Policy Statement—Ritual Genital Cutting of Female Minors Abstract

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Organizational Principles to Guide and Deﬁne the Child Health Care System and/or Improve the Health of all Children Policy Statement—Ritual Genital Cutting of Female Minors

COMMITTEE ON BIOETHICS abstract KEY WORDS The traditional custom of ritual cutting and alteration of the genitalia of female genital mutilation, FGM, female genital cutting, FGC female infants, children, and adolescents, referred to as female genital ABBREVIATION mutilation or female genital cutting (FGC), persists primarily in Africa FGC—female genital cutting and among certain communities in the Middle East and Asia. Immi- This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors grants in the United States from areas in which FGC is common may have filed conflict of interest statements with the American have daughters who have undergone a ritual genital procedure or may Academy of Pediatrics. Any conflicts have been resolved through request that such a procedure be performed by a physician. The Amer- a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any ican Academy of Pediatrics believes that pediatricians and pediatric commercial involvement in the development of the content of surgical specialists should be aware that this practice has life- this publication. threatening health risks for children and women. The American Acad- emy of Pediatrics opposes all types of female genital cutting that pose risks of physical or psychological harm, counsels its members not to perform such procedures, recommends that its members actively seek to dissuade families from carrying out harmful forms of FGC, and urges its members to provide patients and their parents with compassionate education about the harms of FGC while remaining sensitive to the cultural and religious reasons that motivate parents to seek this procedure for their daughters. Pediatrics 2010;125:1088–1093 www.pediatrics.org/cgi/doi/10.1542/peds.2010-0187 doi:10.1542/peds.2010-0187 INTRODUCTION All policy statements from the American Academy of Pediatrics Ritual cutting and alteration of the genitalia of female infants, children, automatically expire 5 years after publication unless reaffirmed, adolescents, and adults has been a tradition since antiquity. Female revised, or retired at or before that time. genital cutting (FGC) is most often performed between the ages of 4 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). and 10 years, although in some communities it may be practiced on Copyright © 2010 by the American Academy of Pediatrics infants or postponed until just before marriage.1 Typically, a local vil- lage practitioner, lay person, or midwife is engaged for a fee to perform the procedure, which is done without anesthesia and by using a variety of instruments such as knives, razor blades, broken glass, or scissors. In developed countries, physicians may be sought to perform FGC under sterile conditions with the use of anesthesia. The ritual and practice of FGC persists today primarily in Africa, the Middle East, and small communities in Asia.2 Immigrants from these countries have brought the practice with them to Europe and North America, but no data are available for the prevalence of this practice in the West.3 The language to describe this spectrum of procedures is controversial. Some commentators prefer “female circumcision,” but others object that this term trivializes the procedure, falsely confers on it the re- spectability afforded to male circumcision in the West, or implies a medical context.4 The commonly used “female genital mutilation” is

