In defence of genital autonomy for children

Article · January 2016with2,609 Reads
DOI: 10.1136/medethics-2015-103030
Abstract
Arora and Jacobs (2016) assume that liberal societies should tolerate non-therapeutic infant male circumcision, and argue that it follows from this that they should similarly tolerate—or even encourage—what the authors regard as ‘de minimis’ forms of female genital mutilation (as defined by the World Health Organization). In this commentary, I argue that many serious problems would be likely to follow from a policy of increased tolerance for female genital mutilation, and that it may therefore be time to consider a less tolerant attitude toward non-therapeutic infant male circumcision. 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.
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In defence of genital autonomy for children
including Appendix (see end of document)
Journal of Medical Ethics
Brian D. Earp
Visiting Scholar, The Hastings Center Bioethics Research Institute
Garrison, New York, USA
Abstract
Arora and Jacobs (2016) assume that liberal societies should tolerate non-therapeutic infant male
circumcision, and argue that it follows from this that they should similarly tolerate—or even
encourage—what the authors regard as ‘de minimis’ forms of female genital mutilation (as defined
by the World Health Organization). In this commentary, I argue that many serious problems would
be likely to follow from a policy of increased tolerance for female genital mutilation, and that it may
therefore be time to consider a less tolerant attitude toward non-therapeutic infant male circumcision.
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.
Key words: female genital mutilation, circumcision, pediatric ethics, autonomy
Authors’ personal copy. Published manuscript. Please cite as:
Earp, B. D. (2016). In defence of genital autonomy for children. Journal of Medical Ethics,
Vol. 41, No. 3, 158-163. Available at
https://www.academia.edu/19117334/In_defense_of_genital_autonomy_for_children
* Note: this is the accepted version of the manuscript; the final, copy-edited version is
available at http://jme.bmj.com/content/42/3/158.full.
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Introduction
In their target article, Arora and Jacobs(1) contend, among other things, that if non-therapeutic infant
male circumcision should be widely tolerated, then so should some forms of what the World Health
Organization calls “female genital mutilation” (or FGM).(2)1 Indeed, there are numerous substantial
overlaps, both physical and symbolic, between these two types of genital alteration that are not very
widely appreciated;(3–10) accordingly, I have prepared an Appendix (see Supplementary Materials)2
in which I outline some of the main morally-relevant features that they share. For now, however, let
us consider only the conditional argument put forward by the authors, namely that: “a liberal society
that tolerates expression of culture and/or religion in the manner of male circumcision should also
permit certain de minimis [female genital altering] procedures.”(1)
I offer a different perspective. Rather than proceeding from the premise that non-therapeutic, non-
consensual male genital alteration (MGA) is clearly permissible (and should therefore be widely
tolerated in liberal societies) to the conclusion that purportedly “de minimis” forms of non-
therapeutic, non-consensual female genital alteration (FGA) should also be permitted, I will instead
move in the opposite direction. My strategy will be to highlight some of the downsides that seem
likely to follow from an increased tolerance for FGA in Western societies, and use this as a premise
from which to argue that it may be time to consider a less tolerant position toward MGA. Please note
that I will not be arguing in favor of a “ban” on MGA (for reasons I go into elsewhere)(11–13) but
rather for its being strongly discouraged, perhaps through some form of regulation (akin to the
proposal by Ben-Yami in an earlier issue of this journal).(14)
Some problems with increasing tolerance for FGA in Western societies
Here are some problems that seem likely to follow from a more tolerant position toward FGA.
Legal problems
FGA, including its “minor” forms, is currently illegal in the vast majority of “liberal societies” (I
will focus on so-called Western countries, such as the United States, Canada, Australia, and the
countries of Europe).(15,16) To change this situation, at least according to one plausible
1 The terminology here is notoriously contentious: see, e.g., Davis(3) for an in-depth discussion. I will simply follow Arora and Jacobs
in using “female genital alteration” (FGA) for the remainder of this essay.
2 Available at [in this document, the Appendix is located immediately following the references section for the main text]. Please note
that this Appendix also includes a more detailed response to many of Arora and Jacobs’s more problematic claims, focusing on those
which I did not have the room to address in the main text of this commentary.
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interpretation, it would require that the laws regarding physical assault on a minor be rewritten,
potentially creating widespread disturbances and inconsistencies throughout their respective legal
systems. This is because, as some scholars have argued, cutting into a child’s genitals without a
medical diagnosis, and without its informed consent, meets the formal definition of criminal assault
under the legal codes of most of these societies.(4,17–20) (Please note that this view assumes that
parental “proxy” consent is invalid for such procedures, for which arguments have been given
elsewhere).(20–22) Indeed, in its move to ban FGA in 1997, the U.S. Congress stated “that it
‘infringes upon the guarantees of rights secured by Federal and State law, both statutory and
constitutional.’ That is to say, [non-therapeutic] female genital cutting [without consent] was already
unlawfulprior to the enactment of specific legislation.(23)
A further issue, as Blackstone noted more than 200 years ago, is that “the law cannot draw [a] line
between different degrees of violence.”(24)[p. 270] What this means is that if any particular act of
violence—such as the cutting of a child’s body in the absence of medical necessity, perhaps
especially with the effect of damaging or removing functional tissue—is legally permitted, then
fraught decisions have to be made “as to where within the continuum of violence the limits are to be
fixed.”(25)[p. 129] This, in turn, could open the door for interested parties to argue, for any proposed
act of cutting, that it is not “violent enough” to warrant the placement of limitations on parental
decision making.(4) More on this will be said in a subsequent section.
An additional problem is that changing the law would remove at least one important tool that
reformers from within the affected communities can appeal to, in their quest to end the spectrum of
FGA practices. Specifically, many women from established immigrant groups report that they do not
wish to continue subjecting their daughters to FGA (for an excellent review of the evidence
concerning “cultural change after migration” with respect to this issue, see the work of Johnsdotter
and Essén)(26) but they may face pressure from fellow group members.(27) This can make it
difficult for any one parent or family to unilaterally challenge, much less abandon, the tradition: as
Mackie has argued, it is a collective action problem.(28,29) What a legal prohibition allows for, then,
is reformers from within these groups to be able to point to the law and say, “I have no choice but to
keep my daughter’s genitals intact,” effectively resolving the social dilemma.(27,30)
Finally, as Ludbrook argues, “the law is an important symbol and if [it] allows parents, carers and
teachers to [so much as hit their] children,” much less cut into a physically and symbolically
sensitive part of their bodies, “it is sending a message to these people and to the community
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generally that children are not entitled to the same right to bodily integrity as adults.”(25)[p. 129]
Against this view, Arora and Jacobs argue that (what they regard as) “de minimis” forms of FGA “do
not constitute a human rights violation” with respect to bodily integrity, because they have “no more
effect than other accepted procedures performed on minors for esthetic enhancement.”(1) In
previous writings, they have listed mole removal and cosmetic orthodontia as examples of such
procedures.(31) But as I have suggested elsewhere: “the genitals (in particular) might plausibly be
seen as having a special, even unique psychosexual significance compared to other parts of the body,
which could make their un-consented alteration more likely to be experienced (later on) as a harm.
[This] could help to explain why there is an active ‘genital autonomy’ movement in the United
States, Europe, and elsewhere—fueled by women, men, and intersex people who are extremely
resentful about their childhood genital surgeries—but not an anti-orthodontics movement or an anti-
mole removal movement.”(32)[p. 45]
More could be said about this disagreement. For a thoughtful analysis of the right to bodily integrity
as it applies to pre-autonomous individuals, see the essay by Ungar-Sargon in a recent issue of this
journal.(33) See also the work of Darby on a child’s “right to an open future.”(34) For an extended
articulation of my own views concerning the ethics of ostensible “enhancement” procedures in
children, see the references here.(5,12,35,36)3
Regulatory problems
Another problem with the authors’ proposal has to do with monitoring and regulation. As Arora and
Jacobs concede, their suggestion might “open the door” for “more invasive procedures [to be carried
out] under the guise of de minimis procedures,”(1) thereby increasing the overall level of harm. In
response to a similar policy proposal by the American Academy of Pediatrics in 2010 (see later
discussion), the Somali-born writer and activist Hirsi Ali asked: “how could we tell that parents who
want to ensure that their daughter will be a virgin on her wedding night will not have her (legally)
nicked [on one day] and then a few months later (illegally) infibulated?”(37) Indeed, as Leye and
colleagues point out, “in some communities, traditional circumcisers will ‘redo’ girls if they notice
that only an incision has been made.”(38)[p. 368]
3 Of particular relevance is the essay, Between Moral Relativism and Moral Hypocrisy: Reframing the Debate on ‘FGM,’” in press at
the Kennedy Institute of Ethics Journal. The accepted manuscript is available online ahead of print here:
https://www.academia.edu/10197867/Between_moral_relativism_and_moral_hypocrisy_Reframing_the_debate_on_FGM_.
