less than six months or both.’ [86] Ghana’s national anti-FGC legislation also stipulates punitive measures for those who undergo FGC; however, it do not distinguish between those who undergo FGC consensually and non-consensually, making either person liable to face ‘imprisonment of not less than three years.’ [87] This conflates consensual FGC with forced FGC and may lead to victims facing the same sanctions as their perpetrators. [88] Criminalisation further discourages people from seeking medical intervention where an FGC procedure is botched, thus further exposing young women and girls to serious health risks.

IX ANALOGOUS PRACTICES

In spite of the vehement opposition to FGC, various practices that are analogous, if not, similar to FGC are carried out upon the request of women in the West. These practices include vaginoplasty, labioplasty, and even hymenoplasty (reconstruction of the hymen). These surgical procedures often have similar risks that are associated with FGC but are entirely permissible and medicalised for the safety of those undergoing the procedure. [89] Rather than being perceived as “mutilation,” practices such as clitoral piercings are viewed as cosmetic “enhancements” [90] There are many anatomical similarities between these procedures and categories of FGC. For instance, Type 1 of FGM involves ‘cutting or removal of the clitoral hood,’ which is ‘is anatomically identical to the Western “cosmetic” practice of clitoral unhooding.’ Cutting of the labia minora, which falls under Type 2 of FGM is similarly ‘anatomically identical to the Western “cosmetic” practice of labial trimming. [91] Even infibulation, one of the more extreme forms of FGC, has parallel features to ‘vaginal tightening procedure(s)’ that exist in the West. [92] These practices are non-therapeutic but WHO has neglected to take a position on these procedures while simultaneously prohibiting all forms of FGC. [93] [94] While some have tried to justify this distinction between “genital cosmetic surgery” and FGC by citing ‘psychological advantages’ of those practices to women, the same can be argued for FGC ‘in societies where [FGC is] acceptable.’ [95] This has led to criticisms that this difference is solely based on the fact that “genital cosmetic surgeries” are ‘simply more familiar’ to a Western viewpoint and therefore are not seen as foreign or ‘barbaric,’ and is permissible in spite of its moral and ethical ambiguities. [96] This further begs the question as to why non-Western women are not permitted to have a say in what they can and cannot do to their bodies while Western women are. [97]

Male circumcision (MC) is another practice that is analogous to FGC but permitted for reasons that are unclear. While some argue that MC has lesser health consequences and some medical benefit, this is not true for all cases as the suggestion that boys are never harmed by MC is a ‘vast oversimplification.’ [98] Just like FGC, MC can vary in its practice and the way in which it is conducted. [99] The idea that MC is largely safer and less ‘medically risky’ is simply untrue as it would depend entirely on the qualifications of the circumciser, whether anaesthesia is used, whether the procedure is undertaken in sanitary conditions and other such factors. [100] These factors would inevitably change according to the context within which the procedure is carried out. In fact there have been recorded cases of MC-related deaths. [101] MC and FGC are also medically comparable. Anatomically, Type 1 FGC, particularly, the removal of the clitoral hood is ‘comparable to [MC] as the clitoral hood and foreskin ‘serve similar functions.’ [102] The reasons cited for justifying non-therapeutic MC also share traits with the justifications used for FGC, with most attributing MC to cultural traditions or religious beliefs. [103] Many have thus questioned as to why there is a double standard to these largely similar practices, with some suggesting that either girls ‘should have the same access to cultural identity-promoting genital rituals as boys’ or MC should also be considered a violation of young boys’ rights to bodily integrity. [104] There are also types of MC that, while may not be anatomically comparable to infibulation, can be subjectively viewed to be as extreme as infibulation, such as subincision, a practice that involves the cutting open of the underside of the penis. However, as is the case of infibulation, this practice is also rare, accounting for ‘approximately 10% of [all MC] cases.’ The psychological impact that MC has on some young boys also cannot be undermined, with some men reporting feeling life they had something ‘taken from them’ and even using the term ‘mutilation to describe their circumcised state,’ [105] with many opting to undergo ‘foreskin restoration.’ [106] The practice of MC also poses a challenge to the claim that FGC is a form of discrimination against women, as there are no known societies that subject their women to FGC whilst not practicing MC as well. [107] The refusal to appropriately address the different treatments of MC and FGC by opponents of FGC further poses a challenge to eradicating FGC as proponents of FGC are ‘quick to identify the double standard’ and gives rise to the accusation of cultural imperialism [108] as it can be perceived that MC is simply tolerated due to its normalisation in Western societies. [109]

X UNIVERSALISM OR CULTURAL IMPERIALISM?

The various issues with WHO’s definition and categorisation of FGC as well as the “double standard” between FGC and comparable “Western” practices detailed above pose a serious risk of undermining the prohibition on FGC. Under the theory of cultural relativism, FGC should be considered a ‘cultural practice’ and it should not be viewed as wrong ipso facto just because it is foreign to Westerners. [110] However, some validly argue that culture alone ‘cannot be a valid justification for human wrongs’ [111] There are of course many problematic features of FGC, including that it is on most occasions, conducted on minors who cannot give informed consent on the procedure. However, there is evidence that a growing number of children in the West, ‘aged 14 or even younger,’ undergo non-therapeutic cosmetic genital surgeries, some of which carry the same risks as FGC, with permission from their parents. [112] That is to say that both practices cannot simply be distinguished as a result of the ages of those that undergo it. [113] Arguments for prohibiting FGC on the basis that it performed on children is also a moot point given that the abolishment of FGC applies to all, including adult women. The reasoning seems to be that no person would ‘freely and consciously consent to the practice,’ but rather are compelled to undergo FGC as a result of societal pressure, patriarchal notions and perhaps even internalised misogyny. [114] [115] This view, however, seems to be based on presumptions that are paternalistic with Westerners playing the role of the “enlightened saviour” for women from non-Western societies and is premised on the assumption of superiority of one’s own culture. [116] It is also reminiscent to the colonial mindset that justified erasure of cultural identities as a form of “civilising” the “savage locals,” thus giving rise to the accusation of cultural imperialism. This ‘racist othering’ of the practice and depicting all who undergo FGC as ‘passive, voiceless or clueless victims,’ is criticised and rightfully so. [117] This continued misrepresentation of FGC as a ‘harmful cultural practice’ also alienates the very community members needed to ‘make headway in abolishing’ FGC. This is reflected in societies where FGC is criminalised but the practice continues to be widespread as [118] the move to eliminate FGC is seen as ‘an unjustified attempt by the West to impose Western cultural values on others.’ [119]

XI REFRAMING THE DEBATE

It is clear from the above that while the move to eradicate FGC may be well-intentioned and came about as a means to protect young girls and their agency in relation to their own bodies, the zero-tolerance approach to FGC merely increases the harms that are experienced by young girls. It should foremost be noted that compelling children who are unable to give informed consent to undergo a non-therapeutic procedure carrying major health risks should be regarded a ‘form of torture’ and be rejected entirely as a practice. [120] However, there is no cogent reasoning that justifies applying the same approach to adult women who are of age to make informed decisions about their bodies as this would in turn take away their agency. It is futile to attempt to protect young girls’ rights to bodily autonomy whilst also violating the same of adult women, particularly, when adult women living in Western societies have said bodily autonomy to undergo analogous practices. Additionally, the stance on non-medicalisation is just a further deprivation of non-Western women’s rights to health and should be abandoned as there is clear evidence that if a milder form of FGC is performed by a medical professional, the procedure would be safer and less risky for women.

This paper thus argues that rather than eliminating the practice entirely, a more pragmatic approach may not only minimise any potential harmful impact on women and children but could also lead to a lesser degree of contention and higher degree of conformity. While some may argue that within particular contexts of entrenched gender inequality, true autonomy for women may not be achievable. This is conceded as the influences of societal pressures on the individual in particular contexts should not be overstated. [121] However, the fact that this practice holds significance for women in certain cultures cannot simply be overlooked and chastised as internalised misogyny or lack of awareness. [122] For instance, Ahmadu ‘presents her own experience of [FGC] as empowerment’ and a means to balance her American identity with her Sierra Leonean roots. [123] She puts forth that ‘the will of the women concerned should be the crucial point of any normative perspective.’ This paper is inclined to accept this view as ultimately any change to such practices be it eradication or continuation solely depends on the communities within which the practice takes place. Suggestions have been made that the procedure should be made exclusively available to consenting adults, [124] as this would represent true bodily autonomy for women and constitute liberty which is a fundamental aspect of human rights. [125] As such, particular forms of FGC when conducted on informed and consenting adults who choose to undergo this practice ‘autonomously and uncoerced’ [126] can in fact be compatible with our standard of acceptable norms and women’s rights to ‘health, physical integrity, and individual autonomy.’ [127]

[1] Janne Mende, ‘Normative and Contextual Feminism. Lessons from the Debate Around Female Genital Mutilation’ [2018] (67) Gender forum 47, 1.

[2] Nnamuchi, Obiajulu, ‘"Circumcision" or "mutilation"? Voluntary or Forced Excision? Extricating the Ethical and Legal Issues in Female Genital Ritual’ (2012) 25(1) Journal of Law and Health 85 , 90-91.

[3] Lunde, Ingvild Bergom et al, ‘‘Why Did I Circumcise Him?’ Unexpected Comparisons to Male Circumcision in a Qualitative Study on Female Genital Cutting Among Kurdish–Norwegians’ (2020) 20(5) Ethnicities 1003, 1005-1006.

[4] Nnamuchi (n 2) 90-91.

[5] Mende (n 1) 2.

[6] Earp, Brian D, ‘Between Moral Relativism and Moral Hypocrisy: Reframing the Debate on “FGM”’ (2016) 26(2) Kennedy Institute of Ethics journal 105, 105–6.

[7] Oba, Abdulmumini A, ‘Female Circumcision as Female Genital Mutilation: Human Rights or Cultural Imperialism?’ (2008) 8(3) Global Jurist 8 , 21.

[8] Mende (n 1) 2.

[9] Oba (n 7) 20.

[10] Female genital mutilation (FGM), UNICEF , (Webpage, February 2020) https://data.unicef.org/topic/child-protection/female-genital-mutilation/

[11] UNFPA, Demographic Perspectives on Female Genital Mutilation (Report, 2015).

[12] Prevalence of female genital mutilation, WHO, (Webpage) https://www.who.int/teams/sexual-and-reproductive-health-and-research/areas-of-work/female-genital-mutilation/prevalence-of-female-genital-mutilation

[13] Gordon, John‐Stewart, ‘Reconciling Female Genital Circumcision with Universal Human Rights’ (2018) 18(3) Developing world bioethics 222, 222.

[14] World Health Organization, Department of Reproductive Health and Research, Eliminating female genital mutilation , 2008.

[15] Elimination of female genital mutilation, HRC Res 44/L.20, UN Doc A/HRC/44/L.20, (14 July 2020, adopted 16 July 2020).

[16] UN,’Goal 5: Achieve gender equality and empower all women and girls,’ Sustainable Development Goals , (Webpage) https://www.un.org/sustainabledevelopment/gender-equality/.

[17] Eliminating female genital mutilation (n 14).

[18] Elimination of female genital mutilation (n 15).

[19] Earp (n 6) 106.

