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Seven Things to Know about Female Genital Surgeries in

by the Public Policy Advisory Network on Female Genital Surgeries in Africa

Western media coverage of female genital modifications in Africa has been hyperbolic and one- sided, presenting them uniformly as mutilation and ignoring the cultural complexities that underlie these practices. Even if we ultimately decide that female genital modifications should be abandoned, the debate around them should be grounded in a better account of the facts.

tarting in the early 1980s, media coverage of research scholars, physicians, and policy experts—is customary African genital surgeries for females not to take a collective stance on the practice of geni- Shas been problematic and overly reliant on tal surgeries for either females or males. Our main sources from within a global activist and advocacy aim is to express our concern about the media cover- movement opposed to the practice, variously de- age of female genital surgeries in Africa, to call for scribed as female genital mutilation, female genital greater accuracy in cultural representations of little- cutting, or female circumcision. Here, we use the known others, and to strive for evenhandedness and more neutral expression female genital surgery. In high standards of reason and evidence in any future their passion to end the practice, antimutilation public policy debates. In effect, the statement is an advocacy organizations often make claims about fe- invitation to actually have that debate, with all sides male genital surgeries in Africa that are inaccurate of the story fairly represented. or overgeneralized or that don’t apply to most cases. Some of the signatories of this policy statement The aim of this article—which we offer as a public support efforts to promote voluntary abandonment policy advisory statement from a group of concerned of all practices of genital surgery on children. Other signatories wish to allow parents to continue to cir- The Public Policy Advisory Network on Female Genital Surgeries in cumcise males, but not females. Still other signa- Africa, “Seven Things to Know about Female Genital Surgeries in Africa,” Hastings Center Report, no. 6 (2012): 19-27. DOI: 10.1002/ tories seek to preserve the right of parents to carry hast.81 forward their religious and cultural traditions and

November-December 2012 HASTINGS CENTER REPORT 19 conceptions of a normal body and we believe that any genuine public they would like it to be. The appropriate gender development and policy debate should be grounded in dream is that the U.S. could bring to continue to surgically modify the the best available evidence and begins about the end of a system of tor- genitals of both girls and boys un- with fact checking. ture that has crippled 100 million der conditions that are not harmful. The dominant tone and substance people now living upon this Others believe that children’s rights of mainstream media representations and every year takes at least two include their rights not to have surgi- of female genital surgeries in Africa is million more into an existence of cal changes made to their bodies be- illustrated by a 1995 opinion piece suffering, deprivation and disease. fore they are old enough to decide for by A.M. Rosenthal, the former editor . . . The torture is female genital themselves. But whatever our ethical and columnist at the New York Times: mutilation. This is what it usu- ideals, whatever policies we might ally includes: the partial or total personally promote, whatever pro- Here is a dream for Americans, excision of the clitoris and all or grams we have tried to implement, worthy of their country and what parts of the labia minora and labia

The Public Policy Advisory Network on Female Genital Surgeries in Africa

The Public Policy Advisory Network Birgitta Essen Carlos Londoño Sulkin on Female Genital Surgeries in Africa is an Associate Professor, Senior Lecturer Professor and Head informal group that includes medical re- in International Maternal Health Department of Anthropology searchers, anthropologists, physicians, le- Consultant in Obstetrics and Gynecology University of Regina gal scholars, geographical area specialists, Department of Women’s and Regina, Saskatchewan, Canada and feminists who have expert knowledge Children’s Health [email protected] about female genital surgeries in Africa and Uppsala University Michelle McKinley are concerned about the accuracy, objec- Uppsala, Sweden Dean’s Distinguished Faculty Fellow tivity, fairness, and balance of current me- [email protected] University of Oregon School of Law dia representations of the practice. “Seven Ellen Gruenbaum Eugene, Oregon Things to Know about Female Genital Sur- Professor and Head [email protected] geries in Africa” is published as a collective Department of Anthropology Wairimu Njambi statement