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The authors’ response to this type of objection is that “given the widespread nature currently” of the
more invasive procedures, “if even a few girls undergo a de minimis procedure instead of a more
invasive one due to this strategy then the strategy is appropriate.”(1) However, they do not provide
any evidence that the more invasive procedures are in fact “widespread” in Western countries,
specifically, which is the legal setting most relevant to their arguments (and readership); in fact the
recent survey by Johnsdotter and Essén stands in direct contrast with this scenario.(26) Moreover, if
permitting “minor” forms of FGA actually had the effect of lending a “cloak of respectability” to all
FGA procedures—a possibility that Arora and Jacobs themselves raise, but do not adequately
consider—then the more invasive forms might very well increase in number, leading (again) to
greater harm overall. Since the authors do not provide any persuasive evidence in favor of their own
predicted outcome as opposed to this plausible alternative, it is unclear why we should endorse their
policy proposal, even on consequentialist grounds.
A related problem is more practical in nature. How would the actual cutting sessions be monitored
(and by whom) to make sure that only the “right amount” of tissue was being incised, damaged, or
removed? Arora and Jacobs admit that this is a problem with their proposal. But instead of
addressing it, they simply divert attention to other problematic practices. As they write: “The
concern regarding amount of tissue being removed is … not unique to FGA, but is similar to male
circumcision as well as cosmetic surgeries on adults.”(1)
They are right to raise the example of male circumcision. At least one under-documented risk of this
procedure, especially when carried out in infancy, is the removal of too much tissue—sometimes
causing painful erections when the child grows up.(39–42) To put it simply, there is no “dotted line”
showing where to cut around an infant’s diminutive penis, just as there is no determinate location
where the foreskin ends and where the rest of the penis begins. This uncertainty in terms of where to
cut, and the associated risk of cutting away too much, arguably speaks in favor of deferring the
surgery until the organ has reached its full size. Then, the individual whose genital integrity is at
stake can indicate exactly how much tissue (and of what kind) he would like to have removed—if
any4—and he can do so under conditions of informed consent.
A similar analysis applies to FGA procedures. In fact, this parallel leads us directly to the other
diversion mentioned by the authors, namely, “cosmetic surgeries on adults.” The key word is
“adults.” If an adult female wishes to undergo a genital surgery (to choose the most pertinent
4 The overwhelming majority of men who grow up with intact genitalia do not go on to pursue circumcision later on.
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example) for cosmetic, cultural, religious, or other reasons, there is indeed, as Arora and Jacobs
point out, a non-trivial risk that too much tissue will be removed, or that the surgery will yield
unsatisfactory results in any number of other ways. But this would be mitigated by the fact that the
surgery was undertaken voluntarily. In other words, the primary (moral) difference between
consensual genital surgery, and both FGA and MGA carried out on children, is that an adult can
assess the relevant risks in light of her own goals and values, and determine whether they are “worth
it” to her, all things considered.(35,43) A child has no such recourse.
Speaking generally, then, the suggestion of harm-tolerance when it comes to interventions into
children’s bodies is untenable. In part, this is due to “the difficulty it presents in terms of specifying
an appropriate threshold for harm that could be measured in an objective way.”(4)[p. 98] As Van
Howe notes, the meaning of “harm,” in practice, therefore, will inevitably be left up to the
interpretational vagaries of each provider, perhaps in consultation with the child’s parents.(44) This
vagueness creates a problem: “there are practitioners, especially in cultures where female
circumcision is common, who fervently believe that more invasive forms of female circumcision”—
that is, forms that even Arora and Jacobs reject—“do not pose risks of physical or psychological
harm.”(44)[p. 167] In fact, these providers could easily make selective appeals to studies from the
medical literature that appear to show health-based benefits for FGA,(4) as well as an absence of
serious harms,(45) much as some supporters of MGA are prone to do.(46,47) When the many
purported cultural benefits of FGA are factored in, Van Howe continues, “practitioners could easily
convince themselves that any harm is more than offset by the many perceived benefits.”(44)[p. 167]
Medical problems
Potential problems concerning clinical and surgical matters have been raised by Leye and colleagues.
They write: “it is difficult to avoid damaging the clitoris when performing a [“de minimis”] incision,
especially in genitalia that are not fully developed.” Moreover, “complications (such as shock,
infections, sepsis, and bleeding) are difficult to avoid [entirely], even with [such a minor]
incision.”(38)[ p. 368] Thus, as Goldman has stated, the assumption that “de minimis” interventions
into a child’s vulva really are essentially harmless is “debatable.” As he goes on to write: even if it
could be shown that the harm is, in some sense, “relatively minor, it is still harm. Certainly, there is
physical harm or risk of physical harm any time a cutting instrument contacts sensitive genital
tissue.”(48) He concludes, then, that the “burden of proof” is on those who argue that the risk of
harm is trivial.
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How Arora and Jacobs could meet this burden is unclear. First, as they note, it is currently illegal in
Western societies to perform FGA procedures in children, so it is impossible to collect the very data
that would be needed to make their case. But let us just assume that the ban were lifted. How long
would it be reasonable to allow for such procedures to be performed in the absence of high quality
long-term follow-up data (concerning such vital issues as the effects of these procedures on, e.g.,
sexual function, sensation, and satisfaction) before it became possible to show that they had, in fact,
been more harmful than Arora and Jacobs guessed that they would be?
An example should elucidate the danger. Consider “procedures resembling elective labiaplasty as
performed in Western nations,” which Arora and Jacobs use to illustrate Category 2 of their
proposed typology. This refers to interventions that “create morphological changes, but are not
expected to have an adverse effect on reproduction or on the sexual satisfaction of the woman or her
partner.”(1)
Arora and Jacobs argue that such procedures should be considered permissible in young girls, so
long as they are requested by the parents. Problematically, however, the only available studies
assessing reproductive and sexual outcomes associated with this particular intervention stem from
surgeries performed on consenting adult women (or older adolescents); and even then the data are
woefully incomplete.(49) But—again—let us just assume that, one day, researchers do produce a
robust and convincing benefit-to-risk (or benefit-to-harm)(50) profile for non-therapeutic labiaplasty
or similar procedures carried out on adults. Even so, we could not be sure that the profile would
apply to children.(32) For one thing, sexual outcomes, in particular, are highly subjective;(51) and
the women who undergo procedures akin to labiaplasty and subsequently report on their effects are
unlikely to be representative of the general female population. This is because, overwhelmingly, they
will have pursued their elective genital surgeries precisely because they were unsatisfied with their
labia/vulva in some way, and wanted a change. In the case of a young girl, however, we cannot
know, in advance, how she will (later) regard her own vulva—she might value her genitals in their
intact state very highly—and so we are not in a position to judge how their modification would
affect her sexual experience.
Sexual problems
Against this view, it might be argued that if genital tissue is excised early enough, a girl will not
“know what she is missing” when she reaches an older age. Similar arguments are raised in support
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of performing male circumcision as early as possible. But this does not guarantee a “harmless”
outcome. On the contrary, such an intervention could just as easily lead to feelings of loss or
resentment—whether or not the surgery itself was consciously remembered. After all, a woman
might reasonably wonder what sex, masturbation, etc., would have been like had her vulva been left
intact, and feel angry that she was not given the chance to find out. In line with this perspective,
there are indeed many documented reports of women (as well as men and intersex people) who had
their genitals modified for non-therapeutic reasons in early childhood, who do in fact experience
anger and resentment. These feelings, in turn, have the potential to impact negatively on sexual
experience, quite apart from any “purely” physical effects that would ensue from the loss of sensitive
tissue (see Box 1).(22,27,52–56)
The lesson here is that classification of childhood genital surgeries based on “predicted” effects on
sexuality is a mistake. Since everyone’s genitals are unique (including the specific distribution of
nerve endings, how sensitive the tissue is in different parts, and so on), and since people have
different attitudes toward intact vs. modified genitals, as well as different sexual preferences that can
range rather widely, it is not particularly ethically useful to make bland, medicalized statements
about expected sexual satisfaction considered as an “average” effect of some intervention. This is
especially the case given that such outcomes are typically measured by reductive “scientific” surveys
involving numbered scales or similar, often failing to control for socially desirable
responding.(32,57)
Indeed, Arora and Jacobs’s willingness to rely on such statements in their endorsement of both
male(31) and female(1) forms of non-therapeutic genital alteration, rather than proceeding cautiously
and recognizing the limitations—or even nonexistence—of the pertinent data,(32) is worrying. When
a child’s genitals are on the line, along with the prospect of diminishing his or her future sexual
function and/or satisfaction (the latter of which is a highly subjective notion), we should be
extremely careful about making assumptions of no-harm when the available data are so weak and
contentious.
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Box 1. What are the likely effects of procedures resembling labiaplasty on a woman’s sexual
experience?
Cultural problems
A further problem is that Arora and Jacobs’s proposal is culturally incoherent. On the one hand, they
decry “culturally insensitive” laws and language that seek to eliminate “female genital mutilation.”
But on the other hand, they offer a made-up, “medicalized” ritual of their own design, without
explaining how this would satisfy the real-life cultural impulses of the families who endorse FGA.
As they themselves state, “We are … not suggesting that people whose beliefs or sense of propriety
leads them to perform these procedures on their children would necessarily accept alterations to their
practices to conform to the authors’ views of what is acceptable.”(1) Indeed—why would they? As
Hirsi Ali has written: “To understand this problem, we need to begin with parental motives. The
‘nicking’ option is regarded as a necessary cleansing ritual … the clitoris is considered to be an
impure part of the girl-child and bleeding it is believed to make her pure and free of evil spirits.