[20] Ibid 107.

[24] World Health Organisation, ‘Female genital mutilation,’ (Webpage, 3 February 2020), https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation

[26] Earp (n 6) 198.

[27] Oba (n 7) 4.

[28] Earp (n 6) 198.

[29] Oba (n 7) 21.

[30] Female genital mutilation (n 24)

[31] Earp (n 6) 111.

[32] Mende (n 1) 7-8.

[33] Earp (n 6) 112.

[34] Mende (n 1) 7.

[35] Earp (n 6) 112.

[36] Mende (n 1) 7.

[37] Earp (n 6) 120.

[38] Oba (n 7) 5-6.

[39] Convention on the Elimination of Discrimination Against Women (‘CEDAW’) , opened for signature: 1 March 1980, 11 UNTS 1249 , (entered into force 3 September 1981), art 2.

[40] Ibid art 5.

[41] Nnamuchi (n 2) 112.

[42] Protocol to the African Charter on Human and People's Rights on the Rights of Women in Africa (‘Maputo Protocol’) , opened for signature: 11 July 2003, OAU/AU Treaties, Conventions, Protocols & Charters, (entered into force 25 November 2005), art 5.

[43] Convention on preventing and combating violence against women and domestic violence (‘Istanbul Convention’) , opened for signature: 11 May 2011, 11 CETS 210, (entered into force 1 August 2014), art 38.

[44] Convention on the Rights of the Child (‘CRC’) , opened for signature: 20 November 1989, 1577 UNTS 3 , (entered into force 2 September 1990), art 24(3).

[45] Ibid art 19(1).

[46] Khosla, Rajat et al, ‘Gender Equality and Human Rights Approaches to Female Genital Mutilation: a Review of International Human Rights Norms and Standards’ (2017) 14(1) Reproductive health 59, 3.

[47] The African Charter on the Rights and Welfare of the Child (‘Children's Charter’) , opened for signature: 1990, OAU/AU Treaties, Conventions, Protocols & Charters, (entered into force 1999), art 1(3).

[48] Nnamuchi (n 2) 113.

[49] Ibid 87–8.

[50] Oba (n 7) 12.

[51] Female genital mutilation (n 24)

[52] Muteshi (n 55) 2.

[54] Earp (n 6) 122.

[55] Ibid 128–9.

[56] Ibid 127.

[57] Ibid 127–8.

[58] Ibid 128–9.

[59] Oba (n 7) 12–13.

[60] Ibid 9.

[61] Earp (n 6) 128–9.

[62] Oba (n 7) 9–10.

[63] Ibid 11.

[64] Nnamuchi (n 2) 94.

[65] Earp (n 6) 117.

[66] Oba (n 7) 10.

[67] Earp (n 6) 117.

[68] Muteshi (n 55) 2.

[69] Oba (n 7) 11.

[70] Mende (n 1) 8.

[71] Clarke, Elinor and Richens, Yana, ‘Female Genital Mutilation: An ‘old’ Problem with No Place in a Modern World’ (2016) 95(10) Acta obstetricia et gynecologica Scandinavica 1193, 1193.

[72] Earp (n 6) 123.

[73] Leye, Els et al, ‘Debating Medicalization of Female Genital Mutilation/Cutting (FGM/C): Learning from (policy) Experiences Across Countries’ (2019) 16(1) Reproductive health 158, 4-5.

[74] Mende (n 1) 9.

[75] Oba (n 7) 19.

[76] Earp (n 6) 123.

[77] Oba (n 7) 19.

[78] Ibid 19-20.

[79] Moschovis, Peter P, ‘When Cultures Are Wrong’ (2002) 288(9) JAMA : the journal of the American Medical Association 1131,

[80] Leye (n 76) 4.

[81] Oba (n 7) 19–20.

[82] Ibid 26–7.

[83] Utz-Billing, I and Kentenich, H, ‘Female Genital Mutilation: An Injury, Physical and Mental Harm’ (2008) 29(4) Journal of psychosomatic obstetrics and gynaecology 225, 228.

[84] Leye (n 76) 3.

[85] Oba (n 7) 25.

[87] Nnamuchi (n 2) 116.

[89] Oba (n 7) 28-29.

[90] Earp (n 6) 121-122.

[91] Earp (n 6) 121.

[93] Oba (n 7) 30.

[94] Earp (n 6) 129.

[95] Oba (n 7) 29-30.

[96] Earp (n 6) 124.

[97] Oba (n 7) 33.

[98] Earp (n 6) 198.

[99] Lunde (n 3) 1004.

[100] Robert Darby and J. Steven Svoboda, ‘A Rose by Any Other Name? Rethinking the Similarities and Differences between Male and Female Genital Cutting’ (2007) 21(3) Medical anthropology quarterly 301, 306.

[101] Earp (n 6) 114.

[102] Nnamuchi (n 2) 95.

[103] Lunde (n 3) 1006.

[104] Ibid 1005.

[105] Earp (n 6) 141.

[106] Ibid 142.

[107] Ibid 112.

[108] Darby (n 101) 313.

[109] Ibid 315.

[110] Nnamuchi (n 2) 96.

[111] Oba (n 7) 2.

[112] Earp (n 6) 118.

[113] Ibid 119.

[114] Mende (n 1) 5.

[115] Earp (n 6) 201.

[116] Oba (n 7) 34.

[117] Mende (n 1) 3.

[118] Nnamuchi (n 2) 95.

[119] Ibid 95–6.

[120] Gordon (n 13) 229.

[121] Nnamuchi (n 2) 106–7.

[122] Earp (n 6) 111.

[123] Mende (n 1) 4.

[124] Nnamuchi (n 2) 103.

[125] Ibid 106–7.

[126] Gordon (n 13) 228.

[127] Ibid 223.

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The New York Times

Tierneylab | a compromise on female “circumcision”, a compromise on female “circumcision”.

Since I invited researchers to debate female initiation rites in Africa, we’ve heard from social scientists based in Chicago, Italy, England, Nigeria and Sweden. I’ve saved the last word in this round of essays for the anthropologist with the most direct knowledge of this topic: Fuambai Ahmadu, a native of Sierra Leone, who grew up in America and then went back to her homeland as an adult to undergo the rite along with fellow members of the Kono ethnic group.

Dr. Ahmadu, a post-doctoral fellow at the University of Chicago, has previously published essays on the practice she calls female circumcision. In this essay, she reviews the debate here on the Lab and suggests a compromise that would protect girls and women from undergoing procedures without their consent, but she is critical of those who advocate “zero tolerance” and who refer to these surgeries as female genital mutilation:

I found some of the commentaries quite interesting and most of them unsurprising, given much of the media sensationalizing and vilification of female circumcision practices over the past thirty years. Much of the horror expressed seems to be based on erroneous presumptions about the clitoris and female sexuality. The fact is, as Dr. Catania has courageously come forward with in the publication of her research findings, that many women who have undergone varying forms and degrees of genital modification can and do experience sexual enjoyment and orgasms. Of course, some don’t. The same holds for uncircumcised women; many experience orgasms and a good number don’t. What this suggests is that (female) sexuality is as much a cultural construct as ideas about sex and gender and we need to revisit some of the received wisdom of western folk models of (female) sexual pleasure. I also take note of readers’ concerns about consent. While I have serious issues with the concept of consent and how it is applied asymmetrically to African practices of female genital cutting, I do agree with Rick Shweder that a possible way forward would be to consider limiting certain types of genital cutting to an age of majority, for instance, the age at which a girl can consent to marriage, abortion or to cosmetic surgery. A minor procedure can be allowed for girls under the age of consent, as is the case with infant male circumcision. Defining what such a minor procedure would entail and what might be the appropriate ages of consent is an important step that must include the voices of the “silent majority” of women who are affected. What western audiences rarely see and anti-FGM activists would prefer them not to see is the fact that many circumcised women who support their tradition are healthy (conditions of dire economic poverty, notwithstanding), lead sexually fulfilling lives and they as well their partners quite like their circumcised bodies. Then, there are some who (like some circumcised men) feel emotionally, psychologically and physically traumatized by their experiences. As Dr. Catania has pointed out and my own research among African immigrant women in Washington, D.C. confirms, it is usually the younger generation of circumcised girls and women who report experiences of sexual anxieties or dysfunction. This is due to what Catania refers to as “mental infibulation,” a provocative metaphor, as Shweder noted, which describes the feelings and experiences of shame, disfigurement and inferiority that these young women are made to endure as a result of the dehumanizing media representations and western social criticisms of their bodies and cultural practices. The way forward is to look for solutions that would empower women (and men) to choose what to do with their own bodies. So, I will end here with a summary of some of the points I made at the 2007 public policy forum on FGC at the annual meeting of the American Anthropological Association. My position is “pro-choice” on any form of female and male genital modifications (with the exception of minor cuts, such as circumcisions of male and female prepuce discussed above) and a complete rejection of the motto “zero-tolerance of FGM”. I am concerned that current U.S. and global polices on African forms of female genital surgeries discriminate against the bulk of circumcised women because of their social, ethnic, cultural and gender identity. This is made possible because of the high levels of illiteracy and low socio-economic status of circumcised women in sub-Saharan Africa as well as the sociopolitical disenfranchisement they face as immigrants in western countries. In particular, I am concerned about the official and exclusive reservation of the term “mutilation” to describe circumcised African women. Not only is this institutionalized discrimination but it is personally offensive to the majority of circumcised African women and to the cultures which practice female (and male) initiation. It is possible to imagine alternative approaches, which would: 1/ validate the positive experiences of the majority of circumcised African women; 2/ recognize the rights of circumcised African women to self-determination; 3/ promote the equality of circumcised women in “underdeveloped” countries of sub-Sahara Africa with uncircumcised women in “developed” western countries; 4/ modify laws, policies and terminologies such as FGM that prejudice circumcised African women because of their social, ethnic and cultural identity, their general lack of formal western education and low socio-economic status (although, as Rick Shweder and others have pointed out, this is not the case for many infibulated women in Egypt, Sudan and Somalia who are well-educated, wealthy and hail from elite families) or in short, because of their difference and inequality vis-à-vis western women. I am referring here especially to western women’s cosmetic vaginal surgeries, the so-called designer vaginas and vaginal rejuvenations – some of which include cutting, trimming, reducing, reshaping the clitoris, labia minorae, surgical tightening of the vagina and even restoration of the hymen! I also call for the protection of the rights of uncircumcised women in countries where female circumcision is the norm as well as the rights of circumcised women who choose to not circumcise their daughters, to abandon or even advocate against female circumcision. Although the vast majority of circumcised African women, like myself, take great cultural pride in our initiation there are clearly those among us who, for whatever reasons and there could be a number of reasons, do not share these positive experiences. So, I give my unequivocal support to such women working collectively for change that would protect them or their choice to opt out of this cultural practice. We can and must listen to women on all sides of this issue and promote policies that ensure equality, dignity, and justice for all women whatever our differences.

What do you think of Dr. Ahmadu’s ideas? Many readers have reacted to previous essays with blanket denunciations of these initation rites, often accompanied by assertions that reveal they haven’t even bothered to read the evidence from physicians and anthropologists presented in these essays. I hope we can get beyond angry generalizations and expressions of personal revulsion. Dr. Ahmadu has suggested a policy that would protect girls without banning these practices altogether. Is this a sensible compromise?