with the support and endorse- Purdue University ment of the network. Portions of the text Associate Professor of West Lafayette, Indiana Women’s Studies and Sociology were initially drafted by Lucrezia Catania, [email protected] Ellen Gruenbaum, and Richard A. Shweder Wilkes Honors College with significant revisions from Fuambai Sia Sara Johnsdotter Florida Atlantic University Ahmadu and Bettina Shell-Duncan, and then Professor, Faculty of Health and Society Jupiter, Florida finalized in the light of editorial suggestions Malmo University [email protected] from the entire network. For more infor- Malmo, Sweden Juliet Rogers mation about the network, contact Fuambai [email protected] Australian Research Council DECRA Fellow Ahmadu. Michelle C. Johnson School of Social and Political Sciences Jasmine Abdulcadir Associate Professor of Anthropology University of Melbourne Resident in Gynecology and Obstetrics Department of Sociology and Anthropology Melbourne, Department of Obstetrics and Gynecology Bucknell University [email protected] University Hospitals of Geneva Lewisburg, Pennsylvania Bettina Shell-Duncan Geneva, Switzerland [email protected] Professor of Anthropology [email protected] Crista Johnson-Agbakwu University of Washington Fuambai Sia Ahmadu Research Assistant Professor Seattle, Washington Advisor (Public Health) Obstetrics and Gynecology [email protected] and Senior Research Fellow University of Arizona College of Medicine Richard A. Shweder Office of the Vice President Founder and Director Professor of Comparative Freetown, Refugee Women’s Health Clinic Human Development The Republic of Sierra Leone Maricopa Integrated Health System University of Chicago [email protected] Phoenix, Arizona 5730 S. Woodlawn Ave [email protected] Lucrezia Catania Chicago, Illinois 60637 Gynecologist, Sexologist Corinne Kratz [email protected] Reference Centre for Preventing and Professor of Anthropology Curing Complications of FGM/C AOUC and African Studies Careggi University Hospital Emory University Florence, Atlanta, Georgia [email protected] [email protected]

20 HASTINGS CENTER REPORT November-December 2012 majora, plus the sewing or pinning early age. Over the past three decades South Korea, and many countries in together of both sides of the vulva, or so, the standard mainstream media Africa) during their preadolescent or by catgut or thorns, and the oblit- narrative has recapitulated and popu- adolescent years.6 Customary female eration of the vaginal entrance ex- larized many of those claims, often genital surgery is far less familiar in cept for a tiny passage. The male without independent fact checking the United States, and also less preva- equivalent would be the removal or a critical and balanced assessment lent globally, although it is practiced of the penis. . . . The purpose is to of the evidence. in many East and West African coun- insure virginity and destroy sexual For example, looking ahead to a tries, among particular ethnic groups pleasure. It is a form of male con- point we will make later, Rosenthal’s in other regions of Africa, and in some trol, perhaps the ultimate except description of what a typical female parts of Southeast (for example, for murder.1 genital surgery in Africa “usually in- Malaysia) and the .7 Na- cludes” (namely, “the sewing or pin- tionally representative survey data on Mainstream news reports on the ning together of both sides of the female genital surgery are available topic have mostly followed suit, re- vulva, by catgut or thorns, and the for twenty-eight African countries. porting as established In some countries, facts claims about the the prevalence among disastrous health con- Ironically, the effect of some women aged fifteen sequences of female antimutilation campaigns in Africa is to to forty-nine is very genital surgeries (in- high (over 80 percent). cluding the attenua- bring women’s bodies and lives under These include esti- tion of female sexual the hegemonic control and mates from capacity). Feature arti- (93 percent), cles have deplored the management of local male religious or (91 percent), custom, quoting (for political leaders. We see it as (89 percent), example) African an- (96 percent), (85 timutilation activists preferable that any changes that may percent), Sierra Leone who declare that fe- be made are led by the women of these (91 percent), Soma- male genital surgery is lia (98 percent), and “the most widespread societies themselves. northern (89 and deadly of all vio- percent). lence victimizing women and girls obliteration of the vaginal entrance As with customary forms of male in Africa”2 and painting the now- except for a tiny passage”) is not genital surgery, the female age for familiar portrait of African female factually correct, since infibulations genital modification varies consid- genital surgeries as savage, horrifying, amount to approximately 10 percent erably, ranging