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The Law and Ethics of Female Genital Cutting

Authors:

Abstract

In this chapter, we contrast legal and ethical perspectives on two forms of nontherapeutic female genital cutting: those commonly known as “female genital mutilation” and those commonly known as “female genital cosmetic surgeries.” We begin by questioning the usefulness of these categories—and the presumed distinctions upon which they rest— stressing the shared features of the two sets of practices. Taking UK legislation as a case study, we show that there are troubling inconsistencies in the way in which female genital cutting is understood in Western contexts. Specifically: (a) all nontherapeutic genital alterations to female minors are criminalised, typically with harsh penalties for transgressing the law, while even more invasive nontherapeutic genital alterations to male and intersex minors are permitted and almost entirely unregulated; and (b) genital alterations of adult women regarded as “cosmetic” in nature are treated as legal, while in some jurisdictions, anatomically identical procedures classified as “mutilation” are illegal. This chapter highlights these and other inconsistencies, speculates as to why they arise in Western contexts, and explores the scope for more consistent and constructive attitudes and legislation.
1
The Law and Ethics of Female Genital Cutting
Arianne Shahvisi & Brian D. Earp
Abstract
In this chapter, we contrast legal and ethical perspectives on two forms of nontherapeutic
female genital cutting: those commonly known as “female genital mutilation” and those
commonly known as “female genital cosmetic surgeries.” We begin by questioning the
usefulness of these categories—and the presumed distinctions upon which they rest—stressing
the shared features of the two sets of practices. Taking UK legislation as a case study, we show
that there are troubling inconsistencies in the way in which female genital cutting is understood
in Western contexts. Specifically: (a) all nontherapeutic genital alterations to female minors
are criminalised, typically with harsh penalties for transgressing the law, while even more
invasive nontherapeutic genital alterations to male and intersex minors are permitted and
almost entirely unregulated; and (b) genital alterations of adult women regarded as “cosmetic”
in nature are treated as legal, while in some jurisdictions, anatomically identical procedures
classified as “mutilation” are illegal. This chapter highlights these and other inconsistencies,
speculates as to why they arise in Western contexts, and explores the scope for more consistent
and constructive attitudes and legislation.
Key words: female genital mutilation, female genital cosmetic surgery, intersex surgery, male
circumcision, genital autonomy
1. Introduction
Nontherapeutic female genital cutting (FGC) typically conjures associations of gender
oppression and child abuse in the Western imagination. More commonly described as “female
genital mutilation” or FGM,” such cutting has been roundly condemned and legislated against
[
1
]. Yet FGM/C is not exclusively a practice of the “Other” as is often assumed. In Western
countries, the demand for a range of surgical procedures collectively known as female genital
cosmetic surgeries (FGCS) is rising [
2
], as women—and, increasingly, teenage girls [
3
]—
pursue a perceived aesthetic ideal identified with “designer vaginas,” including petite clitoral
hoods, non-protruding labia, and pre-pubescent hairlessness, apparently modelled upon
This is the authors’ copy of a published essay. Please cite as follows:
Shahvisi, A., & Earp, B. D. (2019). The law and ethics of female genital cutting. In S.
Creighton & L.-M. Liao (Eds.) Female Genital Cosmetic Surgery: Solution to What
Problem? (pp. 58-71). Cambridge: Cambridge University Press.
Press. Press.
2
exemplars from pornography [
4
]. Moreover, some forms of medically unnecessary “cosmetic”
or “normalizing” surgery performed on intersex children before an age of consent—such as
“feminizing” cliteroplasty to reduce the size of healthy, albeit larger than average clitorises
[
5
]—are consistent with Western legal definitions of “female genital mutilation,” but are
largely accepted and still regularly performed [
6
].
A word on terminology. Since “mutilation” is a value-laden term, indicating intentional
disfigurement or damage, we consider that its use (a) fails to accurately reflect the motivations
of communities within which the class of relevant practices is common (no loving parent seeks
to “mutilate” their child), and (b) tends to prefigure the debate, introducing moral biases that
are not imposed on analogous forms of nontherapeutic genital cutting that are more familiar in
Western contexts, such as FGCS or male circumcision (see Box 1), both of which are typically
picked out by more neutral descriptors. We therefore favour the terms “female genital cutting”
(FGC), “female genital cosmetic surgery” (FGCS), and, where applicable, “male genital
cutting” (MGC) or male circumcision, and we will use these terms throughout the chapter.
