You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our Group site.

Should Doctors Perform “Minor” Forms of Female Genital Mutilation (FGM) as a Compromise to Respect Culture?

25 Feb, 16 | by bearp

by Brian D. Earp / (@briandavidearp), with a separate guest post by Robert Darby

A small surgical “nick” to a girl’s clitoris or other purportedly minimalist procedures on the vulvae of young women and girls should be legally permitted, argue two gynecologists this week in the Journal of Medical Ethics. Their proposal is offered as a “compromise” solution to the vexed issue of so-called female genital cutting or mutilation (FGM).

According to the authors, Kavita Shah Arora and Allan J. Jacobs, legally restricting even “minor” forms of non-therapeutic, non-consensual female genital cutting is “culturally insensitive and supremacist and discriminatory towards women.” Discriminatory, apparently, because non-therapeutic, non-consensual male genital cutting (a.k.a. male circumcision) is widely tolerated in Western societies; why shouldn’t women and girls be allowed to participate in — or be subjected to — analogous cultural rites that are important to members of their own groups?

I take issue with the authors’ proposal. In a commentary published in response to their piece (currently available “online first” along with two other commentaries: see here and here), I argue that to allow supposedly minimalist female genital cutting procedures before an age of consent in Western societies would result in numerous ethical, legal, political, regulatory, medical, and sexual problems, creating a fiasco. So problematic, in my view, is the proposal by Arora and Jacobs, that I have prepared a separate online supplementary appendix to expand upon my published commentary, in which I address each of their specific claims and arguments one by one: see here.

Rather than continuing to tolerate childhood male circumcision, and using this as a benchmark for allowing supposedly “minor” forms of FGM, I argue that we should instead be moving in the opposite direction. In other words, I suggest that the time has come to consider a less tolerant stance toward both procedures. As I write in my piece:

“Ultimately, I suggest that children of whatever sex or gender should be free from having healthy parts of their most intimate sexual organs either damaged or removed, before they can understand what is at stake in such an intervention and agree to it themselves.”

In the initial flurry of media coverage of the controversial new proposal by Arora and Jacobs, some commentators have attempted to drive a wedge between male and female forms of non-therapeutic genital alteration by referring to supposedly distinct symbolic meanings (FGM is “all about” controlling the sexuality of women, according to this view, whereas male circumcision is claimed not to be rooted in norms of sexual control), as well as health implications (FGM “has no health benefits,” it is claimed, whereas male circumcision does or at least may).

However, both of these claims are misleading at best, and at worst, downright false, as I (among other scholars who specialize in this area) have argued at length in other contexts: see also here, here, and here. For a short, reader-friendly introduction to the empirical and conceptual problems with these oft-repeated tropes, please see my essay in Aeon magazine, “Boys and Girls Alike.”

This is not the place to re-state my arguments. Instead, interested readers can explore the links above and reach their own conclusions. What I would like to do now is turn to an interesting new commentary on the proposal by Arora and Jacobs by Dr. Robert Darby, a medical historian and expert in male and female genital cutting rituals as they take place across a range of social contexts. His commentary is published below as a guest post on this blog. Please note that its contents should be taken to reflect the views of Dr. Darby, and not necessarily those of the Journal of Medical Ethics, its editors, or anyone else. 

Male and Female Genital Cutting: A Sex-Neutral Approach?

By Robert Darby, Ph.D.

Two contrasting views on female genital cutting (FGC) have been aired in recent weeks. Writing in the Journal of Medical Ethics, two American obstetricians, Kavita Arora and Allan Jacobs, argue that Western societies should tolerate – and doctors should perform – purportedly mild forms of non-therapeutic genital cutting on female infants and girls if the parents so request. In contrast, Ms. Meiwita Budiharsana, a lecturer in public health in Indonesia – where such forms of FGC are very common and increasingly medicalized – argues that the authorities should discourage such practices and that medical personnel should not perform them.