from infancy to late harmful, misogynist, abusive, and so- of cases across the , accord- adolescence. The meanings and mo- cially unjust—“A Rite of Torture for ing to a 2007 estimate generated by tives associated with the practice vary Girls.”3 P. Stanley Yoder and Shane Khan.5 as well and are not necessarily shared It is noteworthy that Rosenthal That 10 percent includes surgeries by every ethnic group. Nevertheless, credited three antimutilation ad- using medical suture techniques and concerns about carrying forward vocacy groups, including the orga- conducted under hygienic conditions one’s traditions and being included nization that publishes The Hosken in clinics or hospitals. Nevertheless, in them are commonplace. Many Report, a document that popularized the image inscribed by Rosenthal has women who have had genital surger- the expression “female genital muti- become the prototype of an African ies view the procedure as a cosmetic lation” and was widely distributed to female genital surgery in the minds of beautification, moral enhancement, opinion-makers and journalists in the many people. or dignifying improvement of the ap- 1980s and 1990s.4 The advocacy lit- pearance of the human body. This is erature characteristically features lists A Primer on Female Genital true of both male and female genital of short- and long-term medical com- Surgery modifications in African cultures. plications all said to be caused by fe- Within the aesthetic terms of these male genital surgery, including blood ustomary male genital surgery, body ideals, cosmetically unmodi- loss, septic shock, acute infection, re- Csuch as neonatal male circum- fied genitals in both men and women duction of the sex drive, elimination cision, is a familiar practice in the are perceived and experienced as dis- of the capacity for orgasm, menstrual United States, and approximately 30 tasteful, unclean, excessively fleshy, problems, incontinence, sterility, percent of all males in the world have malodorous, and somewhat ugly to child-bearing difficulties (including had their genitals surgically modi- behold and touch. The enhancement maternal mortality), and death at an fied in some way, often (as in Turkey, of gender identity is also frequently a

November-December 2012 HASTINGS CENTER REPORT 21 significant feature of genital surgery, be paid to the perspectives of African responsiveness or orgasm. It is note- from the point of view of insiders women who value the practice and worthy that cosmetic surgeons who who support the practice. In the case describe it accordingly (for example, perform reductions of the clitoris and of male genital surgeries, the aim is as genital beautification or genital the clitoral hood in the United States, to enhance male gender identity by cleansing). In what follows, we hope , and Canada recount that removing bodily signs of femininity to supply the public with accurate in- there is usually no long-term reduc- (the foreskin is perceived as a fleshy, formation about the practice of geni- tion in sexual sensation, which is con- vagina-like female element on the tal surgery in Africa and move the sistent with the findings of research male body). In the case of female coverage of the topic from an over- on African women. genital surgeries, the aim is often to heated, ideologically charged, and Both of these findings fit with the enhance female gender identity by one-sided story about “mutilation,” broader emerging scientific under- removing bodily signs of masculin- morbidity, and patriarchal oppres- standing of sexuality as a complex ity (the visible part of the clitoris is sion to a real, evidence-based policy interaction of mental processes, re- perceived as a protruding, penis-like debate governed by the standards of lational dynamics, and neurophysio- masculine element on the female critical reason and fact checking. To logical and biochemical mechanisms. body). that end, we have all agreed to be It should also be emphasized that The style and degree of surgery signatories of this advisory statement cases of sexual dysfunction and pain also vary. A type I female genital despite differences in our views of the during sex have been reported both surgery, as classified by the World appropriate public policy response to by women who have undergone fe- Health Organization, is restricted to the practice. The first part lists seven male genital surgery and by those procedures involving reduction of ei- facts about female genital surgeries in who have not. Further research is ther the clitoral hood (the prepuce) Africa that we believe to be true based required to understand the physical or the external or protruding ele- on the best research available on the and psychological impact, if any, of ments of clitoral tissue, or both. Type topic. various types of genital surgeries, the II involves partial or complete labial Many of the facts enumerated