Comments are no longer being accepted.

Cuttings, piercings, scarrings, tattoos… all come with some social group pressures whether in Africa or America. So the question to Dr. Ahmadu is in what context would consent be “informed?” Certainly, waiting until a child becomes a adult allows for the possibility of participation in a decision. But if “everyone is doing it,” does that make everyone “informed” about the consequences?

Circumcision of the male prepuce is hardly a “minor cut.” It removes at least 50% of the total number of nerve endings in the male genitalia.

I am an Indian woman who has worked on women’s reproductive health in rural and urban India. I am not sure about Africa, but in India many women are not comfortable talking about their sexuality. Concepts like an orgasm may not even have an equivalent word in some of the local languages.

So I am wondering in collecting the info about circumcised women’s sexual satisfaction, I really wonder/ doubt if the women interviewed really knew what an orgasm is. Asking someone if they had an orgasm versus asking them if they experience sexual pleasure is really quite different. Also one never knows it till it occurs.

Are there any medical studies about how clitoral orgasms occur and could that be used to understand if it is even possible to occur in a circumcised woman’s body? It seems highly unlikely.

Dr. Ahmadu, you’re close but not quite there yet.

Quoting: “My position is “pro-choice” on any form of female and male genital modifications (with the exception of minor cuts, such as circumcisions of male and female prepuce discussed above)”

You are right to employ the concept of “choice”, self-choice. But you are wrong to make an exception for removing the female or male prepuce. They are not “minor cuts”, and make a mockery of the otherwise respectable “pro-choice” (self-choice) argument. Removal of the female or male prepuce is an assault on the physical integrity and sexuality of a person if they have not consented.

Thank your standing firm against those who would vilify self-chosen genital modifications because they seem foreign. Please consider the necessity of standing firm against exceptions to your wise “pro-choice” (self-choice) argument.

We all deserve, by default, to be free from genital cutting, but we also deserve the freedom to consent to our own genital cutting in ways dictated by our conscience and culture.

Religion and certain “cultural” sanctions seem to exert a disproportionate degree of importance around the world. Yes! Even in the United States.

Certain (to my mind, irrational) rituals are considered fine — if they are considered under these (to my mind) irrational systems of thought.

I have always been against male circumcision — their root goes back many millennia and seems now to only reduce sensation in men during sexual relations.

But, recently I read that those men who have NOT gone through the procedure can reduce the incidence of AIDS. Of course more study (replication) has to be done. But, if further inquiry suggests the validity of this assertion, I would be in favor of male circumcision.

For females, they are frequently forced on girls at teen years. And, unlike males this ritual can actually can lead to an increase in STD’s and HIV and AIDS transmission. They are also painful and can prevent pleasurable sexual relations.

But, if used as a bonding technique and consentual at a reasonable age — it’s their business.

I am so conservative that I find body piercing and tatoos objectionable. Even (would you believe), pierced ears! But, other people can do as they wish should they wish.

But, I view our world with significant trepidation — if humans (not to mention all species) can survive a half century — that would surprise me! With the proliferation of nuclear weapons (I look at the U. S./Soviet Mutual Assured Destruction — MAD with nostalgia) and the ever quicking global warming [see the new book SIX DEGREES], the matter of genital mutilation — no matter the type or degree with less moment.

Freud spoke of Thanatos: we, as a species, seem to combine the wish for destruction with a great degree of denial.

I do find the western use of “mutilation” a bit hypocritical. I forsee a future where almost every girl gets plastic surgery and those that don’t are seen as freaks, kind of like a girl who didn’t shave or wear makeup would be seen as a freak. Everyone i know except me seems to have had plastic surgery, and the attitude is ‘why don’t you do something about it?”. and if i looked bad, instead of just ok, i probably would succumb to this temptation to surgically cut my body into a more model-like form too. Modern plastic surgery reminds me of chineese foot-binding, thai neck-stretching, and yes, even FGM mentioned here. Women altering the way they were born to be the way society tells them to be. Why is this cruel everywhere… except in america when women are being cut and shaped into american standards of what women should be?

Just because one may insist on calling it “circumcision,” does not in any way negate the fact that it constitutes mutilation of the male or female genitalia.

Dr Ahmadu wrote:

“My position is “pro-choice” on any form of female and male genital modifications (with the exception of minor cuts, such as circumcisions of male and female prepuce discussed above)”

Here we have a clear double standard: pro-choice on some genital modifications, but no choice on others. This begs the question: who decides what is a “minor cut” and a “major cut”? If the individual does not make the choice, who makes this choice? Do people have the right to object if they object to the choices that others have made about their genitals? If male circumcision is defined as a “minor cut”, then what is to stop those who forcibly circumcise men against their will, as happened in Kenya just a couple of months ago? I think that Dr Ahmadi needs to rethink the implications of the double standard that she has espoused.

“the feelings and experiences of shame, disfigurement and inferiority that these young women are made to endure as a result of the dehumanizing media representations and western social criticisms of their bodies and cultural practices.”

So the problem of shame and inferiority felt by circumcised women is actually the West’s fault. What a great circular way to suppress criticism- if you criticize, you are suddenly the cause of the whole problem, altogether.

Dr Fuambai Ahmadu says: “Much of the horror expressed seems to be based on erroneous presumptions about the clitoris and female sexuality.”

Maybe so. But the same applies to the justifications for the procedure. To quote (once again) from Dr Ahmadu’s own essays:

“First, ritual officials and other Kono women adamantly maintain that if left untouched, the clitoris will continue to grow and become unsightly, like a penis; and second, leaving the clitoris untouched will categorically lead to incessant masturbation and sexual insatiability.”

If that’s not an erroneous presumption about the clitoris and female sexuality, what is?

Cutting the private parts on little girls is child abuse. If adults want to undergo cutting, piercing, whatever, it’s their choice. Leave the kids alone.

There is a vast difference between male circumcision and female circumcision. Male circumcision reduces AIDs transmission, dramatically, with success rates comparable to many vaccines. Male circumcision merely removes skin without a significant number of nerve endings. Male circumcision virtually eliminates penile cancer.

Female circumcision, on the other hand, has no clinically valuable benefits for ANY girl. It eliminates the chance of a clitoral orgasm. It would never be the subject of INFORMED consent by an adult woman with full knowledge of its risks and benefits. Persons who perform female circumcision should be jailed for unlicensed medical practice. Parents who consent to it should be jailed for child abuse.

Removal of the clitoris cheats women of full orgasm. How did this horrific tradition originate? Who decided that men should have pleasure, but women should not?

To be honest, this still sounds like it is asking for abuse in Third World nations where this is practiced, simply because girls who reach the age of majority will still be heavily pressured into female circumcision regardless. It’s much easier to simply do a blanket ban on the practice.

“I hope we can get beyond angry generalizations and expressions of personal revulsion.” Personal revulsion is the exact appropriate response to FGM. Kavita also made an excellent point about the integrity of the data. She really showed how a true scientist works.

A very unconvincing argument.

Dr. Ahmadu says: “Much of the horror expressed seems to be based on erroneous presumptions about the clitoris and female sexuality.”

Perhaps Dr. Ahmadu should read Masters and Johnson’s “Human Sexual Response” (ISBN 0-553-20429-7). While sexuality per se is not dependent on any particular organ, a womens ability to achieve orgasm is highly dependent on the clitoris. In fact, the vast majority of women (perhaps as much as 90%) do not have “vaginal” orgasms and it must be noted that there is no difference between a “vaginal” and “clitoral” orgasm. Thus, removal of the clitoris will likely lead to the anorgasma.

Comparing removal of the clitoris to male circumcision is literally not comparable, if you want a real comparison talk about complete removal of the penis. I think that no culture would condone that.

“Dr. Ben Riley wrote:

There is a vast difference between male circumcision and female circumcision. Male circumcision reduces AIDs transmission, dramatically, with success rates comparable to many vaccines. Male circumcision merely removes skin without a significant number of nerve endings. Male circumcision virtually eliminates penile cancer.”

Mr. Riley, you couldn’t be more wrong. The male foreskin is profusely innervated especially near the tip. In fact, it has been show that the foreskin is the most sensitive part of the penis and that circumcision clearly ablates it. Sorrells et al, Fine-touch pressure thresholds in the adult penis BJU International 99 (4), 864-869 (British Journal of Urology International, Volume 99 Issue 4 Page 864 – April 2007)

//www.cirp.org/library/anatomy/

Further more, your assertion about penile cancer is also wrong. The American Cancer Society published in a 2006 statement that said in part: “The consensus among studies that have taken these other factors into account is circumcision is not of value in preventing cancer of the penis.”

//www.cancer.org/docroot/CRI/content/CRI_2_4_2X_Can_penile_cancer_be_prevented_35.asp

As for your assertion regarding HIV I have not seen or heard of any reasonable explanation why the US has the highest rates of HIV in the western world while at the same time have the highest prevalence of male circumcision. It is likely the results you point to in Africa are context specific. In fact, there was a research paper published last March concerning related to the use of male circumcision as a prophylactic in Nature Medicine, Volume 13: Pages 367-371, de Witte et al. which concluded in part that: “Notably, LCs also inhibited T-cell infection by viral clearance through Langerin. Thus Langerin is a natural barrier to HIV-1 infection, and strategies to combat infection must enhance, preserve or, at the very least, not interfere with Langerin expression and function.” What does this say about circumcision?

“Dr. Ben Riley wrote: Female circumcision, on the other hand, has no clinically valuable benefits for ANY girl. ”

Again not correct. Female circumcision and HIV infection in Tanzania: for better or for worse? Stallings R.Y.1, Karugendo E. presented at the 3rd IAS Conference on HIV Pathogenesis and Treatment in 2005. They concluded in part that: “In the final logistic model, circumcision remained highly significant [OR=0.60; 95% CI 0.41,0.88] while adjusted for region, household wealth, age, lifetime partners, union status, and recent ulcer.” So my question is when are they going to do follow up studies? Hey if we could medicalize this it might help out those in Africa. Of course that would never happen because it is unpalatable to those in the West; boys however don’t deserve such protection. This is an unconscionable double standard.

//www.ias-2005.org/planner/Abstracts.aspx?AID=3138

“Dr. Ben Riley wrote: It eliminates the chance of a clitoral orgasm.”

There have been studies that indicate this is not true under all circumstances.

//www.newscientist.com/article.ns?id=dn2837

“Dr. Ben Riley wrote: It would never be the subject of INFORMED consent by an adult woman with full knowledge of its risks and benefits. Persons who perform female circumcision should be jailed for unlicensed medical practice. Parents who consent to it should be jailed for child abuse.”

Once again not accurate. A recent article in a Chicago paper actually highlighted the increasing demand for vaginal cosmetic surgeries which are very close to what is defined as FGM. Adult women ARE seeking them out for various reasons. It has become such an issue that the Obgyn college issued a statement advising its members to approach this with extreem caution.

I say that ADULT men or women should be free to alter their genitals in anyway they see fit, so long as the standards for full consent are made. Similarly, a Dr. is within their right to refuse such a request. However, surgical alteration (circumcision of male or females) without a clear an pressing medical need is unethical and should be illegal regardless of gender. Boy deserve the same respect and protection as girls.