Problematically, however, for girls in at least some communities, the point of FGA is “to ensure
their virginity … and to curb their libido to guarantee sexual fidelity after marriage.” Thus, when
FGA is intended “to ensure chastity before marriage and to curb female libido … the nick option
[would not be] sufficient” from a cultural perspective.(37)
involved in the process of engorgement during sexual arousal. It follows therefore that labiaplasty has the
potential to remove tissue that contributes to sensory sexual arousal.” In fact, “the labia minora are second
addition, the labia can be orally and manually manipulated, which may yield particular sensations that would
be physiologically impossible if the tissue were removedan outcome that Arora and Jacobs seem to regard
as irrelevant. Whether such an outcome is on balance negative, of course, cannot be “scientifically”
determined; rather, it depends on an individual’s sexual preferences. For example, for those for whom the
ability to fondle, etc., the labia is an important part of their sexual activity, the surgical reduction or
elimination of this tissue would indeed be expected to “have an adverse effect on … sexual satisfaction.”
The upshot is that everyone is different. Thus, as Johnsdotter has argued, there is no consistent relationship
between type or degree of genital cuttingwhether in females, males, or intersex peopleand subjective
sexual pleasure later on. Hence: “the current academic focus on the role of genitalia in understanding sexual
pleasure is a dead end. While genitalia usually are central to sexual activity,
for sexual intercourse, it is a misapprehension to see the state of them (cut or uncut) as determinative of the
individual’s experience of the sexual encounter. Consequently, ongoing debates on enhancing or detrimental
effects of circumcision practices often miss the point, since they are based in too narrow a theoretical
framework of sexual pleasure.(59)[p. 262] See Appendix for further discussion.
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Political problems
Finally, there is almost no chance that Arora and Jacobs’s suggestion will actually be taken up by
lawmakers: it is a political non-starter. This can be inferred from the debacle that ensued in 2010,
when the American Academy of Pediatrics (AAP) issued a policy similar to the one proposed by the
authors, in the name of “cultural sensitivity.” As Arora and Jacobs discuss, it was summarily
retracted (just one month later) after it was met with fierce opposition and outrage.(58) Opponents of
the AAP policy included survivors of FGA such as Ayaan Hirsi Ali(37) and Soraya Mire;(58–60)
members of its own ranks;(44,61,62) distinguished doctors from other countries;(63) U.S.
lawmakers;(64) and organizations such as Equality Now, an international advocacy network fighting
to end female genital cutting.(65)5 In fact, I expect that Arora and Jacobs’s own proposal (as well as
perhaps the Journal of Medical Ethics, for publishing it) will be met with a similar outcry. While
their article constitutes an interesting (if unoriginal)(3) academic exercise, Western societies have,
for the most part, reached the seemingly irreversible conclusion that sharp objects should not be
taken to the vulvas of little girls, unless it to save their life or health.(11) Importantly, many
immigrant communities in these same societies—derived from populations where FGA has
traditionally been performed—have reached the same conclusion, and have willingly given up the
practice.(26) It would be sobering for those who have struggled toward this end to see such progress
reversed.
There are numerous other problems with Arora and Jacobs’s proposal, including misleading (or
inaccurate) citations concerning key empirical assertions, but I do not have the space to cover them
all in detail in this response. Instead, I refer the reader once again to the Appendix accompanying
this article, in which I discuss these and other matters: it is available at the following link: [Please
note: in this document, the Appendix is located immediately following the references section for the
main text].
Conclusion
In summary, if Western societies were to change their laws in order to allow for more “minor” forms
5 Similar patterns have played out in other countries. For example, as Leye et al(38)[p. 367] report (internal references omitted): “In
1992, two researchers in the Netherlands submitted a report to the Dutch Ministry of Health in which they proposed that as a step
toward the total eradication of the practice, incisions of the clitoris be allowed in cases where the parents or family wanted to
circumcise a girl. This kind of incision was considered as a nonmutilating form of ‘female circumcision,’ as FGM is commonly
referred to in the Netherlands. This report’s recommendation provoked a public debate about the issue that resulted in the total
rejection of any form of FGM and, moreover, the rejection of any attempts to differentiate between mutilating and nonmutilating
forms of ‘female circumcision.’”
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of FGA, this would likely result in: (a) disturbances and inconsistencies throughout their legal
systems, possibly requiring new definitions of bodily assault and opening the door for inadvertent
legal protection of a wide range of potentially harmful practices (typically carried out on children,
who cannot adequately defend themselves); (b) removal of an important tool that reformers from
within the affected communities rely on to solve the “collective action” problem introduced by FGA;
(c) regulatory challenges in tracking and monitoring FGA cutting sessions to ensure that they were
not being used as opportunities for more invasive procedures; (d) exposure of young girls to an
unknown amount of surgical risk in the absence of medical need, thereby placing doctors in an
untenable position with respect to their professional duties; (e) accusations of cultural insensitivity,
on account of outsiders having invented a “compromise” intervention to be carried out in a
medicalized setting, with the aim of replacing the traditional rituals that carry meaning for the
relevant communities; and (f) widespread outrage among women who consider themselves victims
and/or survivors of FGA as well as their allies, and other forms of political backlash.
In light of these considerations, let us return to Arora and Jacobs’s major conditional argument:
namely, that “a liberal society that tolerates expression of culture and/or religion in the manner of
male circumcision should also permit certain de minimis [female genital altering] procedures.”(1) I
have tried to show that such permissiveness would result in a fiasco, making this suggestion (for all
intents and purposes) a reductio ad absurdum. Accordingly, there is a growing trend among scholars
of genital cutting, particularly in the fields of bioethics and law, of arguing that it is time to consider
a less lenient position toward MGA (whether by banning it with a possible exception for sincere
religious belief, or by regulating it in other ways), rather than a more lenient position for
FGA.(8,9,17,43,66–68) As Arora and Jacobs themselves point out, “We acknowledge that issues of
cultural sensitivity and gender discrimination in the disparate treatment of male circumcision and
FGA could also be treated by proscribing both, instead of the position for which we are advocating.
In fact, many have criticized male circumcision as a human rights violation due to the lack of
autonomous decision-making and the irreversible nature of the procedure.”(1) Whether it is in fact a
fundamental human rights violation, or rather a morally objectionable practice on other grounds, “it
is clear that the current laissez faire attitude toward MGA that is typical of Western societies – and
in particular the United States – can no longer be maintained without facing serious scrutiny. FGA
and MGA are both highly problematic practices, with far more overlap between them (both
physically and symbolically) than is commonly understood: they should not be discussed, therefore,
in hermetically-sealed moral discourses.”(4) My own perspective is that the most promising way
12
forward would be to argue for an “autonomy-based” ethical framework,(4,9) whereby “Children of
whatever [sex or] gender should not have healthy parts of their most intimate sexual organs removed,
before such a time as they can understand what is at stake in such a surgery and agree to it
themselves.”(69)
Acknowledgements
Thanks are due to Mikey Dunn for constructive feedback on an earlier draft of this response.
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42. Male circumcision. Pediatrics. 2012;130(3):e756–e785.
43. Dustin M. Female Genital Mutilation/Cutting in the UK: challenging the inconsistencies.
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45. Catania L, Abdulcadir O, Puppo V, Verde JB, Abdulcadir J, Abdulcadir D. Pleasure and
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reply_to_Brian_Morris
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50. Darby R. Risks, benefits, complications and harms: neglected factors in the current debate on
non-therapeutic circumcision. Kennedy Inst Ethics J. 2015;25(1):1–34.
51. Johnsdotter S. Discourses on sexual pleasure after genital modifications: the fallacy of genital
determinism (a response to J. Steven Svoboda). Global Discourse. 2013;3(2):256–65.
52. Darby R, Cox L. Objections of a sentimental character: the subjective dimensions of foreskin
loss. In: Zabus C, editor. Fearful Symmetries: Essays and Testimonies Around Excision and
Circumcision. Amsterdam and New York: Rodopi; 2009. p. 145–68.
53. Watson L. Unspeakable Mutilations: Circumcised Men Speak Out. New Zealand: Amazon
Media; 2014.
54. Bossio J. Examining sexual correlates of neonatal male circumcision. Doctoral dissertation
2015. Available from: https://qspace.library.queensu.ca/handle/1974/13627
55. Foldès P, Cuzin B, Andro A. Reconstructive surgery after female genital mutilation: a
prospective cohort study. Lancet. 2012;380(9837):134–41. Available from:
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56. Dreger A. Galileo’s Middle Finger: Heretics, Activists, and the Search for Justice in Science.
New York: Penguin Press; 2015.
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57. Earp BD. The need to control for socially desirable responding in studies on the sexual effects
of male circumcision. PLoS ONE. 2015;10(9):1–12. Available from:
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58. Chen S. Pediatricians now reject all female genital cutting. 2010 [cited 2015 Nov 24].
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59. Pollack M. Circumcision: gender and power. In: Denniston G, Hodges F, Milos M, editors.