The situation seems rich in paradox. Two doctors from a society that has traditionally abhorred (and in fact criminalised) any form of FGC, believe that certain mild forms should be permitted. At the same time, a health expert from a society where certain mild forms of FGC are the norm believes that this is wrong and that such practices should be opposed.

What is going on here?

In this commentary I would like to focus primarily on the short opinion piece from Ms. Budiharsana. This is partly because Arora and Jacobs’s paper has already received both thoughtful peer commentary as well as heated discussion in the media (and is likely to receive much more); and partly because I think that the paper by Ms. Budiharsana in itself provides an interesting commentary on Arora and Jacobs’s controversial proposal.

Certain forms of FGC were brought to Indonesia by the spread of Islam within the archipelago between the 13th and 16th centuries, and are now widespread as a result of Islamic dominance and the displacement of the original Hindu, Buddhist, and animistic cultures (still partly surviving in Bali). Writing in The Conversation, Ms. Budiharsana reveals that while the practice, known as female khitan or sunat perempuan, had originally been performed by traditional community circumcisers, such operations are now increasingly done by medical practitioners, “thus institutionalizing the ritual into medical practice.”

Even more worryingly, “many maternity clinics now offer the procedure as part of a birth delivery package, done [to the newborn girl] without additional charge.”

This trend is of particular concern because it was a similar institutionalization of male circumcision as a routine phase of childbirth, performed on newborn boys by the mother’s obstetrician, that led to the near universality of circumcision in the United States in the 1930s-40s, and the persistence of the practice into contemporary times. In other words, there is evidence that medicalizing non-therapeutic genital cutting does not necessarily succeed as a harm reduction measure, so much as it serves as a mechanism for normalizing, and thus perpetuating, the cutting.

Nevertheless, those who argue in favor of medicalizing such rituals contend that the operation is safer and less risky if performed by trained medical personnel. But as Ms. Budiharsana points out, even this more limited contention is not necessarily accurate: “medicalization may actually be even more dangerous. Midwives tend to use scissors instead of penknives. Hence, they actually conduct real cutting of the skin. Traditional circumcisers, meanwhile, use penknives for more symbolic acts of scraping or rubbing.”

What is certain is that medicalization entrenches the practice: it gives medical personnel a vested emotional, professional, and financial interest in perpetuating it, and thus makes it more difficult to eradicate, or even regulate effectively – as the very slow decline of infant circumcision in the United States could be taken to suggest. If a boy or girl grows up not knowing that their genitals have been surgically altered (or thinks that everyone’s have), and observes that their peers are similar, they are likely to regard their condition as normal and to be unresponsive to calls for reform.

The trend towards medicalization of FGC in Indonesia is similar to what was proposed in the United States with the so-called “Seattle Compromise,” by bioethicist Dena Davis, and in a policy recommending “mild” forms of FGC adopted briefly by the American Academy of Pediatrics (AAP) in 2010. It is therefore open to the same objections. The most important of these, as I have argued elsewhere in a critique of Davis’s position, is not that the proposed vulvar scratch (or similar intervention) poses an unacceptable risk of pain and physical harm to the girl, but rather that it confounds the spheres of medicine and religion, and confuses the functions of doctors and priests.

The proper function of doctors and other health personnel is to attend to the health of their patients; the function of priests and other religious officials is, among other things, to perform the rituals prescribed by their religion. To confound these functions is to take a backward step that threatens the physical integrity of children and does nothing for their spiritual welfare.

To take one well-established example of commonly accepted medical principles, the mission of the AAP is: “to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults.” There is nothing here about performing religious or cultural functions, such as initiation rites, and it is no more necessary or appropriate for pediatricians or other medical personnel to perform ritual genital cutting than for baptism to be performed by hydrologists, tooth evulsion by dentists, or skin scarification by dermatologists. Doctors will, of course, show respect for the religious and other cultural beliefs of the parents of children brought to their care, but this does not mean that they are obliged to perform any and every procedure prescribed by those beliefs, and certainly not those of a quasi-surgical nature that intrude on the bodies or minds of children.