Dr Ben Riley Western doctors use clitorectomy as a treatment for vulval cancer in some cases and it has been shown NOT to automatically prevent orgasm. You ought to know this as a doctor; aren’t you bound to deal in facts not prejudice?

FGC has been shown in Tanzania to apparently lower risk of HIV quite significantly in the female. This would seem to back up the circumstantial evidence that countries which routinely cut women commonly have a lower incidence of HIV. Similarly studies of genital cancer have shown either a direct link with poor female hygiene or an indirect link via higher HPV rates. Yet no North American has wanted to do any further research to investigate this – even just labial excision.

The truth is America wants there to be health benefits for male genital cutting – it is not interested in there being any health benefits to FGC. Call it cultural hypocrisy but whatever you do don’t call it science.

To John Tierney – i find it appalling that you consider the forced removal of the healthy prepuce a ‘minor’ surgery with no ethical implications. [John: Here you’re quoting not me but Dr. Ahmadu, and she didn’t say it had no ethical implications.] Arguable it is more minor in the female as erection for her is not such an issue. In the male it removes up to 80% of the skin he needs to have an erection which is why there are so many reports in America of painful erections and scrotal skin rising up the shaft to contemplate. It also removes most of his fine touch neuroreceptors which are designed to enhance and complete the differen sensitvity inherent in the glans. Intact men are visibly more sensitive – there are things you can do to them with your tongue that are heavenly and a cut man can only dream of.

In terms of the partners appreciation we have evidence as well as anecdotal reports that the loss of the male foreskin impedes female satisfaction (to understand this just take a look at the condoms which are marketed ‘ribbbed for her pleasure’) What exactly do you think this ribbing is meant to mimic if not the loosely retracted foreskin?

It is an ethical outrage to imply a parent may force their religion or culture on a child via surgery on their sexual parts, even if that surgery is only a symobolic slit. The international declaration of human rights and the convention of the rights of the child gives us all a right to choose our religion, and NO ONE a right to harm us on the basis of theirs.

Just as a small addition, i am absolutely with you on the pro choice angle John. But choice is not choice where you sitting in your office wherever you are getting to decide which bits of someone else’s body are minor and unnecesary. That’s just as offensive as you summarily deciding that one race or colour of person has less value than another.

Despite the so called study showing male circumcision reduces HIV infection rates, most of the highest rates of infection occur in countries where male circumcision is practiced routinely. Evidently, there are other factors involved that are much more effective at preventing HIV infection. It is also interesting that China, where circumcision is not routinely practiced has one of the lowest rates of infection.

I take exception to the attitude that if there is a potential for a future medical problem, cut it off. That argument is as valid as removing teeth to prevent cavities.

A more productive and less intrusive approach would be to encourage less promiscuity and better hygene in the case of HIV, and proper dental hygene in the case of cavities.

I was most intrigued by the relative lack of commentary on this article, especially when considering the popularity of posts about male circumcision on sites like CafeMom, which always produce a flood of passionate responses from those for or against. I wondered…do we just not care about the sexual health of our girls as much as our boys? Then I realized, even after exploring the links provided in this article, that I don’t really know what FGM is. I have a vague idea, but not enough to respond with any sincerity. The articles say that there is a chance to develop this or that complication with cute little “%” that have interesting numbers attached to them, but even these are disputed. Worse though, is these findings are not thoroughly explained. Why does this happen? I wanted to know. What exactly is removed or altered? I’m pretty sure that it has something to do with a clitoris but then how can there be varying degrees of removal or alteration? I understand the worry that the female may not be able to experience full sexual satisfaction, but why? It seems that this is disputed too. What about the other complications? Who performs these surgeries? What are their qualifications? Why is it done? I felt as though I was reading political speeches, where in the end you kind of know where everyone stands on the issue, but you’ll be damned if you know what the issue is. I could spend half a day on the internet researching the answers to these questions but I probably won’t. As it stands, my clitoris is safe and sound – and I have errands to run… Yikes! I think this means that a certain degree of apathy could be easily generated by vague explanations and a lack of information…I should care…Shouldn’t I? How about a little more information? Educate us. Help us figure out why we should care. It could be a very important issue.

Joe wrote: “There have been studies that indicate this is not true under all circumstances.” in reference to the statement that removal of the clitoris prevents orgasm.

The study that reported no association between FGC and orgasm is extremely limited. They only examined “the frequency of [self] reports of early arousal during intercourse and the proportions reporting experience of orgasm during intercourse.”

But, most women do not reach orgasm during intercourse and those that do most often orgasm because of direct or indirect clitoral stimulation. So it is an entirely expected result, with a small sample size (which it was) and low reports of orgasm its extremely difficult to find a statistical difference between two groups. It also assumes that they actually know what an orgasm is. Simply feeling pleasure during intercouse is not the same thing as having an orgasm.

If the study really was interested in exploring the relationship between FGC and orgasm it would have asked a more general question along the lines of “how often do you reach orgasm by a) intercourse b) self masterbation c) partner assisted masterbation d) oral sex”

I stand by what I said last time: Adults who are free to choose should be allowed to do what they want with their own bodies, even and especially when it comes to making mistakes.

I have my doubts about Ms. Ahmadu’s findings, which, at least as stated here, seem to imply that female genital cutting does not detrimentally affect women’s sex lives. Sex and gender are not social constructs; they are things to which societies have reacted and around which they have built institutions. While an attitude adjustment may certainly affect sexual experiences, it can’t change the lay of the nerve endings in a person’s body. I would want to know how she came to those conclusions.

John Tierney remarks: “Many readers have reacted to previous essays with blanket denunciations of these initiation rites, often accompanied by assertions that reveal they haven’t even bothered to read the evidence from physicians and anthropologists presented in these essays.”

Of course John Tierney’s caveat has not been heeded. Several commentators react to Dr. Ahmadu’s statement by innocently recycling familiar and sensational (and as it turns out, false) claims about the effects of female genital reshaping (for example on sexuality) that have already been carefully examined and critically questioned in earlier Tierneylab postings. Open-minded readers who are actually willing to read the full set of postings and work their way through the volume of comments will discover, perhaps to their astonishment, that the global campaign to eradicate female genital modifications in Africa cannot be justified on either harm grounds (the evidence is too weak) or on human rights grounds (the arguments are too weak).

Reading those postings and comments one discovers that ninety per cent of genital reshapings in Africa are NOT infibulations. Even among the ten percent who have had infibulations most women have satisfying sexual lives and retain the capacity for orgasm and feel proud of their bodies. Among those peoples in East and West Africa for whom genital reshaping is customary the practice is equitably applied to both boys and girls; and, for both sexes, it is viewed as a process by which the human body is made more beautiful, less sexually ambiguous, and more dignified. Upon examination many of the human rights arguments invoked in the anti-“fgm” literature turn out to be little more than re-descriptions of the author’s personal or culturally shaped preferences and feelings of disgust and outrage dressed up in a discourse about objective universal moral truths that dissolves upon critical analysis; and one is left wondering whether an offense to ones own culturally shaped sensibilities alone is sufficient reason to eradicate someone else’s valued way of life.

In his essay “Anti Anti-Relativism” the anthropologist Clifford Geertz offers a quote from Montaigne. “Each man calls barbarism whatever is not his own practice…for we have no other criterion of reason than the example and idea of the opinions and customs of the country we live in.” Geertz goes on to say, “What the relativists, so-called [I would call them the “cultural pluralists”], want us to worry about is provincialism – the danger that our perceptions will be dulled, our intellects constricted, and our sympathies narrowed by the overlearned and overvalued acceptances of our own society.” If in this case there really is more to it than that (“provincialism”) then the advocates of the global “zero tolerance” campaign should not be permitted to substitute lurid anecdotes and emotive rhetoric for systematic evidence. And they should be expected to come before the universal court of critical reason and respond to various criticisms of their claims about the health effects and effects on sexuality of female genital surgeries. Several such criticisms appear in earlier postings on the Tierneylab. To date there has been no adequate response.

Concerning the connection between male and female genital reshapings: “Why Aren’t Jewish Women Circumcised? Gender and Covenant in Judaism” is the provocative title of a wondrous book by Shaye Cohen, Professor of Hebrew Literature and Philosophy at Harvard University. The book contains pretty much everything you ever wanted to know about the history of Jewish male circumcision, including practical and theologically grounded ancient, medieval and modern interpretations and debates about its legitimacy, with special attention to various Jewish and anti-Jewish attempts to attack, defend and understand the practice. The gender specificity of the Jewish practice was one line of attack against Judaism launched by some Christian critics, who disparaged the ritual of male circumcision (mocking it for its gender bias) and contrasted it with the ecumenical character of baptism. This issue of gender parity has been ubiquitous in the comments on the Tierneylab since the first posting on November 30, 2007 titled “A New Debate On Female Circumcision” and, as several of the recent comments by anti-male circumcision advocates reveal, the issue can’t be avoided in any consideration of Fuambai Ahmadu’s proposal for a “compromise” concerning female genital reshapings.

The concluding chapter of Professor Shaye Cohen’s book is called “Challenges to the Circumcision of Men”. Near the beginning of that chapter (page 107-108) he writes: “Also looming on the horizon is the challenge to the Jewish circumcision of males posed by the non-Jewish (generally Islamic) circumcision of women. As Western governments have moved to outlaw the circumcision of women, the question has been asked: why is the genital mutilation of men tolerated? The goal of the questioners is not to legalize female genital mutilation but to outlaw male circumcision, on the grounds that it too is a genital mutilation. This argument can be refuted, to be sure, but the argument is real, and future defenders of Jewish circumcision well need to deal with it. Hence both the non-circumcision of Jewish women and the circumcision of non-Jewish women challenge the circumcision of Jewish men.”

Professor Cohen also has a final footnote in the book (on page 271, footnote 41) in which he notes that “western discourse about female circumcision has been shaped exclusively by its opponents.” In that footnote he summarizes some of my own published views about female genital surgeries- especially the inadequacy of the evidence in support of the widely publicized claims about devastating consequences for health and sexuality – and he concludes by saying: “If this be true – and I leave this for others to determine – the horror stories told by the opponents of female circumcision have no greater statistical validity than the horror stories told by the opponents of male circumcision. Perhaps, then, an argument could be made for moral parity between female circumcision and male circumcision, not in order to proscribe them both but in order to tolerate them both (this indeed seems to be Shweder’s position).”

Looking at the comments on the Tierneylab over the past several months of debate about this topic the moral parity/moral imparity question is indeed on the table. I suspect that once the hyperbolic claims about the devastating consequences of “fgm” are carefully scrutinized (see the earlier postings on the Tierneylab) the moral parity position advocated by Fuambai Ahmadu is likely to gain more recognition; and it will be a parity in the direction not of equal proscription but rather of equal toleration, under conditions that satisfy our own contemporary liberal democracy’s notions of gender equity, family privacy, expressive liberty, religious freedom and the rights of parents to make decisions about the development of their children.

Richard A. Shweder University of Chicago

What's Next

The Complexity of Female Circumcision: Your Thoughts

Many readers were jarred by an Atlantic interview with an anthropologist who tackled a controversial question: What if some women choose to get cut — and even celebrate it?