Genital Cutting: Protecting Children from Medical, Cultural, and Religious Infringements.
Dordrecht: Springer Netherlands; 2013. p. 297–305.
60. Mire S. The Girl with Three Legs: A Memoir. Chicago: Chicago Review Press; 2011.
61. Strandjord S. Opportunity for education plus protection of minors. Pediatrics. 2010;125(5):n.p.
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63. Bewley S. Sincerity, retraction and apology? Pediatrics. 2010;125(5):n.p. Available from
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64. Luscombe B. Female Genital Cutting: will U.S. doctors approve nicks? TIME. 2010. Available
from: http://content.time.com/time/health/article/0,8599,1988434,00.html
65. Equality Now. American Academy Of Pediatrics (AAP) is advocating or U.S. pediatricians to
perform certain types of Female Genital Mutilation (FGM). Equality Now. 2010 [cited 2015
Nov 24]. Available from: http://www.equalitynow.org/american-academy-pediatrics-aap-
advocating-us-pediatricians-perform-certain-types-female-genital-mut
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International Journal of Children’s Rights. 2006;13:161–81.
67. Tasmania Law Reform Institute. Non-Therapeutic Male Circumcision. 2012 Aug; Available
from: http://www.utas.edu.au/__data/assets/pdf_file/0006/302829/Non-Therapuetic-
Circ_Final-Report-August-2012.pdf
68. Hellsten SK. Rationalising circumcision: from tradition to fashion, from public health to
individual freedom--critical notes on cultural persistence of the practice of genital mutilation. J
Med Ethics. 2004;30(3):248–53.
69. Earp BD. Practical Ethics [Internet]. Female Genital Mutilation (FGM) and male circumcision:
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time-to-confront-the-double-standard/
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Appendix to: “In defence of genital autonomy for children”
Brian D. Earp
Visiting Scholar, The Hastings Center Bioethics Research Institute,
Garrison, NY, USA
Introduction
This is an Appendix to the article, “In Defence of Genital Autonomy for Children”(1) which is itself
a response to “Female Genital Alteration—A Compromise Solution” by Arora and Jacobs.(2)
The Appendix is divided into two parts. In the first part (Part I), I present an overview of various
“overlaps,” both physical and symbolic, between male and female forms of non-therapeutic genital
alteration (MGA, FGA). This is to show why the conditional argument by Arora and Jacobs—
namely that if it is the case that MGA should be widely tolerated, then so should some forms of
FGA—is valid even if it is not, as I argue in my response piece, sound. In the second part (Part II), I
provide a point-by-point response to various specific claims by Arora and Jacobs that are misleading,
inaccurate, or otherwise problematic, but which I did not have the space to cover in the main article.
PART I. A brief overview of the morally-relevant “overlaps” between FGA and MGA
In this section, I provide a brief sketch of the “overlaps” between non-therapeutic male and female
genital altering procedures. I recognize that many of the claims in this section will seem
counterintuitive to those who are new to this area given the prevailing popular and academic
discourses; I can only hope that the reader will take the time to follow up on the references I cite in
support of them. For a much more sustained defense of the view presented in this section, please see
my essay, “Female Genital Mutilation and Male Circumcision: Toward an Autonomy-Based Ethical
Framework.”(3)
Area of overlap #1: harm
Both male and female forms of non-therapeutic genital alteration fall on a wide spectrum. The
physical and sexual harms that they may cause substantially overlap, depending upon the type of
procedure, how much tissue (and of what kind) is removed, which instruments are used and how
sterile they are, what level of training the practitioner has, and so on. In particular, several forms of
18
WHO-recognized FGM procedures, such as cutting and/or removing part(s) of the clitoral hood
(such as is common in Malaysia), as well as some interventions into the labia, are uncontroversially
less physically harmful than the most widespread forms of male circumcision. Conversely, several
forms of male genital cutting/alteration, such as subincision in parts of aboriginal Australia, or tribal
circumcision as it is carried out among the Xhosa of South Africa, can be at least as physically
harmful as the most widespread forms of FGM, and are frequently much more harmful as a matter of
practice.(3)
Area of overlap #2: benefits
The benefits of both male and female forms of non-therapeutic genital alteration overlap as well. As
I have argued elsewhere,(3,4) the health benefits that have been attributed to male circumcision, at
least in a Western context, are relatively minor (in terms of absolute risk reduction for various
diseases, many of which can be prevented and/or treated non-surgically); they apply mostly after an
age of sexual debut (i.e., when meaningful consent could at least in principle be obtained); they can
be achieved in much less harmful ways (such as by the practice of basic hygiene and the adoption of
safe sex practices); and, according to the balance of medical opinion on a global scale, they do not
very likely outweigh the risk of immediate complications plus delayed complications and longer-
term harms(5) (contrary to the insinuations of Arora and Jacobs; see the discussion in Part II of this
Appendix).
On the other side of the coin, we do not actually know that certain minor forms of FGA—such as
neonatal labiaplasty, or perhaps other interventions—would not confer the same degree of
prophylaxis against disease as male circumcision purportedly does, in virtue of removing healthy
tissue from the vulva that could later host an infection, cancer, or other malady. Indeed, it is illegal,
in Western countries, to conduct a trial to find this out.(4) That said, there is in fact some
observational evidence that FGA may be associated with certain health benefits, including reduced
transmission of HIV.(3)
With respect to purported socio-cultural and/or religious (or spiritual) benefits, both male and female
forms of non-therapeutic genital alteration are defended in largely similar terms by those who
endorse them.(3,6–13) Speaking generally, as Gunning notes, “Both can be seen as unnecessary
alterations of normal, healthy genitalia justified by questionable health benefits and bolstered by
culturally, socially, or religiously defined notions of aesthetics and clearly delineated binary ideas of
19
gender.”(14)[p. 655-656]
Area of overlap #3: symbolic meanings
Contrary to common wisdom, FGA “is not always associated with, nor a reflection of, sexist and
patriarchal norms; nor are the norms associated with male genital cutting always as morally innocent
as is typically assumed.”(3) For example, among the Kono of Sierra Leone, “there is no cultural
obsession with feminine chastity, virginity, or women’s sexual fidelity … because the role of the
biological father is considered marginal and peripheral to the central ‘matricentric unit.’”(15) In this
context (as in many other African contexts) “male and female genital alterations are performed in
parallel ceremonies, are not primarily intended to reduce sexual pleasure, and the operations are seen
as mirror images of each other.”(3)
At the same time, as Fox and Thomson show, certain other forms of male genital cutting (as well as
female genital cutting) can in fact be understood as gendering practices tied to patriarchal notions of
masculinity, as well as to cultural systems based on male privilege and the ritual exclusion of
women.(16) For example, as Kimmel argues, male circumcision “means [the] reproduction of
patriarchy.” In the Jewish tradition, “Abraham cements his relationship to God by a symbolic genital
mutilation of his son. It is on the body of his son that Abraham writes his own beliefs. In a religion
marked by the ritual exclusion of women, such a marking not only enables Isaac to be included
within the community of men [but] he can also lay claim to all the privileges to which being a
Jewish male now entitles him.” To circumcise one’s son, therefore, is “to accept as legitimate 4000
years [of] patriarchal domination of women.”(17)
Finally, as Arora and Jacobs themselves point out (and as many others have argued), the supposed
distinction between “religion” and “culture” as a means of distinguishing male vs. female forms of
ritual genital cutting is logically untenable, historically inaccurate, and anthropologically ill-
informed.(6,18,19)
Implication
Taken together, these overlaps imply that “a stark moral distinction between male and female forms
of non-therapeutic, non-consensual genital alteration may be impossible to maintain on principled
grounds.”(3) As a consequence of this fact, liberal societies face a choice if they wish to be
consistent.(20) Roughly speaking, they can either allow both types of genital alteration to be carried
20
out on similar terms, or they can disallow (or at least discourage) both types of genital alteration on
similar terms.
Arora and Jacobs prefer the former option; I prefer the latter. In the next section, I take a closer look
at the arguments and evidence presented by Arora and Jacobs in support of their position, which I
argue is ultimately untenable. Here I go beyond what I was able to cover in my original response
piece.
Part II. A closer look at the various claims advanced by Arora and Jacobs
In this section I address specific weaknesses in Arora and Jacobs’s (A&J’s) argument, by giving a
point-by-point response. I will move sequentially through their paper, and the format will be to give
a quote from A&J, followed by a discussion of any problems contained therein.
“The World Health Organization (WHO), American Academy of Pediatrics (AAP), and the
American Congress of Obstetricians and Gynecologists (ACOG) have policies in place to support
circumcision.”