1088 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 24, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS also problematic. Some forms of FGC italia and promote culturally sensitive marriage is essential to women’s so- are less extensive than the newborn education about the physical conse- cial and economic security. FGC be- male circumcision commonly per- quences of FGC.12 comes a physical sign of a woman’s formed in the West. In addition, “muti- FGC is illegal and subject to criminal marriageability, with social control lation” is an inflammatory term that prosecution in several countries, includ- over her sexual pleasure by clitorec- tends to foreclose communication and ing Sweden, Norway, Australia, and the tomy and over reproduction by infibu- that fails to respect the experience of United Kingdom.13,14 In the United States, lation (sewing together the labia so the many women who have had their federal legislation in 1996 criminalized that the vaginal opening is about the genitals altered and who do not per- the performance of FGC by practitioners width of a pencil). ceive themselves as “mutilated.”5 It is on female infants and children or adoles- When parents request a ritual genital paradoxical to recommend “culturally cents younger than 18 years and man- procedure for their daughter, they be- sensitive counseling” while using cul- dated development of educational pro- lieve that it will promote their daughter’s turally insensitive language. “Female grams at the community level and for integration into their culture, protect her genital cutting” is a neutral, descrip- physicians about the harmful conse- virginity, and, thereby, guarantee her de- tive term.4 quences of the practice.15 Various state sirability as a marriage partner. In some It is estimated that at least 100 million laws exist as well.4 societies, failure to ensure a daughter’s women have undergone FGC and that marriageable status can realistically be between 4 and 5 million procedures CULTURAL AND ETHICAL ISSUES seen as failure to ensure her survival.20 It are performed annually on female in- FGC has been documented in individuals is tragic that the same procedure that fants and children, with the most se- from many religions, including Chris- made the daughter marriageable may vere types performed in Somalian and tians, Muslims, and Jews.5 The relation- ultimately contribute to her infertility.21 Sudanese populations.6,7 Pediatri- ship of FGC and Islam is complex and Parents are often unaware of the harm- cians, therefore, may encounter pa- controversial. Some of the most conser- ful physical consequences of the custom, tients who have undergone these pro- vative Islamic societies, such as Saudi because the complications of FGC are at- cedures, and pediatric surgeons and Arabia, do not practice FGC, whereas in tributed to other causes and are rarely pediatric urologists may be asked by some African settings, the primary moti- discussed outside of the family.22 Women patients or their parents to perform a vation seems tribal and nationalistic from developing countries who are advo- ritual genital operation. rather than religious.16 For many Muslim cates for children’s health have differing During the past 2 decades, several in- religious scholars, male circumcision is perspectives on how to respond to FGC. ternational and national humanitarian considered obligatory, whereas some Some activists put the campaign against and medical organizations have drawn form of female “circumcision” is consid- FGC at the center of their work, but oth- worldwide attention to the physical ered optional but virtuous.17 Across na- ers complain that the West’s obsession harms associated with FGC. The World tions and cultures that practice FGC, the with FGC masks an indifference to chil- Health Organization and the Interna- perception that it is religiously obligated dren’s suffering caused by famine, war, 23 tional Federation of Gynecology and or at least encouraged is ubiquitous.5 and infectious disease. Obstetrics have opposed FGC as a med- Kopelman18 summarized 4 additional The physical burdens and potential ically unnecessary practice with seri- reasons proposed to explain the cus- psychological harms associated with ous, potentially life-threatening com- tom of FGC: (1) to preserve group iden- FGC violate the principle of nonmalefi- plications.8,9 The American College of tity; (2) to help maintain cleanliness cence (a commitment to avoid doing Obstetricians and Gynecologists and and health; (3) to preserve virginity harm) and disrupt the accepted norms the College of Physicians and Sur- and family honor and prevent immo- inherent in the patient-physician rela- geons of Ontario, Canada, also op- rality; and (4) to further marriage tionship, such as trust and the promo- posed FGC and advised their members goals, including enhancement of sex- tion of good health. More recently, FGC not to perform these procedures.10,11 In ual pleasure for men. Preservation of has been characterized as a practice 2006, the Council on Scientific Affairs cultural identity was noted by Toubia19 that violates the right of infants and of the American Medical Association to be of particular importance for children to good health and well-being, reaffirmed its recommendation that groups that have previously faced co- part of a universal standard of basic all physicians in the United States lonialism and for immigrants threat- human rights.24 strongly denounce all medically unnec- ened by a dominant culture. FGC is en- Protection of the physical and mental essary procedures to alter female gen- demic in many poor societies in which health of girls should be the overriding

PEDIATRICS Volume 125, Number 5, May 2010 1089 Downloaded from www.aappublications.org/news by guest on September 24, 2021 concern of the health care community. Although physicians should under- stand that most parents who request FGC do so out of good motives, physicians must decline to perform procedures that cause unnecessary pain or that pose dangers to their patients’ well-being.

TYPES OF FGC Figure 1 shows the normal genital anatomy of a prepubertal female. The various ritual genital practices are classified into 4 types on the basis of severity of structural alteration.2 Type 1 FGC, often termed clitorectomy, involves excision of the skin surrounding the clitoris with or without excision of part or all of the clitoris (Fig 2). When this procedure is performed on FIGURE 1 Normal female genital anatomy. infants and young girls, a portion of or all of the clitoris and surrounding tis- sues may be removed. If only the clitoral prepuce is removed, the physical manifestation of type 1 FGC may be subtle, necessitating a careful exami- nation of the clitoris and adjacent structures for recognition. Type 2 FGC, referred to as excision, is the removal of the entire clitoris and part or all of the labia minora (Fig 3). Crude stitches of catgut or thorns may be used to control bleeding from the clitoral ar- tery and raw tissue surfaces, or mud poultices may be applied directly to the perineum. Because of the absence of the labia minora and clitoris, females with type 2 FGC do not have the typical contour of the anterior perineal structures. The vaginal opening is not covered in the type 2 procedure. Type 3 FGC, known as infibulation, is the most severe form, in which the en- FIGURE 2 tire clitoris and some or all of the labia Type 1 female genital mutilation. minora are excised, and incisions are made in the labia majora to create raw surfaces (Fig 4). The labial raw sur- nary and menstrual flow. In type 3 FGC, Type 4 FGC includes different practices faces are stitched together to cover the patient will have a firm band of tis- of variable severity, including pricking, the urethra and vaginal introitus, leav- sue replacing the labia and obscuring piercing, or incising the clitoris and/or ing a small posterior opening for uri- the urethral and vaginal openings. labia; stretching the clitoris and/or