One of the most provocative pieces on The Atlantic recently came from Olga Khazan, who interviewed anthropologist Bettina Shell-Duncan on the persistent problem of female circumcision in many parts of Africa and the Middle East, despite decades of campaigns led by the United Nations and others. Thousands of you commented via Disqus, Facebook, Twitter, email, and yelling through your screen—"FGM apologist!"—but I tried to compile the most productive points, seen below.

Parsing a reader debate on the best way to end female circumcision—no one is arguing for the practice—is difficult because people are often talking past each other. That difficultly is due to the vast diversity of the 125 million individuals who have gone under the knife; each case is different. Is she an adult, a teenager, or clearly a child? Does she live in a country where the ritual is widespread or a Western nation where it defies all norms? Does she undergo "nicking," excision, infibulation—in which the labia are stitched together—or something in between? Is she forcibly held down, or does she join willingly, even joyfully in some cases?

One such case was described in Olga's interview with Shell-Duncan, who witnessed the ritual cutting of a Rendille woman at her wedding in northern Kenya: "The bride came out [afterwards] and joined the dancing." Olga, though horrified by the practice, emerged from the interview with a more nuanced understanding of how it's performed in various places:

In fact, elderly women [as opposed to men] often do the most to perpetuate the custom. I thought African girls were held down and butchered against their will, but some of them voluntarily and joyfully partake in the ritual. I thought communities would surely abandon the practice once they learned of its negative health consequences. And yet, in Shell-Duncan's experience, most people who practice FGC recognize its costs—they just think the benefits outweigh them.

Here's Shell-Duncan in her own words, prodding people to consider a woman's choice when it comes to circumcision:

The sort of feminist argument about this is that it’s about the control of women but also of their sexuality and sexual pleasure. But when you talk to people on the ground, you also hear people talking about the idea that it’s women’s business. As in, it’s for women to decide this. If we look at the data across Africa, the support for the practice is stronger among women than among men. So, the patriarchy argument is just not a simple one.

Many upset commenters, including Rosemary Fryth , found the interview rife with "cultural relativism":

We are told that in a multicultural country all cultures have equal value—and thus, all cultural practices as well. Well, it is clear that not all cultures are equal, and pretending that they are allows this sort of inhumane cultural practice to thrive.

Guishe Garra agrees:

The article almost acknowledges female genital mutilation as an OK practice given "their culture." This is a great example of a "liberal" publication flirting with extremely illiberal values in the name of misunderstood "diversity and minority's cultures." If we can't emphatically argue that humanistic values and liberal values are clearly better, we are doomed.

Though to be clear, Shell-Duncan is working with the Population Council to reduce female circumcision "by at least 30 percent across 10 countries over five years"—hardly the goal of someone who "almost acknowledges [FGM] as an OK practice." Arwen McCaffrey puts it well:

The researcher is clearly not in support of the practice. The point of the article isn't to lessen the horror of FGM but rather to contextualize it. Societal pressure to belong is incredibly powerful. This is true in Western cultures as well. Shell-Duncan is remarking how she learned about the many sociocultural factors influencing the practice and that there is no one easy way to end it.

So the core debate should be: What's the most pragmatic, effective way to end the practice? That's difficult to say, since legal prohibitions and health messaging have yielded mixed results so far. One controversial idea from Shell-Duncan is to call it "cutting" rather than "mutilation"—the term officially used by the World Health Organization. But "mutilation," she says, "sounds derogatory and can complicate conversations with those who practice FGC [female genital cutting]." Hilary Burrage isn't buying it:

The wish of leading African women themselves is clearly to refer to the practice as MUTILATION—formally, at least, per the 2005 Bamako Declaration . The United Nations has also recently agreed to refer to this harmful traditional practice only as FG*M*. Please let's hear NO MORE about "FGC." Children's lives and future health are more important than comforting —whether to practitioners or observers —euphemisms. Female genital "cutting" also plays very well to Westerners if they want to evade the cruel truth of how defenceless (undefended) children are being tortured because of "respect" for "tradition."

Maria Alisa , on the other hand, sees the logic of calling it "cutting":

The point of the name change is that if you go in as an outsider and tell people how horrible they are and they have to change a cultural practice, do you think that will work? No. They'll cling to it twice as hard. In our discussions with those cultures over the practice, we must do what works, not what makes us feel smug and self satisfied.

Ilona Geary elaborates on that view:

I n the West, we have the luxury of making decisions based on our own beliefs without our children or ourselves being ostracized or disenfranchised or having their future threatened. We enjoy a certain amount of autonomy that doesn't seem to be present in the people groups discussed here. But when you live in a collective, the traditions that signify a belonging and duty to the group become paramount. I appreciated the article's explanation of the social pressure, especially in a nomadic/small village setting, that drives these mothers and young women to make this decision. In their estimation, it is an important way to secure solidarity and a prosperous future for their child within the circumstances in which they live. I think the practice is definitely dangerous and doesn't have the actual benefits that the people group believe they do, but the only way to change hearts and minds is to continue a respectful dialogue and create OTHER opportunities within these communities. One can't march in with disgust, disdain, and legislation and think this will instantly vanish. Constant communication that provides a connection to a larger world view and more options will eventually turn the tide. Sooner rather than later I hope.

Perhaps "mutilation" and "cutting" are equally useful terms; it just depends on the audience. For anti-FGM activists who want to increase awareness and fundraising in the West, "mutilation" rhetoric is more effective. For anti-FGC anthropologists and health officials who confront the cultural divide on the ground, "cutting" is more effective. Here's how this reader frames the tension at play:

The feminist discourse runs up against the post-colonial one. At which point is it okay to dictate terms to native cultures?

Thop looks to history:

Wikipedia It is without doubt that in the cultures practicing human sacrifice, a significant number of young sacrificial victims (or should I be PC and say "celebrants") participated willingly, even joyfully. In colonial India, the Brits effectively ended—though not totally eradicated—the ancient practice of Sati, the burning alive of the widow on the dead husband's funeral pyre. They started with education and mild restrictions, but with little result. That was dropped for a more heavy-handed ban. But the Brits were all about respecting national customs : General Sir Charles James Napier, the Commander-in-Chief in India from 1859 to 1861 is often noted for a story involving Hindu priests complaining to him about the prohibition of sati by British authorities. "Be it so. This burning of widows is your custom; prepare the funeral pile. But my nation has also a custom. When men burn women alive we hang them, and confiscate all their property. My carpenters shall therefore erect gibbets on which to hang all concerned when the widow is consumed. Let us all act according to national customs."

Another dividing line in the reader debate is the age of the females getting cut. How Liz Deutermann sees it:

I think if a woman wants to be circumcised it should be her choice. What's horrible is when a girl is forced into it.

And girls are clearly the ones suffering the most :

Most often, FGC happens before a girl reaches puberty. Sometimes, however, it is done just before marriage or during a woman’s first pregnancy. In Egypt, about 90 percent of girls are cut between 5 and 14 years old. However, in Yemen, more than 75 percent of girls are cut before they are 2 weeks old. The average age at which a girl undergoes FGC is decreasing in some countries (Burkina Faso, Côte d’Ivoire, Egypt, Kenya, and Mali). Researchers think it’s possible that the average age of FGC is getting lower so that it can be more easily hidden from authorities in countries where there may be laws against it.

Which would be a dark irony indeed. But what about adults who undergo FGC? Should it be "their body, their choice"? Sarah White thinks that's a fallacy:

It is not a choice if it is a cultural expectation and one faces ostracism (which means much more in tribal cultures) if one dares to deviate. This is not consent; it is acquiescence. Read Alice Walker's Possessing the Secret of Joy .

Walker also wrote a nonfiction book on FGM, Warrior Marks . Here's a gripping scene from her documentary of the same name:

Even when the participant is an adult, this reader suggests it's still brainwashing:

A lot of people are pointing out that this 16-year-old Rendille girl [witnessed by Shell-Duncan] apparently "chose" to get the procedure done, as if such a thing would have ever occurred to her without getting it drilled into her head since birth that this makes her worthy in the eyes of her community.

Shell-Duncan noted that the Rendille teen "was young by their standards. Mostly they’re 18, 19, 20, around that"—which raises the difficult question of when exactly a minor becomes an adult. When I emailed Hilary Burrage, the aforementioned activist, she had a nuanced take on the consent question:

Regarding the "adults can choose" issue, yes, it is more complex. Some might say there’s a grey area between FGM and female genital "cosmetic" surgery (FGCS), but in reality (regardless of my views on FGCS), I don’t think there is a grey area.  FGCS does not remove physiological functions—everything from normal secretions and dampness to obstruction in childbirth—nor does it remove sexual feelings and sensations. FGM often does interfere with function to one degree or another. We have to be careful that those who claim they want FGM as adults don’t also get it done on minors. One example is this interview with an woman who grew up in the US but returned to Sierra Leone to undergo FGM—but submitted her eight-year-old sister to one as well.

Burrage was upset over Olga's piece:

It is a matter of serious regret (and hurt to survivors) that Melinda Gates commended the Shell-Duncan interview on Twitter: I disagree with the practice, but this article has great insight on understanding different cultures: http://t.co/NodZhzRDpF via @olgakhazan — Melinda Gates (@melindagates) April 15, 2015

The Gates Foundation has undertaken excellent work (e.g. maternal malaria), so the praise for Shell-Duncan's analysis contrasts very poorly with this positive contribution to women’s health. Ms Gates should be strongly encouraged to reconsider her position in the light of the evidence cited in my email and elsewhere. You will I’m sure be aware that the UK Royal Colleges (which also produced our national guidelines on issues around FGM) have produced a strong statement explaining why they found the article unacceptable; and I imagine you may have seen my own post written shortly before then.

I am sure The Atlantic (and, perhaps separately, Ms Gates) will wish as a matter of urgency to make it crystal clear that any position on FGM—a totally illegal practice unanimously condemned by the UN—which falls short of outright denunciation is, in one word, unacceptable.

Olga's response:

The problem here is that the communities where FGC/M occurs are all very different. There are many in which girls are coerced and even tortured. There are some, as Shell-Duncan describes, where the practice is seemingly celebrated. I've always been interested in why so many female elders support this practice. How do you go about ending FGM in those societies? Shell-Duncan's description of the girl who was proud to have the procedure done on her was certainly fascinating, but it was by no means descriptive of all women who undergo FGM. However, it does reflect a need for a different type of approach to ending FGM in these areas, and that's what Shell-Duncan provided. Also, I reject the notion that there are "acceptable" and "unacceptable" ideas, as Burrage describes, when it comes to attempting to end a problem as entrenched as FGM. Shell-Duncan was offering one potential solution for a certain type of community; surely there are other solutions that are more applicable to other situations. We all have the same goal in the end.

