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Female Genital Alteration: a Compromise Solution Kavita Shah Arora,1,2 Allan J Jacobs3,4

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Female Genital Alteration: a Compromise Solution Kavita Shah Arora,1,2 Allan J Jacobs3,4 Clinical ethics PAPER Female genital alteration: a compromise solution Kavita Shah Arora,1,2 Allan J Jacobs3,4 1Department of Obstetrics and ABSTRACT FGA. Eighty-five per cent had an intention to Gynecology, MetroHealth Despite 30 years of advocacy, the prevalence of non- subject their daughters to an extensive FGA proced- Medical Center, Cleveland, therapeutic female genital alteration (FGA) in minors is ure, and 90% supported the continuation of the Ohio, USA 7 2Department of Bioethics, Case stable in many countries. Educational efforts have practice. There have been some more encouraging Western Reserve University, minimally changed the prevalence of this procedure in studies, however. In Kenya, for example, prevalence Cleveland, Ohio, USA – 3 regions where it has been widely practiced. In order to has dropped from 49% in women ages 45 49 years Department of Obstetrics and better protect female children from the serious and long- to 15% in girls ages 15–19 years and in Liberia, the Gynecology, Stony Brook University, Stony Brook, term harms of some types of non-therapeutic FGA, we prevalence has dropped from 85% to 44%, 89 New York, USA must adopt a more nuanced position that acknowledges respectively. a wide spectrum of procedures that alter female Immigrants to Western nations may continue to – Correspondence to genitalia. We offer a revised categorisation for non- subject their daughters to genital alteration,10 12 Dr Kavita Shah Arora, fi Department of Obstetrics and therapeutic FGA that groups procedures by effect and though the frequency is dif cult to assess. While Gynecology, MetroHealth not by process. Acceptance of de minimis procedures laws enacted in these countries make procedures Medical Center, 2500 that generally do not carry long-term medical risks is that alter a female’s external genitalia illegal, they MetroHealth Drive, G230E, culturally sensitive, does not discriminate on the basis of may in some instances worsen health outcomes by Cleveland, OH 44109, USA; gender, and does not violate human rights. More morbid driving the practice underground by sending female [email protected] procedures should not be performed. However, accepting children to Africa or by inviting circumcisers to the 11 Received 17 July 2014 de minimis non-therapeutic f FGA procedures enhances We s t . Making the practice illegal also hampers Revised 24 February 2015 the effort of compassionate practitioners searching for a the ability to study the actual incidence and effects Accepted 21 July 2015 compromise position that respects cultural differences of these procedures, limits an open dialogue but protects the health of their patients. regarding changing the practice, and may impede efforts to voluntarily reduce the incidence of these procedures (thereby improving public health).13 14 Procedures that surgically alter the external geni- This local culture of silence is due to a distrust of talia of children are quite common throughout the the global eradication campaigns as being ‘sensatio- world, though the distribution varies greatly by nalized, ethnocentric, racist, culturally insensitive geography. The majority of male children in and simplistic’.15 1 America are circumcised. While non-therapeutic Since progress in reducing FGA procedures has female genital alteration (FGA) procedures in chil- been limited in states where they are endemic and dren are unusual in the USA, an estimated 80–140 the commitment of people from these cultures to million women throughout Africa, the Middle East, these procedures has led to their persistence in India and South-East Asia have had such proce- states where they are legally discouraged, alterna- 23 dures. The WHO, American Academy of tive approaches should be considered.7 To accom- Pediatrics (AAP), and the American Congress of modate cultural beliefs while protecting the Obstetricians and Gynecologists (ACOG) have pol- physical health of girls, we propose a compromise icies in place to support circumcision; however, solution in which liberal states would legally permit FGA has been deemed a human rights violation by de minimis FGA in recognition of its fulfilment of these same organisations as well as by the United cultural and religious obligations, but would pro- 2–4 Nations. In fact, the US government has scribe those forms of FGA that are dangerous or expressly outlawed any procedure that incises or that produce significant sexual or reproductive changes a female child’s external genitalia in the dysfunction. 