influence of sociocultural context, reductions and partial or complete below may seem astonishing. Sev- and the extent to which sexual sen- reductions of the external or protrud- eral counter the familiar and widely sation and function may be affected, ing elements of clitoral tissue. Ap- circulated horror-inducing represen- particularly in cases of type III. proximately 90 percent of all female tations promoted by antimutilation 2. The widely publicized and genital surgeries in Africa are either advocacy organizations and uncriti- sensationalized reproductive health type I or type II.8 The remaining 10 cally recapitulated by the media in and medical complications associ- percent of cases, classified as type III, the United States, Canada, Europe, ated with female genital surgeries in are those in which the operation is and elsewhere. The second part of the Africa are infrequent events and rep- concluded by shielding and narrow- statement traces a few policy impli- resent the exception rather than the ing the vaginal opening with stitches cations and invites a more balanced rule.10 Reviews of the medical and or other techniques of sealing, which public policy conversation. demographic literature and direct forms a smooth surface of joined tis- comparisons of matched samples of sue that is opened at the time of first Seven Things to Know about “uncut” and “cut” (primarily type II) sexual intercourse. This “infibula- Female Genital Surgeries in African women suggest that, from a tion” or “sealing” procedure occurs Africa public health point of view, the vast largely in the Northeast of Africa and majority of genital surgeries in Af- among certain Fula and other ethnic 1. Research by gynecologists and rica are safe, even with current proce- groups across the belt. In all others has demonstrated that a high dures and under current conditions. other regional and ethnic settings, percentage of women who have had According to some medical experts, type I and type II surgeries are most genital surgery have rich sexual lives, with a proper input of medical re- common, and they are the main focus including desire, arousal, orgasm, sources, the potential for harm can be of this public policy statement. and satisfaction, and their frequen- reasonably managed. The exceptions, Focusing, then, primarily (al- cy of sexual activity is not reduced.9 where and when they occur, are usu- though not exclusively) on the 90 This is true of the 10 percent (type ally the result of inadequate surgical percent, it is our hope that some basic III) as well as the 90 percent (types conditions, hygiene, or malpractice, fact checking and a more thorough- I and II). One probable explanation as well as relative deficiencies in the going representation of the voices for this fact is that most female erec- general health care system in Africa. of research scholars will change the tile tissue and its structure is located Significantly, reviews of the medical character of the media discussion of beneath the surface of a woman’s literature indicate that most of the female genital surgeries. We also be- vulva. Surgical reductions of external widely publicized claims about high lieve that far greater attention should tissues per se do not prevent sexual morbidity or mortality and negative

22 HASTINGS CENTER REPORT November-December 2012 reproductive health consequences of 4. Customary genital surgeries are are more permissive and encouraging female genital surgeries do not stand not restricted to females. In almost all of sexual adventures and experimen- up to critical scientific analysis. In societies where there are customary tation—but these differences do not countries in Africa where morbidi- female genital surgeries, there are also correlate strongly with the presence ties (infertility, stillbirths, menstrual customary male genital surgeries, at or absence of female genital surgeries. problems, damage to the perineum) similar ages and for parallel reasons. In some societies where genital sur- are relatively high compared to North In other words, there are few societ- geries are customary for females and American or European standards, ies in the world, if any, in which fe- males (for example, in Northeast Af- those morbidity levels are just as high male but not male genital surgeries rica), chastity and virginity are highly for “uncut” women.11 In Western are customary. As a broad generaliza- valued, and type III surgeries involv- countries, some medical experts who tion, it seems fair to say that societ- ing infibulation may be expressive of treat affected African women suggest ies for whom genital surgeries are these values, but those chastity and that instances of morbidity may be normal and routine are not singling virginity concerns are neither distinc- related more to miscommunication, out females as targets of punishment, tive nor characteristic of all societies