Our final reader is Soraya Miré, a Somali woman who penned a memoir about her own experience with FGM, The Girl With Three Legs. Here's Soraya 's response from the comments section:

The article failed to understand why our mothers and grandmothers put our bodies through the mutilating ritual and watch us become nothing more than the pleasurable commodity of men. What happened to these women? What about their deep wound, private pain? Didn’t they become wives and mothers, knowing the unthinkable pain? Why then continue the circle of pain? I didn't own a clean razor but felt the prick of the sharp needle as rough hands plucked at my lips like a giraffe feasting on thorny branches. The doctor who was performing my mutilation turned to my mother and said,"Would you like to look at it?" She did and said, "Perfect. Just perfect!" That high praise was meant for my future husband who would find me desirable. I said this many times, that ending the abuse of girls and women is seen as a threat to manhood and a man’s psyche. The article failed to understand the one holding the social and cultural identity mirror. What is the purpose of holding this mirror? And when a young girl looks into that mirror finds a message that reads, “You were born into a female body which automatically labeled you a defected human being in need of reconstruction.” I would love to speak to Bettina Shell-Duncan and offer her education about the cultural mindset of society that views women like chicken without heads. Those of us who survived the horror of Female Genital Mutilation are left with an option to either go along with the cultural torture and abuse or detach ourselves from our roots, our culture and even our family. Reading this article brought back the nightmares about needles biting into my skin and envisioning myself landing on the field of thorns, cut glass, and bloody scissors.

Another Somali-born woman who suffered from FGM, Ayaan Hirsi Ali, touched on the issue in yesterday's Atlantic piece on honor killings in the U.S.:

In the United States, more than half a million women are estimated either to have undergone female genital mutilation (FGM) or to be at risk of it. This number marks a sharp rise in the prevalence of FGM in the U.S. compared to just over just a decade ago. The reason for the increase, according to the Population Reference Bureau, is the rise in the number of immigrants from countries where FGM is common. Those trends show no [sign] of abating.

That trend was the subject of an Atlantic Monthly cover story back in October 1995, "Female Circumcision Comes to America," just at Congress was finally passing a law against FGM. Linda Burstyn's essay opens with an Ethiopian immigrant mother, Genat, frightened that her own mother will circumcise Genat's newborn girl:

"Mother says she will do it anyway, herself—when I'm out of the house—if I don't agree to get it done soon," Genat confides to the woman she hopes will help her. "She says she will take a razor blade and do it." [FGM activist Mimi] Ramsey nods. She has heard this story many times before, and responds by reciting a long list of reasons why the older woman must be stopped, trying to give Genat the courage to buck tradition and disobey her mother. "You cannot let her do this to your child. Please. It is wrong. You know how painful it is. How damaging. Your daughter may hate you for life for what you allow to happen to her." Genat shakes her head. She doesn't want her baby girl, just born in this country, to be circumcised, as is customary in her native land, but her mother is adamant. "She believes in it so strongly," Genat says. "She said if I don't do these things, the girl will grow up horny. She'll be like American girls."

Readers at the time reacted to Burstyn's piece here .  Thanks to all the readers this month who commented on the Shell-Duncan interview. We're thinking of posting a similar follow-up on the male circumcision vs FGM debate that also raged in the comments section . If you'd like to offer your take on the subject, email [email protected] and you'll have a much better chance of seeing it posted.

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Why the law against female genital mutilation should be scrapped

Lecturer in Law, City St George's, University of London

Professor of Women's Health, King's College London

Disclosure statement

Lynne Townley is affiliated with Save Your Rights, a charity campaigning against forced marriage and a committee member of Association of Women Barristers (a voluntary organization campaigning for access to the Bar for women and other under-represented groups). She has lectured and published articles on FGM and was the Legal Advisor on NHS Health Education England E-learning for Health FGM Learning Programme.

Susan Bewley was involved in setting up the UKs second FGM clinic as Director of Obstetrics at Guy’s & St Thomas’ Hospitals in 1996. She has a research interest in violence against women, and has published and lectured on FGM. She was a expert for the defence in R vs Dharmasena.

City St George's, University of London provides funding as a founding partner of The Conversation UK.

King's College London provides funding as a member of The Conversation UK.

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Causing grievous bodily harm, including mutilation, has been outlawed in the UK since time immemorial and has been a statutory offence for over 160 years. Despite this, a law banning female genital mutilation ( FGM ) was introduced in the UK in 1985. Since then, only one FGM prosecution has been brought to trial, and both defendants were acquitted . There has yet to be a conviction under the FGM Act.

It is curious enough that the statute has hardly ever been used, but there are other reasons why the exception made for FGM to have its own law now needs to be reconsidered. The problem of FGM was initially considered to be so extreme and so prevalent that it was thought that extra protection under the law was needed in a belt-and-braces approach, but we believe this is no longer necessary .

FGM is practised for a variety of cultural reasons and involves the ritual cutting or removal of some or all of the external female genitalia. It has no health benefits, but does have well-documented harms .

One in 10 cases of FGM are the most severe form, known as type 3. This involves the greatest removal of tissue and sewing up of the vaginal entrance. An opening can be made in the scar tissue for childbirth (called “reversal”), but tissue cannot be restored. Doctors can attempt to reconstruct the clitoris, if it has been removed, but the procedure is not always possible, or successful .

In children, FGM has parallels with the ritual circumcision of baby boys. Critics think it is inconsistent, if not hypocritical, that one practice is banned while the other is allowed.

In adults, FGM has parallels with cosmetic surgery. Under the FGM Act, it is illegal for a women in the UK to request having her vagina closed again (re-infibulation), following childbirth. It occurs in the few countries that practice type 3 FGM. In the UK, re-infibulation is always considered criminal, maybe protecting women from coercive cultural pressures, but potentially also denying their free choice. On the other hand, the Act specifically exempts those adults who choose to have female cosmetic genital surgery – operations largely performed in the private sector.

For instance, a plastic surgeon who removed a healthy 33-year-old woman’s clitoris, at her request, wasn’t prosecuted under the FGM Act and neither was the psychiatrist who cleared her for the surgery. Given these contradictory positions, opponents of the FGM Act are increasingly wondering whether this is an example of moral relativism and bad law .

Generally, criminal law is intended to prevent or punish an outlawed behaviour. The existence of a law acts symbolically to prevent the outlawed acts. Prosecution is the means to punish them when they occur. The desired end, of having less (or no) FGM, especially of children, is achieved by the absence of FGM, not by the presence of prosecutions.

No longer needed

The demand for prosecutions is a “tough” approach taken by the authorities, but it is not a primary desired end in itself. It may appear counter-intuitive that we think that the lack of successful prosecutions may be supportive evidence that the law is functioning successfully (if not completely) by encouraging positive changes in attitude . We do not advocate scrapping the specific FGM law because it is too difficult to enforce, but because it is no longer needed.

Up to now, the law may have worked by drawing attention to the issue and by setting an expectation of acceptable behaviour for new migrants. But there are difficulties and unintended effects , including concerns that the current law is discriminatory about race .

It has proven difficult to prosecute FGM due to its familial and hidden nature, the shortage of experienced and competent experts , low numbers of reports, and a first failed prosecution of a doctor. In any event, established law already includes FGM in its remit ( Offences Against the Person Act 1861 ) and also safeguards children ( Children Act ).

So, rather than concentrating on government pressure to achieve a successful prosecution with unnecessary law, we could instead divert scarce resources to continuing prevention – such as education, provision of specialist health clinics and community support services. Also, there is evidence that the communities who practice FGM are giving it up with falling prevalence worldwide , though sadly numbers may still rise due to population growth.

Lastly, the involvement of doctors legitimises surgery. Globally, “medical reasons” are used to justify and perform male infant circumcision. Likewise, medicalisation is used to justify FGM in some countries (Egypt and Malaysia) where doctors perform “female circumcision” more safely under anaesthetic, but still without any therapeutic benefit. The law should bring consistency into medical practice: either by banning male infant circumcision or by recognising the harms of this traditional practice .

Doctors in the UK are faced with two discriminatory conundrums : a consenting adult female with normal genitalia can have major genital modification, yet a new mother who had FGM as a child cannot be re-infibulated; girls cannot undergo genital modification as unconsenting children , but boys can.

Increasingly, bodies representing the professional interests of medical doctors, such as in the Netherlands , are cited as saying the health risks of infant male circumcision outweigh the benefits.

Eroding trust

Finally, in the efforts to prosecute FGM, mandatory reporting and recording of all old and new FGM by doctors has been introduced – which raises concerns about confidentiality and erosion of trust in the medical profession. Doctors do not have to ring the police about other criminal events reported by victims that occurred long ago and elsewhere. This extra reporting may cause a loss in trust, not only of individual patients, but of whole communities.

The UK could introduce consistency with a Child Genital Modification Act which would make any non-medical genital modifications of male and female infants illegal because the medical benefits are negligible, at best, and the risks great. Alternatively, given that we already have criminal law that would cover FGM and inappropriate surgical cuttings by doctors in the Offences Against the Person Act 1861 , why do we need the FGM Act at all? It is not fit for purpose and should go.

• Circumcision
• Female genital mutilation
• United Kingdom (UK)

Postdoctoral Research Associate

Project Manager – Contraceptive Development

Editorial Internship

Integrated Management of Invasive Pampas Grass for Enhanced Land Rehabilitation

Key points for abolishing Female Genital Mutilation from the perspective of the men involved

Affiliations.

• 1 University of Alicante, Department of Nursing, Spain. Electronic address: [email protected].
• 2 Universidad de Murcia, C/ Salvador de Madariaga, N°5, 5°B, CP: 30009 Murcia, Spain. Electronic address: [email protected].
• 3 Universidad de Murcia, C/ Pasaje Latino N°:3, 5°B, CP: 30500, Molina de Segura, Murcia, Spain. Electronic address: [email protected].
• PMID: 26971445
• DOI: 10.1016/j.midw.2016.01.017

Introduction: female Genital Mutilation is internationally considered an affront on human rights and an act of violence against women and young girls. Furthermore, it hierarchises and perpetuates inequality and denies the right to bodily and psychosocial integrity of women and young girls.

Aims: to detect the key points for the abolition of Female Genital Mutilation as well as the necessary resources for its eradication.

Material and method: a qualitative methodology with an ethnonursing perspective, via semi-structured interviews, held both individually and in groups, in 21 men familiar with Female Genital Mutilation.

Findings: through the voices of men familiar with this tradition, five key points are presented for its gradual eradication: sensitisation and awareness building, team action, abolition-promoting media, focusing action on rural areas and applying educational means before punitive ones.

Conclusion and practical implications: awareness-raising via the combined efforts of families, communities and governments, together with the promotion of health education programmes in demonstrating the complications derived from this practice, play a vital part in eradicating Female Genital Mutilation.

Keywords: Female circumcision; Men; Nursing; Qualitative research; Transcultural.

Copyright © 2016 Elsevier Ltd. All rights reserved.