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hemorrhage, shock secondary to blood loss or pain, local infection and failure to heal, septicemia, tetanus, trauma to adjacent structures, and urinary retention.25,26 Infibulation (type 3 FGC) is often associated with long- term gynecologic or urinary tract diffi- culties. Common gynecologic prob- lems involve the development of painful subcutaneous dermoid cysts and keloid formation along excised tissue edges. More serious complications include pelvic infection, dys- menorrhea, hematocolpos, painful intercourse, infertility, recurrent urinary tract infection, and urinary calculus formation. Pelvic examina- tion is difficult or impossible for women who have been infibulated, and vaginal childbirth can present significant challenges. Scarring may FIGURE 3 prevent accurate monitoring of la- Type 2 female genital mutilation. bor and fetal descent. Although dein- fibulation may facilitate delivery, women who have undergone dein- fibulation are at increased risk of complications, including perineal tears, wound infections, separation of repaired episiotomies, postpar- tum hemorrhage, and sepsis.27 Less well-understood are the psychological, sexual, and social consequences of FGC, because little re- search has been conducted in countries where the practice is en- demic.28 However, personal accounts by women who have had a ritual genital procedure recount anxiety before the event, terror at being seized and forcibly held during the event, great difficulty during childbirth, and lack of sexual pleasure during intercourse.29 Some women have no rec- FIGURE 4 ollection of the event, particularly if Type 3 female genital mutilation. it was performed in their infancy. Other women have described the labia; cauterizing the clitoris; and scrap- The physical complications associated event in joyful terms, as a communal ing or introducing corrosive substances with FGC may be acute or chronic. ritual that inducted them into adult into the vagina. Early, life-threatening risks include female society.30