fear, distrust, delays for whom genital sur- in seeking care, and geries are customary. avoiding medical and Female genital surgeries worldwide Indeed, female geni- surgical interventions tal surgeries are not should be addressed in a larger than to surgical genital customary in the vast modification per se.12 context of discussions of health majority of the world’s 3. Female genital most sexually restric- promotion, parental and children’s surgeries in Africa tive societies. are viewed by many rights, religious and cultural freedom, 6. Female genital insiders as aesthetic surgery in Africa is typ- gender parity, debates on permissible enhancements of the ically controlled and body and are not cosmetic alterations of the body, and managed by women. judged to be “muti- Similarly, male genital female empowerment issues. lations.”13 From the surgery is usually con- perspective of those trolled and managed who value these surgeries, they are as- sexual deprivation, or humiliation. by men. Although both men and sociated with a positive aesthetic ideal The frequency with which over- women play roles in perpetuating and aimed at making the genitals more heated, rhetorically loaded, and in- supporting the genital modification attractive—“smooth and clean.” The appropriate analogies are invoked in customs of their cultures, female gen- surgeries also serve to enhance gen- the antimutilation literature (“female ital surgery should not be blamed on der identity from the point of view castration,” “sexual blinding of wom- men or on patriarchy. Demographic of many insiders. These aesthetic and en,” and so on) is both a measure of and health survey data reveal that gender identity norms are in flux and the need for more balanced critical when compared with men, an equal are variable even among mainstream thinking and open debate about this or higher proportion of women favor populations in Europe and North topic and one of the reasons we are the continuation of female genital America. The globalization of images publishing this public policy advisory surgeries. A more thoughtful analysis of women’s bodies has increasingly statement. is needed: those who want to ensure popularized the ideal of a smooth 5. The empirical association be- that women have a say in the conduct and clean genital look that is remi- tween patriarchy and genital surger- of their lives should support women niscent of the aesthetic standards as- ies is not well established. The vast in their quest for choices about their sociated with genital surgeries in East majority of the world’s societies can own bodies and traditions. Ironi- and . As an index of this be described as patriarchal, and most cally, the effect of some antimutila- recent trend, although the number either do not modify the genitals of tion campaigns in Africa is to weaken of operations performed each year is either sex or modify the genitals of female power centers within society quite small, type I and type II genital males only. There are almost no patri- and bring women’s bodies and lives surgeries (described as clitoroplexy, archal societies with customary geni- under the hegemonic control and clitoral reduction, and labiaplasty tal surgeries for females only. Across management of local male religious by cosmetic surgeons) are gaining in human societies there is a broad range or political leaders. We see it as pref- popularity in and Eu- of cultural attitudes concerning fe- erable that any changes that may be rope in what is now one of the fastest male sexuality—from societies that made are led by the women of these growing forms of cosmetic surgery in press for temperance, restraint, and societies themselves. those regions of the world.14 the control of sexuality to those that

November-December 2012 HASTINGS CENTER REPORT 23 7. The findings of the WHO Study not display the within-nation results discussion of the topic in the press Group on Female Genital Mutila- so that one could determine if the and in public policy forums. Female tion and Obstetric Outcome15 is the results replicated well. There was no genital surgeries worldwide should subject of criticism that has not been direct control for the quality of health be addressed in a larger context of adequately publicized. The reported care available for “cut” versus “uncut” discussions of health promotion, pa- evidence does not support sensational women. Although it is understand- rental and children’s rights, religious media claims about female genital able that a hospital-based study could and cultural freedom, gender parity, surgery as a cause of perinatal and not offer a sample that would repre- debates on permissible cosmetic al- maternal mortality during birth. sent the whole population, a dispas- terations of the body, and female em- The WHO study was published in sionate assessment of the WHO study powerment issues. the prestigious medical journal