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Ethical and Cultural Issues in Genital Cutting and Strategic Suggestions for Reduction

Fr. Kevin T. FitzGerald, SJ, Ph.D., Ph.D. Dr. David Lauher Chair of Catholic Health Care Ethics Center for Clinical Bioethics Georgetown University Washington, D.C. [email protected]

Samantha Wu, MS Research Assistant Pellegrino Center for Clinical Bioethics Georgetown University Washington, D.C. [email protected]

In April 2017, a physician in Detroit, Michigan was charged with performing female genital mutilation/cutting (FGM/C) on girls aged six to eight. A few weeks later, another physician and his wife were also indicted for participating in or facilitating the procedures. At least two young girls had been transported across state lines to a clinic in Eastern Michigan where the procedure occurred, bringing this case under federal jurisdiction and leading to the indictment of the accused by the Federal Bureau of Investigation. 1

As the most recent, or perhaps the only, case to be brought under federal law, it brings renewed attention to the issue of FGM/C in the United States. FGM/C, is defined as circumcision, excision, or infibulation of the labia majora, labia minora, or clitoris. 2 Since 1996, FGM/C performed on minors has been considered illegal in the U.S. and is punishable by fines and imprisonment of up to five years. 2 In 2013, "vacation cutting" or transporting a girl to a country outside the U.S. to undergo the procedure was also outlawed. Additionally, state-level legislation, with even harsher penalties in some cases, has been introduced in 23 states. 3

Adding to the already complex legislative landscape, laws regarding FGM/C may overlap with child abuse laws, depending on the state. As a result, there is variation among the states in what is considered "child abuse," and what is considered culturally excusable medical treatment of children. 3 Such variation in state-level policies makes for unclear guidelines and obligations for mandated reporters, including physicians.

The Catholic Moral Tradition and FGM/C Catholic moral theology considers FGM/C to be non-therapeutic surgery that violates the principle of totality. It is therefore morally equivalent to mutilation. This principle is stated clearly in the Catechism (#2297), as well as in the 1995 edition of the Charter for Health Care Workers where it says, ... surgical] interventions are acceptable "for the restoration of the person to health" (#66). Elsewhere, the document quotes Pius XII regarding the principle of totality: "It is not lawful to sacrifice to the whole, by mutilating it, modifying it or removing it, a part which is not pathologically related to the whole" (note #144). This principle is reiterated in the New Charter for Health Care Workers (2017), especially in #88 and #89.

There are also serious ethical questions about the ability of young women to understand or consent to the procedures involved in FGM/C. Informed consent is one of the most basic principles in health care ethics; procedures performed without it — or without the informed consent of parents or guardians for minors — are serious violations of basic ethics.

More recently, Pope Francis has made explicit reference to FGM/C. On February 1, 2015, in an address that was part of a meeting on women's issues hosted by the Vatican's Council for Culture, he associated the practice with violence against women: "The many forms of slavery, the commercialization, and mutilation of bodies of women call out to us to be committed to defeat these types of degradation that reduce them to mere objects that are bought and sold," he said. "Although it is a symbol of life, the female body is unfortunately not rarely attacked and disfigured, even by those who should be its protector and life companion." 4

There are also local efforts to end FGM. In Kenya, the church has established a child education and Rescue Centre in Suguta Mar Parish premises, located 42 kilometres away from Samburu County headquarters where they provide shelter for girls who leave home to avoid FGM. 5

Elsewhere in Kenya, Sr. Ephigenia Gachiri has tried to replace cutting with an alternative "coming of age" ceremony. 6 Efforts in the United States, such as those sponsored by the Diocese of Rochester, New York (described elsewhere in this article) are aimed at recent immigrants in the U.S. who might still be at risk for FGM.

FGM/C in the Clinic: A Complex Legal and Ethical Landscape Regarding FGM/C, physician behavior and decision-making in the clinic are a delicate balance of legal obligations, professional guidelines and medical ethics. Legal obligations are often unclear, and, in practice, provide little in the way of how to provide care that is in the best interest of the up to 507,000 U.S. women and girls that have either undergone FGM/C or are at risk. 3

Guidelines from The American Academy of Family Physicians (AAFP) that pertain to FGM/C are consistent with U.S. federal law. They encourage physicians to provide the patient and family with "culturally sensitive counseling and education", as well as referral to social support groups, to discourage them from carrying out the procedure. 7 While the AAFP's policy reflects consideration for the sociocultural context of patients and the cultural aspects of FGM/C — consideration not present in most legislation — these professional guidelines alone do not go far enough to address the complex ethical challenges that an increasing number of physicians face when treating FGM/C survivors and at-risk populations.

The U.S. has a growing immigrant and refugee population, with approximately 39,000 refugees arriving between October 2016 and March 2017 alone. 8 Socioeconomic status, lack of insurance coverage, language and cultural barriers, ability to navigate the health care system, and immigration status can contribute to this population's experience of poor access to quality health care. 9 Although not a risk exclusive to women and girls in immigrant and refugee communities, FGM/C is viewed as a cultural, religious, and/or social tradition in some of the communities from which these populations have emigrated. For communities of newcomers that already have difficulty in accessing health care and in receiving quality care (i.e., reproductive and maternal care 10 ), policies and practices that seek to build trust in the clinic are urgently needed.

Policies on FGM/C in the U.S. are often seen through the lens of human rights, viewing the practice as gender-based violence that is an affront to women and girls, and, hence, as a practice that needs to be eliminated. At the core of these policies, is the intent to reduce harm and to respect the value and dignity of affected women and girls. Indeed, the AAFP guidelines and those from other medical and professional organizations are informed by these legal and ethical principles. In the clinic, however, these criminalizing policies are not easy to implement.

Ethical Considerations Both policymakers and physicians face several ethical questions and challenges when it comes to FGM/C in the clinic. The first is whether FGM/C can ever be considered a legitimate, non-therapeutic, surgical procedure. Here, it is worthwhile to consider the risks and potential complications associated with the practice, namely: short-term (e.g., infection, sepsis, hemorrhage) and long-term (cysts, recurrent infections, labor complications) physical, mental (e.g., PTSD, trauma) 11 , and social risks (exclusion and marginalization). 12 These significant risks make FGM/C distinct from and potentially more harmful than other procedures that are usually considered legitimate, non-therapeutic, surgical procedures, such as body piercings or body ink.

While most in the medical community advocate against performing FGM/C procedures due to their associated complications and the desire to do what is in the best interest of the patient, criminalizing policies may not be the best approach for treating patients who have survived FGM/C, or for preventing the practice. 13 Similar questions about legitimacy and medical risks are being raised in regards to male circumcision — a practice that is currently tolerated both legally and clinically — by some who express concern over respect for autonomy, and a lack of benefits of circumcision. 14 While FGM/C and male circumcision are distinct from one another in many ways, male circumcision may face similar challenges in the future.

Appropriate patient care and effective prevention of FGM/C are contingent upon the ability of policymakers and physicians to navigate these complex ethical and cultural issues. While approaches to addressing FGM/C in communities and in clinics have taken on a variety of forms (such as advocacy groups, community clinics, community organizing and mobilizing, and so on) and guiding principles (diversity, empowerment, trust, etc.), what these efforts have in common is a commitment to meaningful engagement with groups of interest, typically to both assess and meet community needs.

The Need and Rationale for Community/Patient Engagement Health systems and providers are uniquely positioned to engage in important considerations of the practice of FGM/C. Physicians are tasked with identifying and treating the physical and psychological effects of cutting. In some cases, the physician may be among the first to discover that a woman or girl has been cut — whether recently or not — and is then faced with several questions related to legal obligations and to the ethical care of the patient.

If the physician is legally obligated to report the case, would reporting it be in the best interest of the patient? If the patient is a minor, what might happen to the patient if the parents are imprisoned? Will reporting this case prevent future cases of FGM/C, or will it lead to greater distrust of physicians in the community, and, perhaps increased secrecy? How does FGM/C impact a patient's medical care? How do the patient, her family, and her community view FGM/C?

Given the lack of clear legal guidance, insufficient and under-evaluated training for health professionals 15 , and the dearth of best practices on how to care for survivors of FGM/C and those at risk, many providers and health systems are currently ill equipped to address these pertinent questions. As a result, there has been a consistent pattern of women with FGM/C receiving inadequate preventive and reproductive care 11 , as well as underreporting in the health care sector. There is also a lost opportunity to build partnerships and trust with communities that practice cutting.

While, indeed, the practice of FGM/C has harmful consequences — physical, mental, and social — the practice derives meaning from its cultural, religious, and/or social origins. If prevention attempts are to be effective, efforts must be made to understand these sources and how each patient's sociocultural context informs their conceptualizations of the harms, and purported benefits, of FGM/C. Community engagement offers the opportunity to understand sociocultural contexts, as well as values and motives, that may be encouraging the continued practice of FGM/C.

Key Elements of Effective Community Engagement In the U.S. and other countries with growing immigrant and refugee populations, such as the UK and Canada, organizations and clinics are engaging with these communities in a variety of ways to reduce health disparities, improve health outcomes, and address unique health needs. A brief review of these diverse engagement efforts, as well as published resources on community engagement, reveal some key characteristics of effective approaches both in the clinic and within communities. The elements identified in these ongoing programs, and in the literature, fall into three main categories: communication and dialogue, work within the health sector, and sustainable partnerships (see Table 1).

Table 1. Elements of Effective Community Engagement. Based on a brief review of ongoing community engagement efforts to address health disparities in U.S. refugee and immigrant communities (and in some cases, FGM/C directly), as well as published resources on community engagement from the U.S. and other receiving countries (UK, Canada). 16,17,18,19,20,22,23,24,25

Examples of Key Elements in Practice Maricopa County, Arizona: The Refugee Women's Health Clinic

Maricopa County, has a population of 4,242,997 (July 2016 population estimate), of which 14.8% are foreign-born persons. 21 The Refugee Women's Health Clinic (RWHC) was founded in 2008 to provide refugee women in this population with comprehensive, culturally-appropriate care. The clinic sees patients from countries such as Burma, Somalia, Iraq, Burundi, and the Democratic Republic of Congo, some of whom are survivors of, or at risk for, FGM/C. 22 Notably, the stated mission of the clinic is not specifically to eliminate FGM/C in the communities that it serves. Such a statement would jeopardize the relationship it has built with the local refugee communities. Instead, the clinic's stated mission is to address health inequalities and cultural barriers to care.

To achieve its mission, the RWHC has implemented programming focused on empowering and mentoring refugee women. The clinic employs members of the community as patient navigators, "who act as liaisons between the health care system and patients" and offer interpretation services that can facilitate communication and access to appropriate care. 22 Furthermore, the clinic offers educational classes and focus groups on childbirth, newborn care, breast cancer screening and sexual health education. In addition, the RWHC is integrated into a network of local and state agencies that conduct screenings, vaccinations and referrals of new arrivals to the state. Within the network, RWHC specifically supports the improvement of screening and referral for behavioral health.

Program design and clinical practices are informed by ongoing research — specifically, community-based participatory research (CBPR) — carried out by the clinic and its founding director, Crista Johnson-Agbakwu, MD. For example, in partnership with members of the Somali refugee community in Phoenix, Johnson-Agbakwu, et al. (2014), conducted focus groups and interviews to determine Somali male perspectives on FGM/C and childbirth. 23 This study had important insights for culturally-appropriate reproductive health care for Somali women: for example, male participants expressed awareness and concern over the risks of FGM/C, and attributed poor relationships between women with FGM/C and the health care system to the unfamiliarity of physicians with the practice.

Programming that focuses on empowering and mentoring refugee women and their communities, paired with CBPR aimed at understanding community perspectives on FGM/C and creating dialogue between providers and patients, has contributed to improved, culturally-appropriate reproductive health care at RWHC.