There are several problems with this statement. First, the WHO has a policy in place to support so-
called Voluntary Medical Male Circumcision (VMMC), not in “Western” countries (which is the
main subject of A&J’s proposal), but rather in sub-Saharan Africa as a form of partial prophylaxis
against heterosexually transmitted HIV (female-to-male only) in areas with high base-rates of such
transmission, and low base rates of male circumcision.(21) Crucially, the “Voluntary” part of
VMMC implies (or should imply) that the circumcision should be undertaken by an individual who
can provide his own consent, not an infant or young child (who cannot). Nobody objects to truly
informed, consensual adult circumcision; it is the circumcision of infants and children that is
ethically contentious. Moreover, the data that the WHO appeals to in support of its policy were
derived from Randomized Control Trials (RCTs) performed with adult male participants (in Africa),
not infants or young children (in Western countries). Since “the spread of disease, including sexually
transmitted infections, is determined much more by socio-behavioral and situational factors than by
strictly anatomical-biological factors, such as the presence or absence of a foreskin ... the apparent
findings from these studies cannot be simply mapped on to non-analogous public health
environments, nor to circumcisions performed earlier in life, i.e., before an age of sexual debut.”(4)
21
Second, A&J do not mention that the policy by the AAP they cite (which does not recommend
circumcision, but rather leaves the decision up to parents) was roundly criticized by international
pediatric and sexual health experts,(22) and is in fact inconsistent with comparable policies from
many other pediatric societies in peer nations, including the recently-released statement by the
Canadian Paediatric Society.(23,24) As Wolfram Hartmann, President of the German Pediatric
Society, explained, “The statement from the AAP ... has been graded by almost all other paediatric
societies and associations worldwide as being scientifically untenable.”(25) For an incomplete
sample of published critiques of the 2012 AAP policy statement and technical report—none of
which were cited by Arora and Jacobs in their paper—see the references collected here.(4) For an
incomplete sample of medical bodies which, in their current policies, either fail to conclude that the
benefits of involuntary male circumcision outweigh the risks, or state that the risks in fact outweigh
the benefits, see statements from: the Canadian Paediatric Society;(23) the Royal Australasian
College of Physicians;(26) the Royal Dutch Medical Association;(27) the German Academy for
Pediatrics and Adolescent Medicine;(25) the Swedish, Norwegian, and Icelandic Pediatrics
Societies;(28) and the National Health Service of England.(29) Why Arora and Jacobs decided to
emphasize the position of a minority of medical bodies—from the single developed country in the
world that practices routine circumcision for non-religious reasons—whose policies could be
interpreted as supporting their views on health benefits for male circumcision is unclear.
Finally, please note that the ACOG does not have its own policy “supporting” male circumcision,
but rather signed on to the AAP policy as a formal gesture. The document available from the
ACOG’s own website actually states: “At the present time, there is not enough information to
recommend routine newborn circumcision for health reasons.”(30)
“While years of advocacy and legislation aimed at eliminating non-therapeutic procedures on
female external genitalia has resulted in a decline in the prevalence of the practice, the magnitude of
this decline has been soberingly small. … In a study in Somalia, the country in the world with the
highest prevalence of these procedures, 81% of subjects underwent infibulation and only 3% did not
have FGA. Eighty-five percent had an intention to subject their daughters to an extensive FGA
procedure, and 90% supported the continuation of the practice.
This citation is misleading. The study involved a sample of 215 persons from one county in one
town in Somalia; there is no way of knowing whether the reported estimates are nationally
representative.(31) Moreover, the statement that “Eighty-five percent” of participants “had an
22
intention to subject their daughters to an extensive FGA procedure” is false: as the authors of the
report themselves stated, of this 85%, fully “154 (71.6%) were planning to use the Sunna form [i.e.,
the least extensive form], with the reason behind their decision either being because they considered
the Sunna form to be harmless or because it was seen as a religious requirement.”(31)[p. 4].
Similarly, with respect to the statement (from A&J) that “90% supported the continuation of the
practice,” it should be noted that the authors of the report actually wrote: “Of this, 164 (76.3%)
persons supported the continuation of the Sunna form only, while [only] 10.7% supported the
continuation of all forms” of the practice.(31)[p. 4)] The broader point, however, is that there has, in
fact, been significant progress in many African countries in reducing the rate of non-therapeutic
FGA procedures (as A&J themselves concede later on in the paragraph).
Even more importantly, however, what A&J appear to be advocating (although their language is
ambiguous on this point) is a change in laws in Western countries, not Africa. So the only data that
are relevant to their argument is the prevalence of FGA in Western countries (among immigrant
populations), and the effect of laws that prohibit FGA on its prevalence in those countries. In other
words, it is a non-sequitur to argue that, since the effects of anti-FGA advocacy in African countries
have been “soberingly small” (whether or not that really is the case), we should therefore “relax” the
laws concerning FGA in countries like the United States!
On this point, A&J provide no compelling estimates of FGA prevalence in Western societies, but
instead state that: “Immigrants to Western nations may continue to subject their daughters to genital
alteration, though the frequency is difficult to assess.” By contrast, in a recent review of the evidence,
Johnsdotter and Essén report that: “Exploratory studies show trends of radical change of this harmful
practice, especially the most extensive form of its kind. The widespread interpretation that Islam
would require circumcision of girls becomes questioned when, e.g., Somalis meet other migrants,
such as Arab Muslims, who do not circumcise their daughters. The few criminal court cases for
circumcision of girls that have taken place in Western countries corroborate the conclusion that
substantial change of the practice has occurred among migrants.”(32) Insofar as A&J’s policy
proposal really is motivated by a concern about “widespread” FGA being carried out on an
“underground” basis in Western countries, due to their restrictive laws concerning the practice, it is
not clear that there is enough of a problem that changes to these laws should in fact be seriously
entertained.
“While laws enacted in [Western] societies make procedures that alter a female’s external genitalia
23
illegal, they may in some instances worsen health outcomes by driving the practice underground, by
sending female children to Africa, or by inviting circumcisers to the West.”
They may have this effect, or they may not. Unfortunately, the authors do not provide any evidence
that prohibitions on FGA in Western countries lead to worse health outcomes overall by, e.g.,
“driving the practice underground.” Instead, they cite a paper by Leye et al., which in turn cites
another paper by Leye (and a colleague) in which those authors state: “The true magnitude of the
problem of FGM in [the studied countries] could not be assessed, and this lack of accurate FGM
prevalence data make it hard to substantiate the claim for services, legislation and funds for
prevention work.”(33)[p. 47] It is easy to speculate. But on a harm-reduction analysis, prohibition
would only be an imprudent strategy if the amount of harm that was added through the postulated
“underground” FGA procedures (including overseas trips, etc.) as a consequence of the law were
greater than the amount of harm that was reduced by an overall drop in prevalence of FGA (due to
its being illegal).
In short, we do not know how many girls are at risk of FGA in Western countries, and we have no
evidence that the law (as it stands) is not an effective harm-reduction measure compared to
alternatives (including A&J’s proposal), particularly when it comes to “health outcomes.”(32) In
Africa and the Middle East, by contrast, where many communities see the prohibitions in their
countries as being effectively forced on them by cultural outsiders/ former colonial powers, the laws
may indeed lead to resentment and backlash and may therefore be much less effective. But this
would suggest that cultural imperialism is a problem,(34) not (necessarily) that the laws in Western
countries should be changed to accommodate the practices of immigrants who come to their shores
(just as we would not expect, e.g., China to change its laws to accommodate the controversial
practices of Westerners who might immigrate there). As Chapin (quoted in Belluck)(35) stated in
response to an earlier U.S. policy proposal (by the AAP) similar to the one advanced by A&J:
“There are countries in the world that allow wife beating, slavery and child abuse, but we don’t
allow people to practice those customs in this country. We don’t let people have slavery ‘a little bit’
because they’re going to do it anyway, or beat their wives ‘a little bit’ because they’re going to do it
anyway.” More generally, when certain acts in a host country are considered morally impermissible,
such as sexual assault—yet nevertheless persist for whatever reason (whether in immigrant
communities or in the majority population)—this does not normally cause us to consider “relaxing”
the laws against sexual assault (to repeat that example), including its “minor” forms.
24
Now, one could certainly argue that the law should not be the only tool for reducing harm associated
with FGA, especially if it is being applied in a “sensationalized, ethnocentrist, racist, culturally
insensitive, and simplistic” manner as A&J worry. But rather than “relaxing” the law, the law could
instead be complemented with, e.g., sensitivity training, and could be applied in a nonracist, non-
ethnocentric way by being expanded to cover similar practices that happen to be more popular in the
host country.(34)
“To accommodate cultural beliefs while protecting the physical health of girls, we propose a
compromise solution in which liberal states would legally permit ‘de minimis’ FGA in recognition of
its fulfillment of cultural and religious obligations, but would proscribe those forms of FGA that are
dangerous or that produce significant sexual or reproductive dysfunction.”
First, there is a question of whether it is the role of liberal state to “accommodate cultural beliefs,”
and a further question about what a “cultural belief” is in the first place, but those are minor points.
More important is the suggestion that FGA should be tolerated if it is not “dangerous” or does not
“produce significant sexual or reproductive dysfunction.” Language can be slippery. What do A&J
mean by “significant” sexual dysfunction? Is there (by contrast) “insignificant” or “mild” sexual
dysfunction that would still be permitted on this analysis? And who gets to decide what degree of
sexual dysfunction is “significant” (and in what sense), or what degree of risk of such dysfunction is
tolerable? One plausible argument is that it is the individual herself (whose possible sexual
dysfunction is at stake) who should be able to decide the degree of risk she is willing to take on—as
well as what she considers to be “significant” in this very personal area—when she reaches an age of
mental competence. This is as opposed to the individual’s parents before such an age.