PEDIATRICS Volume 125, Number 5, May 2010 1091 Downloaded from www.aappublications.org/news by guest on September 24, 2021 EDUCATION OF PATIENTS AND community member and advocate only resist decisions that are likely to PARENTS pricking or incising the clitoral skin as cause harm to children. Most forms An educational program about FGC sufficient to satisfy cultural require- of FGC are decidedly harmful, and pe- requires, above all, sensitivity to the ments. This is no more of an alteration diatricians should decline to per- cultural background of the patient than ear piercing. A legitimate concern form them, even in the absence of and her parents and an appreciation is that parents who are denied the co- any legal constraints. However, the of the significance of this custom in operation of a physician will send their ritual nick suggested by some pedia- their tradition.5 Objective informa- girls back to their home country for a tricians is not physically harmful and tion should include a detailed expla- much more severe and dangerous pro- is much less extensive than routine nation of female genital anatomy and cedure or use the services of a non– newborn male genital cutting. There function, as well as a thorough re- medically trained person in North is reason to believe that offering view of the lifelong physical harms America.33,34 In some countries in such a compromise may build trust and psychological suffering associ- which FGC is common, some progress between hospitals and immigrant ated with most forms of FGC. It toward eradication or amelioration communities, save some girls from should be emphasized that many has been made by substituting ritual undergoing disfiguring and life- countries in Africa have supported “nicks” for more severe forms.2 In con- threatening procedures in their na- efforts to educate the public about trast, there is also evidence that medi- tive countries, and play a role in the the serious negative health effects of calizing FGC can prolong the custom eventual eradication of FGC. It might FGC and that prominent physicians among middle-class families (eg, in be more effective if federal and state from Africa are advocates for the Egypt).35 Many anti-FGC activists in the laws enabled pediatricians to reach elimination of these practices be- West, including women from African out to families by offering a ritual cause of their adverse conse- countries, strongly oppose any com- nick as a possible compromise to quences. Pediatricians and pediatric promise that would legitimize even the avoid greater harm. surgical specialists who care for pa- most minimal procedure.4 There is Efforts should be made to use all avail- tients from populations known to also some evidence (eg, in Scandina- able educational and counseling re- practice FGC commonly, such as So- via) that a criminalization of the prac- sources to dissuade parents from malian, Ethiopian, Eritrean, and Su- tice, with the attendant risk of losing seeking a ritual genital procedure for danese communities, should be custody of one’s children, is one of the their daughter. For circumstances in aware of local counseling centers. factors that led to abandonment of this which an infant, child, or adolescent 36 Successful educational programs tradition among Somali immigrants. seems to be at risk of FGC, the Ameri- typically require the active involve- The World Health Organization and can Academy of Pediatrics recom- ment and leadership of immigrant other international health organiza- mends that its members educate and women, whose experience and tions are silent on the pros and cons of counsel the family about the detrimen- knowledge can address the health, pricking or minor incisions. The option tal health effects of FGC. Parents social status, and legal aspects of of offering a “ritual nick” is currently should be reminded that performing FGC. Health educators must also be precluded by US federal law, which FGC is illegal and constitutes child prepared to explain to parents from makes criminal any nonmedical proce- abuse in the United States. outside North America why male gen- dure performed on the genitals of a ital alteration is routinely practiced female minor. RECOMMENDATIONS here but female genital alteration is The American Academy of Pediatrics The American Academy of Pediatrics: routinely condemned.31 policy statement on newborn male 1. Opposes all forms of FGC that pose Some physicians, including pediatri- circumcision expresses respect for risks of physical or psychological cians who work closely with immi- parental decision-making and ac- harm. grant populations in which FGC is the knowledges the legitimacy of includ- norm, have voiced concern about the ing cultural, religious, and ethnic 2. Encourages its members to become adverse effects of criminalization of traditions when making the choice of informed about FGC and its compli- the practice on educational efforts.32 whether to surgically alter a male in- cations and to be able to recognize These physicians emphasize the signif- fant’s genitals. Of course, parental physical signs of FGC. icance of a ceremonial ritual in the ini- decision-making is not without lim- 3. Recommends that its members ac- tiation of the girl or adolescent as a its, and pediatricians must always tively seek to dissuade families

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from carrying out harmful forms of COMMITTEE ON BIOETHICS, Jeffrey L. Ecker, MD – American College of FGC. 2006–2007 Obstetricians and Gynecologists Marcia Levetown, MD – American Board of Douglas S. Diekema, MD, MPH, Chairperson Pediatrics 4. Recommends that its members pro- Armand H. Matheny Antommaria, MD, PhD Ellen Tsai, MD, MHSc – Canadian Paediatric vide patients and their parents with Mary E. Fallat, MD Society compassionate education about the Ian R. Holzman, MD CONSULTANT physical harms and psychological risks Steven R. Leuthner, MD Lainie F. Ross, MD, PhD *Dena S. Davis, JD, PhD of FGC while remaining sensitive to the Sally Webb, MD STAFF cultural and religious reasons that mo- Alison Baker, MS tivate parents to seek this procedure LIAISONS [email protected] for their daughters. Philip Baese, MD – American Academy of Child and Adolescent Psychiatry *Lead author REFERENCES