As the Royal Dutch Medical Association has argued, the only valid argument in favour of physicians taking charge of these sorts of procedures is that they may otherwise be performed by unskilled “kitchen table” operators, with a consequent high toll of injury and death. This is indeed a dilemma that must be faced, but insofar as the underlying reasoning holds, it is an argument in favor of not making genital cutting illegal (thus creating a dangerous black market); it is not an argument for condoning or encouraging such practices, nor for subsidizing them through health insurance systems. One approach might be to establish a suitably trained cadre of paramedicals, similar to mohels (Jewish ritual circumcisers), whose surgical competence would be certified by the appropriate regulatory authorities, and whose cultural acceptability would be approved by the relevant sub-culture. This would free medical personnel from the invidious requirement to deal with parental requests to cut their babies’ genitals, and make a clear distinction between medical treatment and cultural rites.

It will be appreciated that the mode of FGC typically performed on girls in Indonesia is less extensive and less injurious than the modes common in many regions of Africa, and usually involves no more than a nick or scratch on parts of the girls’ vulva or clitoris. (Ms. Budiharsana does not go into specifics here.) According to a survey she cites, 24% of the procedures involved no more than rubbing or scraping; 49% an incision without loss of tissue; and 22% some tissue excised. Despite the relative mildness of the operation in most cases, and the absence of “evidence of immediate or long-term physical or psychological complications” (not that absence of evidence equals evidence of absence; these subjective areas are notoriously difficult to study scientifically), the operation still involved pain to the child, and was “unacceptable” because it offered no medical advantage and was a violation of the child’s human rights. In the words of Ms. Budiharsana: “any form of female genital mutilation is unacceptable. That it is done without the consent of the baby or little girl and without clear health benefits or religious mandate is enough to classify this act as a violation of human and health rights of the girl child.”

Unlike Arora and Jacobs, who have previously published spirited defenses of male (ritual) circumcision — inviting several critiques — and who devote a good deal of their new paper to discussing its parallels with and differences from FGC, Ms. Budiharsana does not mention male genital cutting. Yet as a number of commentators on her report pointed out, (1) circumcision of boys is also widespread in Indonesia for the same reason as is FGC of girls (Islamic tradition), and (2) her objections to FGC are equally relevant to male circumcision. The apparent blindspot exhibited here is all the more striking, given that the mode of FGC that she criticizes is significantly less injurious than the mode of circumcision performed on boys in the same culture and elsewhere: while girls typically receive a superficial nick or scratch (and at worst lose a minimal amount of tissue), boys typically experience the excision of their entire foreskin – a large, retractable sleeve of functional, erogenous tissue – and find themselves with a penis that looks (and feels) sharply different to what they possessed originally. Since the cutting is more extensive, it is also more subject to infections and other complications; as a victim of Islamic extremism and forced genital cutting during the 2001 “holy war” in Aceh stated: “I know the men suffered more than us women. The circumcision hurt them more that it did to us because their scars could not heal fast. Several of the men I knew got serious infections after suffering from severe bleeding” (Sydney Morning Herald, 27 January, 2001).

In many accounts, it is the greater harm of FGC compared with MGC that makes the former abhorrent and the latter acceptable. Arora and Jacobs rely heavily on the proposition that if the circumcision of boys is both (a) harmless and (b) not a violation of their human rights, then a less damaging procedure on girls must be acceptable. But as Brian D. Earp has argued, this argument is dubious for a number of reasons, and in any event, it cuts both ways. Indeed, as a senior British judge has recently stated, since even mild forms of FGC do amount to significant harm in the eyes of the law, then the same must be true of male circumcision.