Lan- group findings might well conclude The voices of African women cet in 2006 and received widespread that the results of the study have been who support female and male genital and rather sensationalized coverage sensationalized and misrepresented. modification for their children and by the media. A story in the New York The reported findings suggest that fe- themselves have not been adequately Times began as follows: “The first male genital surgeries are less hazard- represented in the media or in public large medical study of female genital ous than cigarette smoking as a risk policy forums. These parents are nei- cutting has found that the procedure factor for pregnancy.17 ther monsters nor fools: like parents has deadly consequences when the It should also be pointed out that everywhere, they want to do the right women give birth, raising by more the WHO study was not the first thing for their children and are con- than 50 percent the likelihood that large medical study of female genital cerned about their children’s health. the woman or her baby will die.”16 cutting. A high-quality Medical Re- Nor are they necessarily uneducated A careful reading of the WHO search Council study of the reproduc- or ignorant or helpless prisoners of study reveals that the results are very tive health of over one thousand “cut” an insufferably dangerous tradition complex. There were no statistically and “uncut” women in that they themselves would like to significant differences in reproduc- published in 2001 suggested that escape, if only they could find a way tive health between those who had many of the reproductive morbidities out. Many highly educated women in a type I genital surgery and those publicized by antimutilation activists Africa embrace the practice and do so who had no surgery. The perina- were equally prevalent among “un- without negative health consequenc- tal death rate for the women in the cut” women.18 That study received es. For the sake of a balanced discus- sample who had a type III surgery no media attention. sion, it will be necessary to create a was, in fact, lower (193 infant deaths context where women can express out of 6,595 births) than for those Policy Implications their support for the practices with- who had no surgery at all (296 in- out being attacked. African women fant deaths out of 7,171 births) and 1. Better fact checking and better who live outside Africa but who grew became statistically significant only representation of the voices of scholars up in regions of Africa where genital through nontransparent statistical and the perspectives and experiences surgeries are routine and have a posi- adjustment of the data. After statis- of African women who value female tive connotation should be included tical adjustments, there was no sig- genital surgery are likely to change in a more respectful and productive nificant difference in risk of maternal the character of the discussion. For discourse that creates a supportive mortality when comparing “uncut” nearly three decades, there has been or protective context against stigma- women with the sample of women an uncritical relationship between tization, fear, or humiliation. Some with type I and type III genital sur- the media and antimutilation advo- medical practitioners have suggested geries. “Infibulated” women did not cacy groups. In the face of horrifying that the horror-inducing media cov- have higher maternal mortality than and sensational claims about African erage of the topic over the past three “uncut” women, although women parents “mutilating” their daughters decades can have a psychological im- with type II surgeries did. Maternal and damaging their sexual pleasure pact on a woman’s genital self-image death was not a frequent event. The and reproductive capacities, there has upon immigration to countries where absolute raw numbers for maternal been surprisingly little journalistic ex- female genital surgery is condemned, deaths were as follows: out of 28,393 ploration of alternative views or con- thereby inducing an “acquired sexual deliveries, fifty-four women died be- sultation with experts who can assess dysfunction.”19 fore discharge: nine had no female current evidence. 2. It should be acknowledged genital surgeries, fifteen had type I, We recommend that journalists, that female genital surgeries are not twenty-three had type II, and seven activists, and policy-makers cease us- unique to African women. Surgi- had type III. The study collected data ing violent and preemptive rhetoric. cal practices that reduce or alter the on women across six nations but did We recommend a more balanced external genitalia of women include

24 HASTINGS CENTER REPORT November-December 2012 Further Reading Some of the publications cited in the endnotes provide a core reading list for readers wanting more information about female genital surgeries. Other relevant publications are listed here.

