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 compas- sionate 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 per- form 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, physi- cians must decline to perform proce- dures 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 surround- ing the clitoris with or without excision of part or all of the clitoris (Fig 2).