In the Indonesian case, however, the greater harm of MGC compared with the local form of FGC does not lead Ms. Budiharsana to criticise or even mention MGC. But if cutting a girl’s healthy genitals without her informed consent is a violation of her human rights, then cutting a boy’s penis without his informed consent must also be a violation of human rights. To understand this silence we must look again at the key paragraph:

“Any form of female genital mutilation is unacceptable … [because] it is done without the consent of the baby or little girl and without clear health benefits or religious mandate is enough to classify this act as a violation of human and health rights of the girl child” (emphasis added).

The telling phrases that exclude boys from consideration are “clear health benefits” and “religious mandate.” Obviously, scratching a girl’s vulva can be of no medical utility,  and merely risks infection: the reason “health benefits” are mentioned here at all is to provide an implicit contrast with male circumcision, which is still regarded by many people (including Arora and Jacobs and some health authorities) as a legitimate means of reducing a male’s risk of certain diseases – notwithstanding that these diseases are typically rare in Western countries and can be prevented in much less injurious ways than by pre-emptive surgery (the literature in this area is hotly contested). Likewise “religious mandate” … if there were a religious requirement or sanction for performing it, FGC of girls might be seen as acceptable and might even require protection under the rubric of religious freedom. The assumption is that there is no religious mandate for FGC, but that there is such a mandate for circumcision of boys. However, the supposed logical distinction between “religion” and “mere culture” as a grounds for justifying the genital cutting of male but not female children is rather tenuous indeed.

These points bring us to Ms. Budiharsana’s policy recommendations:

“Indonesia should stop the medicalization of FGM. The government should carry out a campaign that informs the public that female circumcision is not obligatory under Islamic law. The government should also update the pre-service midwifery training curricula.”

There is nothing wrong with these proposals, as far as they go. On the contrary, they represent practical steps to control a practice with widespread community support and which would not be stopped by heavy-handed attempts to outright prohibit or criminalize. As Matthew Johnson has argued recently on this blog, jailing or otherwise harshly punishing parents for circumcising their daughters does little for the child and is likely to inflict further harm on her. If laws with stiff penalties have not prevented FGM even in developed Western countries, they are hardly likely to arrest it in its countries of origin.

So let us be clear: a moderate approach such as the one proposed by Ms. Budiharsana seems a perfectly sensible way of tackling a practice deeply entrenched in local custom and tradition. Its weakness lies in its inconsistency: as campaigners in other regions have found, it is very difficult to eradicate FGC while remaining silent about MGC. For example, as Sami Aldeeb has argued: “Female circumcision will never stop as long as male circumcision is going on … [for how] do you expect to convince an African father to leave his daughter uncircumcised as long as you let him do it to his son?”

It is even more difficult when bodies such as the WHO and the United Nations condemn FGM while simultaneously promoting male circumcision. The justification for this double standard is the supposed greater harm of FGC and the supposed medical value of male circumcision, especially as a means of reducing the risk of HIV. But no health authority recommends circumcision of male infants or boys for this reason (whereas adult males can choose circumcision if they please). While the “benefits of circumcision” are the subject of considerable debate, with no consensus in sight, the balance of world opinion is tilting towards the view that there is insufficient net benefit to the child to justify the operation, and that he should be left to make the decision for himself when competent. As for the religious/cultural argument, Islamic law and tradition treat both male and female circumcision in much the same way: each is meritorious as a sign of commitment and piety, but neither is required. There is no obligation placed on parents to circumcise their children.

When J. Steven Svoboda and I first began to publish on this topic, we concluded our papers** with a plea for greater gender neutrality in discussions of this controversial subject. As we saw it, the issues raised by non-therapeutic genital surgery did not hinge on the sex or gender of the child, but rather on the child’s age, and on whether informed consent had been given. A decade ago, comparisons between male and female genital cutting were all but unthinkable, and often regarded as offensive if they were nevertheless raised. Today, as the lively media response to the papers in the Journal of Medical Ethics shows, it has become headline news.