“Grouping all forms of FGA in discourse and condemnation assumes that all FGA procedures carry
the same risks, which is medically inaccurate.”
This is not true. It is not in fact necessary to assume that all FGA procedures carry the same medical
risks in order to object to them without discrimination, since “medical risk” is not necessarily the
only morally relevant feature that they share. Indeed, most people who argue against all forms of
FGA acknowledge that there is more or less risk of certain kinds of physical or psychological harms
depending upon the type of the procedure and the context in which it is carried out. What they
suggest does not vary between type, however, and which may therefore justify their being “grouped
together,” is that all forms are in conflict with (what they see as) (a) the child’s right to bodily
25
integrity, and (b) her interest in making an informed decision about irreversible genital surgery when
she understands what is at stake in such an intervention and is competent to weigh alternatives.(36)
“Authors arguing against all forms of FGA … argue that physical well-being trumps social and
cultural well-being.”
A&J do not cite any authors specifically, so it is hard to know whose work they are referring to.
However, speaking generally, those who argue against all forms of FGA do not necessarily suggest
that physical well-being trumps social and cultural well-being; rather, they include in “social and
cultural well-being” a child’s interest in having her future autonomy preserved when it comes to
making controversial and irreversible bodily alterations that she (or he, in the case of MGA) may
later come to resent. Moreover, they question why a child’s social and cultural well-being should
hinge on having a non-therapeutic genital surgery performed before an age of meaningful consent.
As an alternative, they suggest that cultural groups should reconsider holding a child’s social well-
being hostage to such a surgery, and should instead love and care for the child unconditionally until
the child herself can make an informed decision about so “private” a part of her own body.(37–39)
“We believe that all procedures should be performed with adequate analgesia.
What do A&J consider “adequate” in this regard? In the case of male circumcision, where pain
control has been better studied, Bellieni et al. argue that “no procedure has been found to definitively
eliminate pain; the gold standard procedure to make MC totally pain free has not yet been
established.”(40) Just as with their vague phrasing about “significant sexual dysfunction,” then, one
could reasonably wonder how much pain, exactly, A&J think is acceptable to inflict on a young girl
for non-therapeutic reasons.
“Given that the more extensive forms of FGA are physically harmful and may constitute oppression
towards women, these practices should be actively discouraged by means such as education, social
pressure, regulation, and prohibition. [However, since] ‘de minimis’ alternate procedures are not
associated with the same risks of long-term harm, these should be encouraged as a compromise
solution that upholds cultural and religious practices without sacrificing the health and well-being
of female children.
A&J change their standard of analysis halfway through this paragraph. They begin by arguing that
the “more extensive” forms of FGA should be prohibited because, in addition to being “physically
harmful” they also “may constitute oppression towards women.” But then when it comes to the more
26
“minor” forms that they believe should be “encouraged” (note that this is a stronger claim than that
they should merely be “tolerated”), they suddenly forget the issue of oppression towards women. But
these “minor” forms, too, may also constitute oppression towards women (and therefore be
objectionable), even if they are not as “physically harmful” as the more extensive forms.(41)
“We use the term ‘procedure’ in the context of FGA rather than ‘surgery’ to emphasize that there is
no medical benefit established by well-designed trials, and that the primary purpose is not health-
related.
A&J are indirectly alluding to male circumcision here, which is presumed to have medical benefits
“established by well-designed trials,” but there are a couple of things wrong with this (implied)
contrast. First, in the case of ritual male circumcision, which is the relevant comparison, the
“primary purpose” is not “health-related” either. Health benefits are often referred to when secular
critics question the practice, but that is also the case for FGA.(7,13,42) Second, there is no “medical
benefit established by well-designed trials” (for FGA) because it is illegal to conduct such trials in
the first place. There is in fact research showing a “significant and perplexing inverse association
between reported female circumcision and HIV seropositivity,”(43) but as the medical
anthropologist Kirsten Bell has noted (personal communication, January 16, 2015): “These findings,
which were presented at an International AIDS Society conference in 2005, have never been
published in a peer-reviewed journal and it is difficult to imagine any agency willing to entertain [the
authors’] call for further research. Indeed, the topic is self-evidently a non-starter. Regardless of any
evidence that might suggest an association, it is impossible to imagine a parallel research agenda [to
the one on male circumcision] solidifying around the procedure, irrespective of whether the surgery
was conducted in a medical context and [irrespective of] the extent of cutting involved.”
“Category 1 includes procedures that should almost never have a lasting effect on morphology or
function if performed properly. A small nick to the vulvar skin fits into this category. Category 2
consists of procedures that create morphologic changes, but are not expected to have an adverse
effect on reproduction or on the sexual satisfaction of the woman or her partner. Examples include
surgical retraction of the clitoral hood or procedures resembling labiaplasty as performed in
Western nations.”
Several points here. To count for Category 1 (on A&J’s proposed typology), the procedure must
“almost never” have a lasting effect on morphology or function if performed properly. This raises
27
the regulatory issue of how individuals will be trained (and by whom), and how “proper”
performance will be monitored and assessed. In this context, we should ask: How many girls should
we be willing to subject to “improperly performed” Category 1 procedures (which would in fact risk
changing morphology and/or damaging function), as we sort out the issues of training and
regulation? Here it should be remembered that even the slightest nick to the vulvar skin carries risk:
the knife can slip; the equipment may not have been properly sterilized, introducing the risk of
infection, and so on.
With respect to male circumcision, which has been performed in a Western context for centuries,
and primarily by medical professionals, there is—even so—little guarantee of a “proper
performance.” A recent study in the Canadian Urological Association Journal, for example, found:
“Most physicians performing neonatal circumcisions in our community have received informal and
unstructured training, [leading to] unsatisfactory results [being] witnessed in our pediatric urology
practice. Many practitioners are not aware of the contraindications to neonatal circumcision and
most non-surgeons perform the procedure without being able to handle common post-surgical
complications.”(44) How much worse might the situation be with FGA procedures performed on a
diminutive genital organ, given that comparable MGA procedures have had a much longer time
period to become stabilized and thus “properly” performed?
For Category 2, A&J give the examples of surgical retraction of the clitoral hood and procedures
akin to labiaplasty, arguing that these would “create morphological changes, but are not expected to
have an adverse effect on reproduction or the sexual satisfaction of the woman or her partner.” It
must first be noted that it is likely to be difficult to retract “just” the clitoral hood, since, in a young
girl, the external clitoral organ (including its prepuce) is typically very small. Thus there would be a
substantial risk of damaging (or over-exposing) the glans clitoris, which is extremely sensitive and
which can be excruciating to touch directly (i.e., without the covering of the clitoral prepuce, which
typically only retracts in a state of high arousal).(45) Why this is not seen as posing a meaningful
risk of an “adverse effect on … the sexual satisfaction of the woman” is unclear.
With respect to labiaplasty, it might be helpful to keep in mind what sort of tissue is at stake in this
procedure, so that we can assess the likely effects of its removal on sexual sensation, function,
etc.(46) As Schober et al. state: “Labia minora is highly innervated along its entire edge. Related
vascular compartment tissue involved in engorgement during sexual arousal makes this tissue
important for sexual response. Labioplasty risks removal of tissue with an important contribution to
28
sensory sexual arousal.”(47) Brzyski and Knudtson state: “The labia majora [are] relatively large,
fleshy folds of tissue that enclose and protect the other external genital organs. They are comparable
to the scrotum in males. The labia majora contain sweat and sebaceous glands, which produce
lubricating secretions [while] the labia minora are lined with a mucous membrane, whose surface is
kept moist by fluid secreted by specialized cells.”(48) Of course, if an adult female would like to
sacrifice any of this tissue—with its concomitant sensory and protective functions, lubricating
secretions, and so on—for “cosmetic” (or other) reasons, one could argue that that is her business.
But to suggest that removing this tissue from a minor, who might very well grow up to wish that she
still had her labia intact, is only a “de minimis” intervention, strikes me as somewhat harder to
defend than the authors seem to think it is.
Indeed, it is worrying that A&J would include labiaplasty in a category that is “not expected to have
an adverse effect on [the] sexual satisfaction of the woman or her partner” while providing no
evidence whatsoever in support of this assertion. What is relevant to this debate is the likely (future)
sexual effects of labiaplasty (or similar) as performed on a young girl. But since performing
labiaplasty on young girls is illegal in Western societies, it is impossible to collect the relevant data.
So, there is no way to know whether such an intervention would in fact fall into Category 2 unless it
were first permitted, but A&J argue that it should be permitted on account of falling into Category 2.
That seems somewhat circular.