1. Toubia N. Female circumcision as a public 12. Council on Scientific Affairs. Female genital 25. Institute for Development Training. Health health issue. N Engl J Med. 1994;331(11): mutilation. JAMA. 1995;274(21):1714–1716 Effects of Female Circumcision. Chapel 712–716 13. Government Offices of Sweden, Ministry of Hill, NC: Institute for Development 2. World Health Organization. Female genital Health and Social Affairs. Act Prohibiting the Training; 1986 mutilation (FGM). Available at: www.who.int/ Genital Mutilation of Women. 1995;SFS 1982: 26. Armstrong S. Female circumcision: fighting reproductive-health/fgm/index.html. Ac- 316 a cruel tradition. New Sci. 1991;129(1754): cessed May 6, 2009 14. United Kingdom Female Genital Mutilation 42–48 3. Strickland JL. Female circumcision/female Act 2003. Chapter 31. Available at: 27. Nour N. Female genital cutting: clinical and genital mutilation. J Pediatr Adolesc Gy- www.opsi.gov.uk/acts/acts2003/pdf/ cultural guidelines. Obstet Gynecol Surv. necol. 2001;14(3):109–112 ukpga࿝20030031࿝en.pdf. Accessed May 6, 2004;59(4):272–279 2009 4. Davis DS. Male and female genital alter- 28. Dorkenoo E, Elworthy S. Female Genital Mu- ation: a collision course with the law? 15. Illegal Immigration Reform and Immigrant tilation. Proposals for Change. London, Health Matrix Clevel. 2001;11(2):487–570 Responsibility Act of 1996. Pub L No. England: Minority Rights Group; 1992 104–208 5. Lane SD, Rubinstein RA. Judging the other: 29. Crossette B. Female genital mutilation by 16. Douglas J. Female circumcision: persis- responding to traditional female genital immigrants is becoming cause for concern tence amid conflict. Health Care Women Int. surgeries. Hastings Cent Rep. 1996;26(3): in the US. New York Times. December 10, 1998;19(6):477–479 31–40 1995:118 17. Winkel E. A Muslim perspective on female 6. Kouba LJ, Muasher J. Female circumcision 30. Gibeau AM. Female genital mutilation: when circumcision. Women Health. 1995;23(1): in Africa: an overview. Afr Stud Rev. 1985; a cultural practice generates clinical and 1–7 28(1):95–110 ethical dilemmas. J Obstet Gynecol Neona- 18. Kopelman LM. Female circumcision/genital 7. Ntiri DW. Circumcision and health among tal Nurs. 1998;27(1):85–91 rural women of southern Somalia as part of mutilation and ethical relativism. Second 31. Abu-Sahlieh SA. To mutilate in the name of a family life survey. Health Care Women Int. Opin. 1994;20(2):55–71 Jehovah or Allah: legitimization of male and 1993;14(3):215–226 19. Toubia N. Female Genital Mutilation: A Call female circumcision. Med Law. 1994; for Global Action. New York, NY: RAINBo; 8. World Health Organization. UN Agencies Call 13(7–8):575–622 for End to Female Genital Mutilation. Geneva, 1995 32. Kelley T. Doctor fights ban on circumcising Switzerland; World Health Organization; 1997 20. Teare P. Culture shock. Nurs Times. 1998; girls. Seattle Times. June 6, 1996:B3 9. World Health Organization, International 94(27):34–35 33. Ostrom C. Harborview debates issue of cir- Federation of Gynecology and Obstetrics. 21. Almroth L, Elmusharaf S, El Hadi N, et al. cumcision of Muslim girls. Seattle Times. Female circumcision: female genital mutila- Primary infertility after genital mutilation in September 13, 1996:A15 tion. Eur J Obstet Gynecol Reprod Biol. 1992; girlhood in Sudan: a case-control study. 45(2):153–154 Lancet. 2005;366(9483):385–391 34. Hamm L. Immigrants bring the practice of 10. American College of Obstetricians and Gy- 22. Female circumcision/genital mutilation. female circumcision to the U.S. Associated necologists. Committee Opinion: Female Forward News. 1990;2:1–10 Press. December 1, 1996; Domestic News Genital Mutilation. Washington, DC: Ameri- 23. Gruenbaum E. The cultural debate over fe- 35. El-Gibaly O, Ibrahim B, Mensch BS, Clark WH. can College of Obstetrics and Gynecology; male circumcision: the Sudanese are argu- The decline of female circumcision in Egypt: 1995 ing this one out for themselves. Med An- evidence and interpretation. Soc Sci Med. 11. College of Physicians and Surgeons of On- thropol Q. 1996;10(4):455–475 2002;54(2):205–220 tario. New Policy: Female Circumcision, Ex- 24. James SA. Reconciling international human 36. Esseń B, Johnsdotter S. Female genital mu- cision and Infibulation. Toronto, Ontario, rights and cultural relativism: the case of tilation in the West: traditional circumcision Canada: College of Physicians and Surgeons female circumcision. Bioethics. 1994;8(1): versus genital cosmetic surgery. Acta Ob- of Ontario; 1992 1–26 stet Gynecol Scand. 2004;83(7):611–613

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Downloaded from www.aappublications.org/news by guest on September 24, 2021 Ritual Genital Cutting of Female Minors Committee on Bioethics Pediatrics 2010;125;1088 DOI: 10.1542/peds.2010-0187 originally published online April 26, 2010;

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