Such a rapid change of attitude suggests that one day, compassionate health workers such as Ms. Budiharsana might see fit to recommend that their government launch a campaign to inform the public that neither FGC nor male circumcision is obligatory under Islamic law, nor are they necessary as a social statement before the child is old enough to make an informed choice. It might be urged, as well, that the government should update midwifery training curricula and other health advice sources to inform health workers and parents that circumcision, whether of girls or of boys, is not recommended as a health precaution.

** A Rose By Any Other Name: Rethinking the Differences/Similarities Between Male and Female Genital Cutting. Medical Anthropology Quarterly, 21, September 2007. Text available here. See also: A Rose By Any Other Name: Symmetry and Asymmetry in Male and Female Genital Cutting. In Chantal Zabus (ed.), Fearful Symmetries: Essays and Testimonies around Excision and Circumcision (Amsterdam and New York: Rodopi, 2008). Text available here.

Biography

Robert Darby is an independent scholar and author of A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain (University of Chicago Press), as well as numerous articles on the history and ethics of male and female circumcision. He lives in Canberra. @RobDarbyCanberr

By submitting your comment you agree to adhere to these terms and conditions
  • Cluck Owens

    This question should not even need to be asked. NO form of “genital mutilation”, whether it is “nicking” or complete removal of the clitoris and labia, should be allowed to be performed against females. “Cultural sensitivity” is absurd. A civilized culture that does not wish to perform a stupid “religious” or “cultural” ritual intended to deprive females of sexual enjoyment or is damaging to a healthy sexual organ deserves to be culturally IMPERIALISTIC, meaning that we can say to those backward, ignorant, retrograde social constructs calling themselves “cultures” that “NO WE ARE NOT GOING TO HARM FEMALES, ESPECIALLY WHEN THEY ARE HELPLESS INFANTS.”

    It’s already bad enough that we have justified MALE genital mutilation in the form of circumcision. We teach children to brush their teeth and to wipe their behinds after defecating, so teaching a male to clean under the foreskin, which is highly enervated, ought to have been the default position, instead of capitulating to a “cultural” demand that originates from Bronze Age Hebrew religious covenants.

    Regrettably, that ship has sailed for the majority of boys in the United States, but hopefully today’s parents can become more informed and allow their sons to remain intact, despite specious claims of “aesthetics” (we don’t automatically pin back an infant’s ears if they stick out too much) or “hygiene” (the foreskin is easy to keep clean). Of course, if there is a medical reason to circumcise, then by all means, but not for the most superficial reasons, and let’s not start that process on females because “social justice warriors” and “political correctness” have run amok in recent memory.

    Is that in any way unclear? NO TO FGM AND MGM.

    • Just a citizen

      Whilst I disagree in principle with both female and male circumcision, mutilation, cutting whatever it is described as, we must be honest enough to admit the huge difference between FGM and MGM is that a male can still without a piece of foreskin enjoy sexual pleasure whereas a girl having undergone FGM CAN’T which is the whole point of it of course in a truly patriarchal and extreme misogyny society? (FGM was not a Hebrew ritual ever. Proof is always in the pudding?)

      Whilst there might be the odd male around who finds pleasure difficult after MGM, it was and is not widespread otherwise no way any male would ever agree to this being performed on themselves or their sons. (or it would have been outright banned centuries ago!)

  • Cluck Owens

    Genital Mutilation is unacceptable in any way, even if it is “nicking”, especially if it is perpetrated on infants on minor children. It is inherently inhumane, and its pervasiveness in a given culture is irrelevant. It is astonishing that an obvious ethical abomination is even under consideration to determine whether a “softening” in attitude is even merited toward such an obvious ethical abomination.

You can follow any responses to this entry through the RSS 2.0 feed.

Latest from JME

Latest from JME

Blogs linking here

Blogs linking here