But at least A&J are consistent. In a previous paper,(49)[p. 32] they argued that ritual infant male
circumcision should have “little negative effect on sexual health and functioning,” based on data
collected from trials of medicalized adult circumcision that involved only limited follow-up and
which did not use validated questionnaires.(24) In a reply piece,(50) I pointed out that these data,
quite apart from being of poor quality, were not actually applicable (along several dimensions) to the
form of circumcision A&J were defending. Moreover, I stressed that the foreskin itself consists of a
substantial amount of touch-sensitive tissue that is both manually and orally manipulable, and that its
removal necessarily eliminates any concomitant motions and sensations. To this, they replied:
“Sexually sensitive skin unquestionably is removed during circumcision. It does not follow that this
causes a loss of function or of satisfaction, or that remaining skin cannot compensate.”(51)[p. W1]
But it depends on how you define function, how you measure satisfaction—and who you ask. Any
sexual functions (including masturbatory gestures) that require manipulation of the foreskin are, in
fact, lost to circumcision. Similarly, any sexual functions involving manipulation of the labia
29
(including some possible aspects of oral sex) are, in fact, lost to labial excision. Whether the inability
to have one’s foreskin or labia manually or orally manipulated counts against one’s sexual
satisfaction will depend upon one’s sexual preferences. Some men who have sex with men (MSM)
use their foreskins in a sexual act known as “docking”(52) – an act that is impossible if the foreskin
has been removed. In fact, in a recent study, “men indicated a strong preference toward intact
penises for all sexual activities assessed and held more positive beliefs about intact penises.”(53)
Similarly, the labia can be tugged, stretched, sucked on, and otherwise fondled during sexual
interaction, and for those for whom such activities are an important part of their sexual experience,
the loss of labia would indeed be a problem.
“Surgical resection of the clitoral hood is the vulvar procedure that most closely resembles male
circumcision.”
The two interventions are similar in that they both involve resection of the genital prepuce. However,
the highest concentration of sensitive nerve endings for the female is in the glans clitoris, not the
clitoral prepuce; whereas, according to some researchers, in males the inverse is true: the glans penis
is relatively lacking in fine-touch neuro-receptors, whereas the penile prepuce has a greater
concentration of such receptors.(45) Moreover, the clitoral prepuce is very small, whereas the penile
prepuce is very large, constituting between 30 and 50 square centimeters, on average, of sexually
sensitive tissue according to available estimates.(54,55) That said, both the clitoral and penile
prepuces serve similar functions in protecting the soft, sensitive, and moist glans tissue, preventing
abrasion and drying out. In that specific regard, then, there would be a comparable effect of
removing them.
“Category 3 contains those procedures that are likely to impair the ability of the recipient to engage
in or enjoy sexual relations. Clitoridectomy, whether partial or complete, falls into this category.
It is unclear whether excision of the external clitoris is “likely to impair the ability of the recipient to
engage in or enjoy sexual relations,” and thus whether clitoridectomy is an apt illustration for the
proposed Category 3. This is because the clitoris is a “multiplanar” organ that is nearly as long as the
vagina is deep, that is, about 5-7.5 cm, with approximately 80% of its length and most of its erectile
tissue being subcutaneous.(56,57) This tissue may be able to be stimulated through the vagina; it can
also be stimulated externally even if the external glans has been resected, by applying pressure to the
remaining tissue. There is certainly a risk of diminished sexual experience with clitoral excision, but
30
as Catania et al. state: “our results suggest that FGM/C [including clitoridectomy] does not
necessarily have a negative impact on psychosexual life (fantasies, desire, pleasure, ability to
experience orgasm). [Even] in infibulated women, some fundamental structures for the orgasm have
not been excised.”(58)
What this suggests is that it is possible to remove even a great deal of tissue from the external female
genitalia and yet “leave enough behind” that there is nevertheless a decent chance that the person
will be able to “enjoy sex” (as measured broadly by these kinds of studies), “experience pleasure
during sexual intercourse,” and even orgasm. However, that those should be the benchmarks for
acceptability is doubtful: even if it is physiologically possible to have an orgasm after one’s external
clitoral glans has been excised (or to experience at least some degree of pleasure during sex due to
the stimulation of other parts of the vulva/vagina that have not been removed), this does not mean
that sex would be no different if one still had one’s glans. Some women who have had parts of their
genitals removed in childhood—even if they can still “enjoy sex”—feel upset, angry, violated, and
mutilated, simply because of the fact that part of their genitals were removed without their
permission.(34) Other women who have undergone such procedures do not feel this way.(59,60)
However, there is a crucial difference between these two cases. Anyone who would like to have her
clitoral glans, clitoral hood, or labia removed or altered (but hasn’t yet had this done) can always
undertake the surgery later; whereas, someone who did have those things done to her—but wishes
they hadn’t been—has no recourse.(61) Similarly with respect to male circumcision/MGA: many
men—precise numbers are hard to come by, but a recent YouGov survey concluded that fully 10%
of American men wish that they had not been circumcised(62)—have impaired sexual lives either
because their surgery was “botched,” or because they feel angry, violated, mutilated, etc., in virtue of
having had a large sleeve of functional, erogenous tissue removed from their genitals before they
could object.(63,64)
“Critics of FGA have pointed out that there is no medical benefit to factor in the risk versus benefit
calculus so often used in medicine and when compared to male circumcision. However, up to
recently, the medical benefits of male circumcision were also thought to be tenuous, contested, or so
minor that circumcision was classified as an elective, cosmetic procedure.”
Again, A&J are conflating adult (and hence voluntary), medicalized circumcision and infant (and
hence involuntary), ritual circumcision. There is little in the way of robust data on “health benefits”
as concerns the latter, and most of the data that do exist are in fact extremely “tenuous” and
31
“contested.” In fact, the only medical bodies that have suggested that the known benefits of
circumcision outweigh the known risks (though note that these bodies, too, conflate adult and infant
circumcision in their assessments of the available data) are the ones mentioned by A&J in their paper.
But they are in the minority on a global scale (see earlier discussion).
“The Jacobs’s three-pronged test has been previously proposed that, if satisfied, would morally
preclude a government or regulatory agency from reversing a parental decision to involve a child in
a minority group practice. First, the practice in question must not significantly burden either society
or its members outside the group. Second, the practice must not (a) create burdens that a reasonable
person outside the group would not accept for himself, or that a reasonable parent would not accept
for her child (such as child marriage or slavery); or (b) carry a substantial chance of death or of
major disruption of a physiological function. Third, the burden on society or individuals must be
actual and substantial, not hypothetical or unlikely. … Categories 1 and 2 of FGA ... fulfill these
criteria and thus, a government or regulatory agency does not have a medical basis for interfering
with a parental decision to practice a cultural or religious belief.”
First, the “Jacobs’s three-pronged test” was proposed by the same Jacobs who now advocates, with
Arora, for “minor” forms of FGA, in a paper in the Israeli Medical Association Journal whose
overriding purpose was to mount a defense of ritual male circumcision. There is no evidence that
ethicists, moral philosophers, or political theorists accept this test as having any validity, and what
attention it has received has not necessarily been favorable.(65) But let us just take it for granted.
Criterion #2 is that “the practice in question must not … create burdens that a reasonable parent
[outside the group] would not accept for her child.” So one can ask: Would a reasonable parent in a
Western country, that is not a member of an immigrant group that practices FGA, accept for their
daughter a non-therapeutic cutting procedure to the child’s vulva that carries the risk (however
slight) of damaging erogenous tissue? My guess is “no,” but this is admittedly an empirical question.
Finally, please note that A&J once again shift the terms of their analysis halfway through the
paragraph. They begin by stating that the three-pronged test, if satisfied, would “morally preclude” a
government from reversing a parental decision. But they finish by stating that a government “does
not have a medical basis” for interfering with a parental decision. This careering back and forth
between medical and moral arguments does not give the impression of a principled stand on the
issue, but rather a desire to defend the permissibility of culturally-motived cutting of children’s
genitals (of whatever sex) by whatever argumentative means.
32
“Procedures that compromise sexual function, sexual enjoyment and reproductive capacity clearly
violate the best interest of the child. ‘De minimis’ procedures such as removal of the clitoral hood or
a ritual nick on the external female genitalia .. cause little or no functional harm.”
It seems clear that removal of the clitoral hood would cause functional harm: specifically, it would
eliminate all the functions performed by the clitoral hood itself, including protection of the clitoral
glans (much as the penile prepuce serves to protect the penile glans). Notice also the phrasing “little
or no” harm – is a “little” harm acceptable then? And who gets to decide how much harm is only “a
little”? Harm is a subjective matter. Given that A&J cannot imagine how removing something as
large, sensitive, and functional as the labia minora could have a meaningfully adverse effect on a
woman’s sexuality (see above discussion), it seems unlikely that their subjective judgments about
sexual harm would be particularly widely shared by others. An alternative proposal is that it is the
individual herself (who will be affected by the genital procedure) who should be able to decide how
much value she places on having an intact vulva, and how “harmful” it would be to her sexual
experience to have parts of it surgically altered or removed.
“The best interests of a child encompass not only physical well-being, but social, economic,
psychological and spiritual well-being.”
If the best interests of the child encompass not just physical well-being (which is clearly the case)
but also social, economic, psychological, and spiritual well-being, then preservation of the child’s
future autonomy (i.e., the freedom to make an important decision about a private part of one’s body
later on) should arguably be counted among those non-physical interests that need to be factored into
the equation.(66)
“The tolerant attitude in the United States to male circumcision is in stark contrast to its treatment
of FGA. Yet, ‘both are likely voluntary choices influenced by cultural conditioning.’”