1. J. Abdulcadir et al., “Care of Women with Female Genital 15. C. Kratz, “Female Circumcision in Africa,” in Africana: The Mutilation/Cutting,” Swiss Medical Weekly 140 (2011): Encyclopedia of the African and African American Experience, w13137. 2nd ed., ed. K.A. Appiah and H.L. Gates, Jr., (New York: 2. R. Abusharaf, “Virtuous Cuts: Female Genital Mutilation Oxford University Press, 2004). in an African Ontology,” Differences: A Journal of Feminist 16. M. Malmstrom, “Just Like Couscous: Gender, Agency and Cultural Studies 12 (2001): 112-40. the Politics of Female Circumcision in Cairo,” doctoral 3. K. Bell, “Genital Cutting and Western Discourses on thesis, University of Gothenburg, Sweden, 2009, http:// Sexuality,” Medical Anthropology Quarterly 19, no. 2 gupea.ub.gu.se/dspace/handle/2077/20269. (2005): 125-48. 17. M. McKinley, “Cultural Culprits,” Berkeley Journal of 4. J. Boddy, Civilizing Women: British Crusades in Colonial Gender, Law and Justice 24 (2009): 91-164. Sudan (Princeton, N.J.: Princeton University Press, 2007). 18. W. Njambi, “‘One Vagina To Go’: Eve Ensler’s Universal 5. J. Boddy, “Violence Embodied? Circumcision, Gender Vagina and Its Implications for African Women,” Australian Politics, and Cultural Aesthetics,” in Rethinking Violence Feminist Studies 24, no. 60 (2009): 167-80. Against Women, ed. R.E. Dobash and R.P. Dobash 19. W. Njambi, “Rescuing African Women and Girls from (Thousand Oaks, Calif.: Sage, 1996). Female Genital Practices: A Benevolent and Civilizing 6. J. Boddy, “Womb as Oasis: The Symbolic Context of Mission,” in Burden or Benefit? Imperial Legacies of Pharaonic Circumcision in Rural Northern Sudan,” Benevolence, ed. H. Gilbert and C. Tiffin (Indianapolis: American Ethnologist 9 (1982): 682-98. Indiana University Press, 2008). 7. D.L. Coleman, “The Seattle Compromise: Multicultural 20. M. Parker, “Rethinking Female Circumcision,” Africa 65 Sensitivity and Americanization,” Duke Law Review 47 (1995): 506-524. (1998): 717-83. 21. B. Shell-Duncan and Y. Hernlund, “Female ‘Circumcision’ 8. G. Einstein, “From Body to Brain: Considering the in Africa: Dimensions of the Problem and the Debates,” Neurobiological Effects of Female Genital Cutting,” in Female “Circumcision” in Africa, ed. Shell-Duncan and. Perspectives in Biology and Medicine 51, no. 1 (2008): Hernlund, 1-40. 84-97. 22. R.A. Shweder, “What about ‘Female Genital Mutilation’? 9. C. Fernandez-Romano, “The Banning of Female And Why Understanding Culture Matters in the First Circumcision: Cultural Imperialism or a Triumph for Place,” in Engaging Cultural Differences, ed. R. Shweder, Women’s Rights?” Temple International and Comparative M. Minow, and H. Markus (New York: Russell Sage Law Journal 13 (1999): 137-61. Foundation Press, 2003), 216-51. 10. M. Johnson, “Becoming a Muslim, Becoming a Person: 23. R.A. Shweder, “When Cultures Collide Whose Rights? Female ‘Circumcision,’ Religious Identity, and Personhood Which Tradition of Values? A Critique of the Global in Guinea-Bissau,” in Female “Circumcision” in Africa: Anti-FGM Campaign,” in Global Justice and the Bulwarks Culture, Controversy and Change, ed. B. Shell-Duncan of Localism: Human Rights in Context, ed. C.L. Eisgruber and Y. Hernlund (Boulder, Colo.: Lynne Rienner, 2000), and A. Sajo (Leiden, the Netherlands, and Boston, Mass.: 215-34. Martinus Nijhoff, 2005), 181-99. 11. S. Johnsdotter, “Projected Cultural Histories of the Cutting 24. N. Sullivan, “‘The Price to Pay for Our Common Good’: of Female Genitalia: A Poor Reflection in the Mirror,” Genital Modification and the Somatechnologies of History and Anthropology 23, no. 1 (2012): 91-114. Cultural (In)Difference,” Social Semiotics 17, no. 3 (2007): 395-409. 12. S. Johnsdotter and B. Essen, “Gender and Ethnicity: The Politics of Genital Modifications,” Reproductive Health 25. L.M. Thomas, Politics of the Womb: Women, Reproduction, Matters 18, no. 35 (2010): 29-37. and the State in (Los Angeles: University of California Press, 2003). 13. C. Kratz, “Circumcision, Pluralism, and Dilemmas of Cultural Relativism,” in Applying Anthropology: An 26. C.J. Walley, “Searching for ‘Voices’: Feminism, Introductory Reader, 9th ed., ed. A. Podelefsky, P. J. Brown, Anthropology, and the Global Debate over Female Genital and S. Lacey (New York: McGraw Hill, 2008), 269-80. Operations,” Cultural Anthropology 12 (1997): 405-38. 14. C. Kratz, “Seeking Asylum, Debating Values and Setting 27. L. Williams and T. Sobieszyzyk, “Attitudes Surrounding Precedents in the 1990s: The Cases of Kassindja and the Continuation of Female Circumcision in the Sudan: Abankwah in the United States,” in Transcultural Bodies: Passing the Tradition to the Next Generation,” Journal of Female Genital Cutting in Global Context, ed. Y. Hernlund Marriage and the Family 59 (1997): 966-81. and B. Shell-Duncan (New Brunswick, N.J.: Rutgers University Press, 2007), 167-201.