Where it is necessary to use the term “FGM,” for example, when referencing the
activist/advocacy literature devoted to the elimination of such practices, it will appear in scare
quotes to draw attention to its disfavoured status among scholars of genital cutting [
7
,
8
,
9
].
In section two, we describe the different varieties of female genital cutting, focussing on the
differences and commonalities between (a) purportedly “mutilating” forms of FGC and (b)
Western-style FGCS. Section three interrogates the law in the UK (and other Western contexts)
in relation to each class of procedure. Section four highlights the inconsistencies arising from
the differential legislative approaches, while section five explores some of the problematic
assumptions that underwrite these inconsistencies. Section six concludes.
2. Varieties of genital cutting
According to the World Health Organization (WHO), “female genital mutilation” refers to any
procedure “involving partial or total removal of the external female genitalia or other injury to
the female genital organs for non-medical reasons” [
10
]. The term therefore covers a loose
assemblage of different interventions, carried out by different groups for different reasons in
different settings, ranging from a “prick” to the clitoral hood (which does not remove tissue
and is thus less invasive than male circumcision—see Box 1) to the excision of the external
clitoris followed by suturing of the vaginal opening (known as infibulation). These
interventions may occur in a hospital setting or a rural village; they may be carried out by a
3
Box 1. Comparison to male genital cutting (MGC).
Nontherapeutic MGC ranges from ritual pricking (e.g., hatafat dam brit), to piercing, scraping the inside of the urethra,
bloodletting, shaft scarring, and/or foreskin slitting (among, e.g., various ethnic groups in Papua New Guinea) [
11
], to
circumcision as it is traditionally performed on male newborns in Judaism and generally in the United States (tearing of the
membrane that fuses the immature foreskin to the head of the penis followed by excision of the majority of the foreskin)
[
12
], to metzitzah b'peh (the same followed by direct oral suction of the wound, risking herpes infection, performed on
more than 3,000 babies in New York City each year among some ultra-Orthodox Jews) [7], to non-sterilized, un-
anaesthetized circumcisions performed in the bush during rites of passage in Eastern and Southern Africa [
13
], to highly
traumatic mass cutting of pre-teen boys carried out on school tables in the Philippines (tuli) [
14
], to forced circumcision of
men following political conflict in various countries [
15
], to subincision (slicing open the underside of the penis lengthwise,
often through to the urethra) in Aboriginal Australia [
16
], to involuntary castration (now rare but occasionally documented
among the hijras of India). The extent of the cutting, the tools used, the skill of the practitioner, the age of the initiate, and
so on, vary widely across circumstances, leading to a heterogeneous risk profile both within and across types. There is also
considerable variation in associated social and symbolic meanings (e.g., sealing a divine covenant, punishing an enemy,
mimicking menstruation, proving oneself as a man, basis for marriageability, perceived hygiene, ritual purification,
conformity to peer pressure, etc.) as well as physical context (e.g., sometimes medicalised, often not), depending on the
group in question.
The most common form of male genital cutting is circumcision. Male circumcision involves the partial or total removal of
the foreskin of the penisan elastic sleeve of erogenous tissue that normally covers and protects the glansoccasionally
to address a medical problem, but most often for ethnoreligious or cultural reasons [
17
]. In Western countries the surgery
is typically performed on healthy newborn babies or young male children as part of a medicalized birth custom, as in the
United States [
18
], or in the context of a religious ritual, for example, among practicing Muslims and Jews. Such non-
therapeutic circumcision of infant males is legal throughout the Global North, with few restrictions or exceptions [
19
].
Supporters of circumcision tend to view the procedure as relatively harmlessexcept in the case of botchedoperations
possibly due to a lack of awareness of the anatomical properties of the excised tissue (if the tissue itself has value, its sheer
removal is a harm) [
20
]. Increasingly, men who were circumcised in infancy or early childhood, that is, before they were
old enough to give or withhold their informed consent, are voicing distress and opposition to the surgery, often citing a lack
of personal choice concerning an irreversible alteration to their most private sexual anatomy [
21
]. In addition to this
perceived violation of their genital autonomy, there are also inherent (or highly probable) effects of early circumcision that
some such men regard as deleterious. These include the presence of scar tissue and associated discoloration, inability to
engage in sexual acts requiring foreskin motility [
22
], elimination of the parts of the penis most sensitive to light touch
[
23
], and irritation and possible altered sensitivity of the glans.