If either male circumcision or FGA is performed on a child before that child can understand what is
at stake in the procedure, then the procedure cannot meaningfully be described as “voluntary.” It is
true, however, that parents who perform (or authorize) such procedures are typically influenced by
cultural conditioning.
“Neonatal boys are certainly just as vulnerable as girls. In fact, one could argue that the pubescent
or adolescent girl undergoing FGA is more capable of assenting to the procedure and claiming the
33
culture/religion as her own, than the neonatal boy. We do not condone the forcible practice of FGA
if a child developmentally capable of providing assent declines to do so.”
One cannot help but agree. Neonatal boys (and girls) are uniquely vulnerable: they cannot
effectively resist having a non-therapeutic procedure carried out on their genitals. But if A&J do not
think that a child who is capable of declining to assent to FGA (and presumably MGA) should have
the procedure forced on her (or him), then why do they approve of forcing the same procedure on an
infant who is not yet capable of declining to assent (at least not articulately, using words)?
Presumably, they would respond: “because the vulnerable infant is entirely in the parents’ care, and
must depend on them to make decisions that they judge to be in its best interest.” But one could
equally recommend that irreversible surgeries whose very status as being in the child’s best interest
is contentious should be deferred until such a time as the individual who will actually be affected by
them is in a position to weigh the pros and cons in light of her (or his) own values.(34,67)
34
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    • There have been some propositions in Western countries to allow doctors to perform pricking[10,15]. However, in all cases, the negative reactions against these suggestions from those supporting a zero tolerance approach have been fierce[14][15][16][17]. As a result, no changes to allow pricking have been made.
    [Show abstract] [Hide abstract] ABSTRACT: Background Pricking, classified as female genital cutting (FGC) type IV by the World Health Organization, is an under-researched area gaining momentum among diaspora communities. Our aim was to explore factors associated with being supportive of pricking among Somalis in Sweden. Methods In a cross-sectional design, attitudes and knowledge regarding FGC, and measures of socioeconomic status, acculturation, and social capital, were assessed by a 49-item questionnaire in four municipalities in Sweden. Data were collected in 2015 from 648 Somali men and women, ≥ 18 years old, of which 113 supported the continuation of pricking. Logistic regression was used for the analysis. Results Those more likely to support the continuation of pricking were older, originally from rural areas, and newly arrived in Sweden. Further, those who reported that they thought pricking was: acceptable, according to their religion (aOR: 10.59, 95% CI: 5.44–20.62); not a violation of children’s rights (aOR: 2.86, 95% CI: 1.46–5.61); and did not cause long-term health complications (aOR: 5.52, 95% CI: 2.25–13.52) had higher odds of supporting pricking. Religion was strongly associated with the support of pricking among both genders. However, for men, children’s rights and the definition of pricking as FGC or not were important aspects in how they viewed pricking, while, for women, health complications and respectability were important. Conclusions Values known to be associated with FGC in general are also related to pricking. Hence, there seems to be a change in what types of FGC are supported rather than in their perceived values. Electronic supplementary material The online version of this article (doi:10.1186/s12978-017-0351-0) contains supplementary material, which is available to authorized users.
    Full-text · Article · Aug 2017
    • They are learning about the dubious establishment of male circumcision as a " medicalized " procedure in the late 1800s (Aggleton, 2007; Gollaher 2000), and are questioning how it came to be settled as a cultural norm. They are finding out about the anatomy, innervation, and functions of the foreskin, and about the ways in which these attributes may contribute positively to sexual experience (see Ball 2006; Bossio, Pukall, & Bartley 2015; Cold & Taylor 1999; Earp 2016b; Earp & Darby 2015). They are learning that the foreskin may be the most touch-sensitive part of the penis (Bossio, Pukall, & Steele 2016; Earp 2016a; Sorrells et al. 2007), and that only 1/2 of 1 percent of boys will ever need a circumcision for therapeutic reasons prior to the age of 18 (Sneppen & Thorup 2016; Frisch & Earp 2016).
    [Show abstract] [Hide abstract] ABSTRACT: The spectrum of practices termed “Female Genital Mutilation” (or FGM) by the World Health Organization is sometimes held up as a counterexample to moral relativism. Those who advance this line of thought suggest the practices are so harmful in terms of their physical and emotional consequences, as well as so problematic in terms of their sexist or oppressive implications, that they provide sufficient, rational grounds for the assertion of a universal moral claim—namely, that all forms of FGM are wrong, regardless of the cultural context. However, others point to cultural bias and moral double standards on the part of those who espouse this argument, and have begun to question the received interpretation of the relevant empirical data concerning FGM as well. In this article I assess the merits of these competing perspectives. I argue that each of them involves valid moral concerns that should be taken seriously in order to move the discussion forward. In doing so, I draw on the biomedical “enhancement” literature in order to develop a novel ethical framework for evaluating FGM (and related interventions—such as female genital “cosmetic” surgery and non-therapeutic male circumcision) that takes into account the genuine harms that are at stake in these procedures, but which does not suffer from being based on cultural or moral double standards.
    Full-text · Article · Jul 2016
    • While the scientific literature on the 'average' sexual consequences of circumcision is inconclusive and contradictory (Bossio, Pukall, & Steele, 2014 Johnsdotter, 2013) – and granting that circumcision is likely to affect different men differently, even when it is properly performed – at least two outcomes can be known with certainty due to the inherent nature of the procedure: first, any sensation in the foreskin itself is necessarily eliminated; and, second, any sexual (e.g. masturbatory) functions that require its manipulation are also of necessity precluded (Earp, 2015aEarp, , 2016).
    [Show abstract] [Hide abstract] ABSTRACT: In December of 2014, an anonymous working group under the United States’ Centers for Disease Control and Prevention (CDC) issued a draft of the first-ever federal recommendations regarding male circumcision. In accordance with the American Academy of Pediatrics’ circumcision policy from 2012 - but in contrast to the more recent 2015 policy from the Canadian Paediatric Society as well as prior policies (still in force) from medical associations in Europe and Australasia - the CDC suggested that the benefits of the surgery outweigh the risks. In this article, we provide a brief scientific and conceptual analysis of the CDC’s assessment of benefit vs. risk, and argue that it deserves a closer look. Although we set aside the burgeoning bioethical debate surrounding the moral permissibility of performing non-therapeutic circumcisions on healthy minors, we argue that, from a scientific and medical perspective, current evidence suggests that such circumcision is not an appropriate public health measure for developed countries such as the United States.
    Full-text · Article · May 2016
    • Put her health at risk? Sexually disable her? Traumatize her? Its totally not ethical to remove any healthy organ of children, unless its required to maintain their health, or for purpose of their own healthy life so in this way their genital autonomy could be kept safe until the reach the legal age (Earp, 2016). So any act of harming without any legal reason is considered crime (Cook, Dickens, & Fathalla, 2002).
    Full-text · Article · Apr 2016 · Trends in Urology & Men's Health
  • [Show abstract] [Hide abstract] ABSTRACT: Bossio et al. (in press) report that circumcision does not reduce sensitivity of the penis. However, their own results show that the foreskin is the most sensitive part of the penis to tactile stimulation, as well as more sensitive to warmth than the penile glans. Since the foreskin is (a) the most touch-sensitive part of the penis, and (b) it is removed by circumcision, circumcision reduces sensitivity of the penis by definition. Further problems with the study by Bossio et al. are discussed.
    Full-text · Article · Apr 2016 · Trends in Urology & Men's Health
  • [Show abstract] [Hide abstract] ABSTRACT: A recent study (Bossio, Pukall, & Steele, 2016) reported that neonatal circumcision is not associated with changes in adult penile sensitivity, leading to viral coverage in both traditional and online media. In this commentary the author questions the conclusions drawn from the study and explores the relationship between objective assessments of penile sensitivity and subjective sexual experience and satisfaction. The author concludes with suggestions for improving future research.
    Full-text · Article · Jul 2016
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Exploring the science and ethics of using biotechnology to enhance romantic relationships.
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Understand the replication crisis in science and medicine and devise solutions to it.
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To understand the scientific and ethical disputes concerning non-therapeutic alterations of children's genitals, and to create an ethical framework for evaluating such alterations in a coherent and…" [more]
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Understand unconscious mental processes and their relationships to perception and behavior.
Article
September 2016 · The Journal of Sex Research · Impact Factor: 2.70
    Hypospadias is a relatively common genital condition in which the urethral opening forms on the underside of the penis, as opposed to at the tip of the glans. Patients with hypospadias are typically referred for surgery during infancy or early childhood. Recent evidence, however, indicates that many individuals with hypospadias do not experience the functional or psychosocial difficulties that... [Show full abstract]
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    June 2016 · Pediatrics · Impact Factor: 5.47
      In a recent editorial, Dr. Andrew L. Freedman, a member of the 2012 AAP task-force on circumcision, argues that “health issues” are only a “small piece of the puzzle” when it comes to this procedure. “Although parents may use the conflicting medical literature to buttress their own beliefs and desires,” he writes, “for the most part parents choose what they want for a wide variety of... [Show full abstract]
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