Buffalo, New York: Hope Refugee Drop-in Center The Hope Refugee Drop-in Center in Buffalo is another noteworthy example of community-based organizing and multidisciplinary collaboration. The center is part of the Jericho Road Community Health Center, and is grounded in a community-based participatory development model that allows its constituents to identify their own needs and goals — medical, financial, educational, or other — and the center then facilitates reaching that goal or fulfilling that need. 24

Also focused on empowerment and diversity, the center offers services including client-driven case management, transportation, advocacy, education, referrals, and medical services. It also has integrated itself into a community support network that includes ethnic-based community organizations and other service providers (i.e. legal and employment services). 24,25

Rochester, New York: General Medical Group, Catholic Family Center, and the Monroe Department of Public Health Rochester is in Monroe County, and is home to approximately 225,000 residents. Each year, Monroe County receives, on average, 800 refugees from countries such as Bhutan, Nepal, Burma, Afghanistan, Iraq, Cuba, and Somalia. The Rochester General Medical Group (RGMG, now part of Rochester Regional Health), in collaboration with the Monroe County Department of Public Health and the Catholic Family Center, stepped up to meet the primary care needs of this population. Services offered through these organizations include: primary care, TB screening, lead testing, referrals, mental health, employment, education, and housing services. 26,27

Collaboration and identification of each partner's strengths were key to developing a plan that worked to meet the needs of the community. Along the way, flexibility was invaluable, as adjustments had to be made for scheduling, space, and unanticipated challenges. Efforts met with relative success: in a single year, 98% of refugees who arrived in Monroe County were seen within a week of arrival. Additionally, all refugees were vaccinated and put into the care of a primary care physician. 20 This collaboration helps the Catholic Family Center provide a Refugee Resettlement Program that addresses the needs of refugees in a "holistic and culturally appropriate manner, supporting their successful integration, fostering their independence and promoting their earliest possible self-sufficiency." 28

Ethical Implications for FGM/C: A Framework for Policy and Guideline Development All projects mentioned in this articleemphasize empowerment, diversity, collaboration, and reflection. Developing policies and guidelines for medical management of FGM/C within such a social and ethical framework gives greater consideration to sociocultural context and creates room for more open communication between physicians and patients who have either undergone FGM/C or who may be at risk. This public engagement framework not only empowers all the principle stakeholders involved in the FGM/C issue to greater self-reflection and self-determination, but it does so in a manner that also fosters greater community level reflection and cultural interaction that can result in an improved understanding of health and health care for all involved. Hence, in the end, not only are basic human rights protected, but everyone in the community benefits from improved health care systems and delivery.

• Department of Justice, "Three Indicted for Female Genital Mutilation," 26 Apr 2017.
• 18 USC § 116 1996.
• M Mather and C Feldman-Jacobs, "Women and Girls at Risk of Female Genital Mutilation/Cutting in the United States," Population Reference Bureau, 2016.
• Pullella P. "Pope Condemns Female Mutilation, Domestic Violence Against Women." Reuters. 7 Feb 2015. http://www.reuters.com/article/us-pope-mutilation/pope-condemns-female-mutilation-domestic-violence-against-women-idUSKBN0LB0JM20150207
• <href="#rymtm2dxbkf5dhcp.99">http://www.patheos.com/blogs/publiccatholic/2014/05/kenyan-catholic-church-takes-stand-against-female-genital-mutilation/#rYmtm2DXbKf5DHCp.99 </href="#rymtm2dxbkf5dhcp.99">
• See "A Discussion with Sr. Ephigenia Gachiri, IVBM, Stop FGM." Berkley Center for Religion, Peace & World Affairs. Georgetown University. 23 April 2015. https://berkleycenter.georgetown.edu/interviews/a-discussion-with-sr-ephigenia-gachiri-ivbm-stop-fgm .
• Congress of Delegates, "Female Genital Mutilation," American Association of Family Physicians, 2015.
• Office of Admissions Refugee Processing Center, Summary of Refugee Admissions as of 31-March-2017, Bureau of Population, Refugees, and Migration, U.S. Department of State, 21 Mar 2017.
• IH Cheng, A Drillich, P Schattner, Refugee experiences of general practice in countries of resettlement: a literature review, British Journal of General Practice , 2015 Mar, 65(632): e171-6.
• K Kentoffio, SA Berkowitz, SJ Atlas, SA Oo, S Percac-Lima, "Use of Maternal Health Services: Comparing Refugee, Immigrant and U.S.-born Populations," Maternal and Child Health Journal , 2016, 20(12): 2494-2501.
• N Nour, Female Genital Mutilation/Cutting: Health Providers Should Be Advocates for Change, Population Reference Bureau, 2015.
• B Vissandjee, et al., Female genital cutting (FGC) and the ethics of care: community engagement and cultural sensitivity at the interface of migration experiences, BMC International Health and Human Rights, 2014.
• R Mishori, "The Criminalization of FGM in the United States: Responding to Female Genital Cutting: the Michigan Case and Beyond," Berkley Forum, Berkley Center for Religion, Peace & World Affairs, Georgetown University, 8 Aug 2017, https://berkleycenter.georgetown.edu/responses/the-criminalization-of-fgm-in-the-united-states.
• JS Svoboda, "Nontherapeutic Circumcision of Minors as an Ethically Problematic Form of Iatrogenic Injury," AMA Journal of Ethics , Aug. 2017, 19(8): 815-824.
• J Abdulcadir, L Say, C Pallitto, "What do we know about assessing healthcare students and professionals' knowledge, attitude, and practice regarding female genital mutilation? A systematic review," Reproductive Health, 2017 May 22, 14(1): 64.
• Barret H, Brown K, Alhassan Y, and Beecham D. The REPLACE Approach: Supporting Communities to End FGM in the EU., Coventry University. 2015. http://www.replacefgm2.eu/documents/content/toolkit/executive_summary_print.pdf
• Boucher M. "Follow the Leader: Supporting Refugee Efforts to Self-Organize." Center for Refugee Health. Conference. 2014. http://centerforrefugeehealth.com/wp-content/uploads/2015/10/Sat-830AM-Boucher-Follow-the-Leader.pdf
• National Institute for Health and Care Excellence. Community engagement overview. 2017. https://pathways.nice.org.uk/pathways/community-engagement/community-engagement-overview.
• Raising Voices. SASA! Mobilizing Communities to Inspire Social Change. 2013. http://raisingvoices.org/wp-content/uploads/2013/03/downloads/resources/Unpacking_Sasa!.pdf
• Younge M. "Complex Collaborations: Public, Private and Non-Profits Working (happily!) Together." Center for Refugee Health. http://centerforrefugeehealth.com/wp-content/uploads/2015/10/Fri-11AM-Younge-Complex-Collaborations-Public-Private-and-Non-profits-Working-happily-Together.pdf
• U.S. Census Bureau, "QuickFacts: Maricopa County, Arizona," 2015.
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Critical Discussion on Female Genital Cutting/Mutilation and Other Genital Alterations

Perspectives From a Women’s Rights NGO

• Sociocultural Issues and Epidemiology (J Abdulcadir & D Bader, Section Editors)
• Published: 12 November 2020
• Volume 12 , pages 292–301, ( 2020 )

Cite this article

• Stéphanie Florquin 1 &
• Fabienne Richard 1 , 2  

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Purpose of Review

The goal of this paper is to discuss the juxtapositions between FGM/C and other medically unjustified genital alterations performed on adult women (aesthetical genital surgeries) and on children (male circumcision and intersex genital surgeries). The authors join the debate from their position as professionals working in Belgium’s main “anti-FGM organization” as well as researchers.

Recent Findings

Recent research and contributions from scholars have raised critique of policies around FGM/C, particularly in the global North. Some of the concerns include critiques of laws that infantilize adult women, problematic use of genital examination, discourses that stigmatize migrant persons from FGM/C practicing communities, and professionals who are insufficiently trained to support women with FGM/C in a respectful and empowering way. Scholars have also argued that there is a lack of medical distinction between different types of genital cutting such as FGM/C type I and type IV, male circumcision, and aesthetical genital cutting. Authors have stressed the discrepancy in terms of both discourse on genital cutting, and called for equal protection of girl, boy, and intersex children from medically unnecessary genital cutting, without discrimination in regard to ethnicity, religion, or immigration status of their parents.

The paper argues that the discussion on FGM/C and other genital alterations must consider existing socially constructed inequalities, particularly gender and “race”, and how they affect those submitted to genital alterations. The authors highlight practical challenges raised in their daily work in a women’s rights NGO and conclude with recommendations.

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A Review of Female Genital Cutting (FGC) in the Dawoodi Bohra Community:

Zero tolerance for genital mutilation: a review of moral justifications, medicalized female genital mutilation/cutting: contentious practices and persistent debates.

While these practices are not integrated in the description or the specific examples, the WHO (2008 ) states that labia elongation « might be defined as a form of female genital mutilation » because of the social pressure on young girls to undergo it and because it created permanent physical changes. [ 12 , p. 27 ]

For information on care of women living with FGM/C in Belgium, see Caillet, M. et al. “Addressing FGM with Multidisciplinary Care. The Experience of the Belgian Reference Center CeMAViE”, Current Sexual Health Reports , vol. 10, p.44–49

We chose to use the term “survivor” as “this term to emphasize the woman or girl’s resilience and as an empowering element of language, but without prejudice to the fact that the woman or girl may prefer to use the term victim.” [ 1 ]

Even clitoridectomies were historically used in “the West” to treat female “conditions” such as hysteria, nymphomania, lesbianism, and other “deviant” behaviour.

For example, in Senegal, the Fulani use the term kaddungal , while the Wolof use the term xarafal

See for example the French organization « Droit au corps »

https://www.secularism.org.uk/news/2015/10/council-of-europe-retreat-on-circumcision-of-young-boys

“Cisgender” refers to a person whose gender identity fits the gender they were assigned at birth. A baby born with male sex attributes and therefore assigned male, who perceives himself to be a boy/man, is cisgendered. The opposite of cisgender is trans-gender.

While national studies on SGBV are lacking in Belgium, in the neighbour country France, the extensive VIRAGE study found that 14.5% of women and 3.9% of men reported experience of at least one form of sexual assault (excluding harassment and exhibitionism) in their lifetime. The authors stress that « [s]exual violence against women is not only much more frequent, but occurs in all life spaces throughout life. ». The study further shows that « [w]hatever the life space, sexual violence reported by women is practically always committed by one or more men (between 94% and 98%) » while the majority of cases of violence reported by men is also committed by other men. [ 8 ]

Intersex people are born with sex characteristics that do not fit typical binary notions of male or female bodies. See OII Intersex Network http://oiiinternational.com/

The exception is Malta who banned unnecessary genital surgeries on minors in 2015.

Contrary to common beliefs about the rarity of intersex persons, people who are intersex in Belgium probably represent several 100,000 if you go with the available data, a much larger group than women having undergone FGM/C.

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Florquin, S., Richard, F. Critical Discussion on Female Genital Cutting/Mutilation and Other Genital Alterations. Curr Sex Health Rep 12 , 292–301 (2020). https://doi.org/10.1007/s11930-020-00277-1

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DOI : https://doi.org/10.1007/s11930-020-00277-1

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• Female genital cutting
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