November-December 2012 HASTINGS CENTER REPORT 25 a wide range of behaviors, from the to balanced critical discussion and do genital surgeries are considered nor- genital modification rites of passage not help the process of change. Such mal and routine. Research should celebrated by some African women to slogans tend to limit debate and im- include dimensions of variation in genital piercings on college campuses ply that those who disagree are bad different age groups, social classes, to cosmetic labia or clitoral reduc- people. Such slogans do not promote generations, and religions and should tions and vaginal rejuvenations re- the thoughtful, respectful dialogue study change over time. quested by some Western women, to that is essential to cross-cultural un- 7. Women and girls who have un- ritual practices and excisions among derstanding and to encouraging those dergone genital surgery as children particular ethnic groups in Malaysia, who are considering change. Indeed, and who are living in countries where the Middle East, India, and South criminalization, although it may be female genital surgery is not practiced America. Global health policies have well-intended, often serves to drive or is illegal should not be subjected to singled out African female genital a practice underground (as has hap- social messages that stigmatize them, surgeries as “mutilation” and have pened at times with abortion), mak- teach them to expect sexual dysfunc- targeted these for global eradication ing it less accessible to the public tion, or make them fear sexual rela- while largely ignoring similar cul- health measures and the open dia- tionships. In particular, we question tural, religious, and aesthetic surgical logue that could improve health and the discourse that creates negative practices involving female (and male) promote the possibility of change. expectations about sexuality among genitalia in other parts of the world. 5. Adult women should be free to women and girls who have had geni- This has led to further stigmatization choose what makes them happy with tal surgeries during childhood in and prejudicial treatment of affected their own bodies. Legislation and their countries of origin (including African women in clinics and hospi- regulations in countries that crimi- girls who are adopted from practic- tals on the continent, as well as those nalize female genital surgeries for ing societies in Southeast Asia, Africa, in the Western diaspora. A more adult women should be reexamined. and other parts of the world) but who forthright and critical discussion of In effect, they treat women from Af- are now living in Europe and North this focus is called for. rican backgrounds in a discrimina- America. The horrifying, stigmatiz- 3. There are medical advocates tory way by denying their autonomy. ing, and frequently erroneous or hy- worldwide seeking to promote public If an adult woman wants to undergo perbolic messages of the media, some health by broadening the legal scope cosmetic surgery to reduce the size activists, and well-meaning health for safe, hospital-based genital surger- of her labia or clitoris in accordance educators and doctors may provoke ies for females. Parental and religious with her aesthetic and cultural ideals, what could be called “psychological rights advocates who argue for such she should be free to do so. Similarly, mutilation”: being told that one is choices claim moral and legal parity those who believe such surgeries to mutilated or is a victim of mutilation with the practice of neonatal male be unnecessary or harmful should be and that one should expect no sexual genital surgery and with other legally free to present their information and pleasure can compromise the devel- available body modification proce- argue their case. Some feminists in opment of a normal and healthy psy- dures (breast implants, sex change the West have argued that such pro- chosexual life. To help women avoid operations, and cosmetic surgeries cedures as breast implants, liposuc- these social messages, they should for “normalizing” the appearance tion, and cosmetic genital surgeries be allowed to choose knowledgeable of Down syndrome children). They exploit women and pressure them to caregivers and counselors who are should be given a voice in public conform to a cultural ideal of femi- comfortable treating them. policy forums. Advocates of such ap- nine beauty. This, in turn, may create Our aim in this policy statement proaches should be encouraged to a desire for cosmetic surgical proce- is not to take a collective stance or articulate their proposals and defend dures, which are never entirely free of arrive at a moral judgment about the them with reference to relevant legal, risk. Others argue that a woman has practice of genital surgeries for either ethical, and cosmetic medical norms. the right to decide herself whether to females or males. Our hope is that A more respectful and less ethnocen- have cosmetic surgery. But these de- this essay might serve as an invitation tric discourse is needed—one that bates have respected that individuals to recognize that there actually are breaks with the old schemes for de- are in fact choosing for themselves. many sides to this story, to sound a monizing and criminalizing others, 6. Studies of genital surgeries for call for greater accuracy and genuine provides the scientific and ethical ba- males or females should be multidis- fact checking in media representa- sis for a better informed discussion, ciplinary, and there should be support tions of other cultures, and to place and more effectively contributes to for a network linking researchers and the provocative topic of female geni- social and cultural change. advocates who have diverse points of tal surgeries in a forum where critical 4. “Zero tolerance” slogans of the view about the topic. Experts should reason, free inquiry, and debate in the type promoted by antimutilation ad- deepen their knowledge of variations pursuit of accurate and relevant bio- vocacy groups are counterproductive in practices in the countries where ethical information are highly valued.

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