5 absence of medical indications. Regrettably, academic and public health consider- While years of advocacy and legislation aimed at ation of non-therapeutic FGA has been hampered eliminating non-therapeutic procedures on female by several issues. First, there is no recognised external genitalia has resulted in a decline in the nomenclature based on the functional effects of prevalence of the practice, the magnitude of this each of the several procedures that may be decline has been soberingly small. In Egypt, the employed to alter female genitalia. Second, discus- percentage of women who had any procedure that sion often is infused with a strong cultural and altered external genitalia performed on a daughter gender bias against FGA in all forms. Third, group- only fell from 77.8% to 71.6% over 5 years from ing all forms of FGA in discourse and condemna- 2006 to 2011. This relatively small decrease in tion assumes that all FGA procedures carry the To cite: Arora KS, prevalence was associated with minimal change same risks, which is medically inaccurate. Finally, 6 Jacobs AJ. J Med Ethics in attitude towards the procedures. In a study in authors arguing against all forms of FGA construe Published Online First: Somalia, the country in the world with the highest the concepts of beneficence and non-maleficence [please include Day Month prevalence of these procedures, 81% of subjects narrowly with regard to their scope, and too Year] doi:10.1136/ fi medethics-2014-102375 underwent in bulation and only 3% did not have broadly with regard to their applicability. On the Arora KS, Jacobs AJ. J Med Ethics 2015;0:1–7. doi:10.1136/medethics-2014-102375 1 Clinical ethics one hand, they argue that physical well-being trumps social and NOMENCLATURE cultural well-being. On the other hand, they argue that concepts We use the term ‘procedure’ in the context of FGA rather than originally used to apply to the actions of physicians are equally ‘surgery’ to emphasise that there is no medical benefit estab- applicable to parents. lished by well designed trials, and that the primary purpose is We are not arguing that any procedure on the female genitalia not health-related. ‘Procedure’ is defined by Merriam-Webster is desirable. We are also not suggesting that people whose beliefs as a “series of steps followed in a regular definite order,” or sense of propriety leads them to perform these procedures and does not imply that the intervention is done for health on their children would necessarily accept alterations in their reasons, in a health facility or by a medical professional.20 The practices to conform to the authors’ views of what is acceptable. terms ‘surgery’ and ‘operation,’ however, connote a medical Rather, we only argue that certain procedures ought to be toler- context. Much as circumcision performed by a mohel, ear ated by liberal societies. We hold that the ethical issues are no piercing done at a mall, or tattoo performed at a tattoo parlour different for procedures that are performed as cultural or reli- follow a series of steps in a regular, definite order, morpho- gious expressions by a minority group than for procedures that logical alterations of the female external genitalia are also proce- are performed for aesthetic reasons by members of a main- dures, whether or not performed by a medical professional or stream culture. Finally, we believe that all procedures should be in a health facility. performed with adequate analgesia. FGA is a highly complex Many terms have been used to describe the procedures that issue. In some forms, it is deeply rooted in traditions of female alter female external genitalia, such as ‘female circumcision,’ submission to their male counterparts. We by no means ‘female genital cutting,’‘female genital alteration,’‘female condone oppression. Given that most communities that practice genital surgery,’ and ‘female genital mutilation’.13 14 21 ‘Female FGA also practice male circumcision, some forms of FGA reflect circumcision’ has been abandoned as critics of the procedures cultural norms of gender differentiation that are more pro- felt it conferred the greater ‘respectability’ of male circumci- nounced than in Western society. However, in order to reduce sion.21 We agree that the word circumcision should be confined the prevalence of the extensive forms of FGA, we propose a to men as it applies to a specific procedure, whereas procedures compromise solution that is ethical, culturally sensitive and on female external genitalia encompass a wide variety of distinct practical. procedures. Also, circumcision potentially confers health bene- We will begin by discussing nomenclature, then describe the fits on the male child and on his future sexual partners.1419 various types of FGA and classify them according to their While health benefits may be a component behind the motiv- effects. This revised classification will rationalise discussion of ation for FGA, there is a paucity of empirical data supporting the subject, and should prove useful even to those who disagree this and the primary advantages are aesthetic as well as compli- with our conclusions. After discussing the medical safety of ance with religious or cultural norms.22 Second, since the major- FGA procedures, we will argue that liberal governments should ity of procedures are not being performed in hospitals or by tolerate de minimis procedures with no more effect than other trained healthcare professionals, ‘female genital surgery’ is an accepted procedures performed on minors for aesthetic inappropriate term, since it inaccurately implies a medical enhancement.
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