Common side effects include meatal stenosis (pathological narrowing of the urethral opening) [
24
], bleeding, infections,
and incomplete skin removal requiring revision surgery. Additional side effects of unknown frequency include painful
erections due to excessive skin removal, partial or complete amputation of the organ due to surgical error, urinary problems,
fistulae, skin bridges, and cysts [
25
]. Finally, death is a possible outcome: in the United States, early deaths following
circumcision in clinical settings occur at a rate of approximately 1 for every 50,000 circumcisions [
26
]. In rural settings,
such as among the Xhosa of South Africa, deaths as well as penile amputations are far more common: between 2006 and
2010, more than three thousand Xhosa boys were hospitalized due to botched circumcisions in the Eastern Cape alone, with
269 recorded deaths among this group and 146 penile amputations [
27
,
28
].*
In settings where circumcision is relatively common, such as the United States, prophylactic health benefits are often cited
in support of the practice [
29
]. However the evidence is contested and is primarily associated with adult, voluntary
circumcision in Sub-Saharan Africa, not newborn circumcision in economically developed regions with advanced
healthcare systems [
30
]. In any case, the claimed health benefits can also be achieved non-surgically through, e.g., safe sex
practices and basic hygiene. Accordingly, the vast majority of international health authorities to have issued formal
statements on the health benefits and risks associated with newborn and early childhood male circumcision have concluded
that the benefits do not outweigh the risks [
31
]. Even if they did, however, removing healthy tissue as prophylaxis without
consent is not automatically morally acceptable. Consider that performing non-consensual mastectomies on adolescent girls
with high-risk genetic profiles in order to guard against future breast cancer would not be tolerated. Similarly neonatal
labiaplasty, though it might conceivably reduce the risk of certain labial cancers or other such problems, is not seriously
entertained as a means of health promotion [
32
]. Although prophylactic tonsillectomies were once common, they are no
longer regularly performed; moreover, the tonsils, in contrast to the genitals, are not a visually prominent, psycho-sexually
significant external organ. Among ethicists and legal scholars, it is now increasingly argued that male infants and young
boys, just like female infants and young girls, have a strong interest in having their genital integrity preserved until they
are old enough to make an informed, personal decision [
33
].
* Please note: the published version of this article misstates the number of hospitalizations due to an erroneous secondary source. Please refer to this
version for the correct information.
4
medical practitioner or a medically untrained ritual provider; they may be performed with
sterile instruments and anesthesia or with a septic tool and no pain control whatsoever [
34
]. As
noted, we will use “female genital cutting” (FGC) to refer to all such nontherapeutic
procedures—nontherapeutic in the sense that they are imposed on healthy genitalia and are not
intended to treat a recognized disease nor are required to preserve or restore functionality
(sexual, reproductive, urinary, or otherwise). In practice, FGC almost always involves the
clinically unnecessary modification of vulvar tissue in order to adhere to perceived religious
or cultural norms or ideals.
Table 1 shows the extent of the similarities between the set of practices described by the WHO
as “FGM” and those more commonly described as FGCS. As has been noted elsewhere [
35
],
genital cutting procedures are diverse, falling on a wide spectrum of severity, in part because
the motivations for the procedures—both conscious and unconscious, historical and
contemporary—are likewise diverse. Some groups, for example, are openly committed to
tempering the sexual desires of women, as is apparent in many contexts throughout in Egypt,
where clitoridectomy (partial or total removal of the external clitoris) is common [
36
]. In other
contexts, the procedure marks a transition from childhood to adulthood and may have little to
do with reducing sexual desire or exerting sexual control [
37
]. In still others, such as among
the Muslim Malay population of Southern Thailand, both boys and girls are subjected to genital
cutting as a form of ritual purification as well as to symbolize full acceptance into the Islamic
community. For their part, the boys have their foreskins removed in a public ceremony between
the ages of 7 and 12, while the girls experience a “prick” to the clitoral hood shortly after birth
[
38
,
39
]. Similar cutting occurs among the Dawoodi Bohra sect of Shia Islam, whose followers
are concentrated in Gujarat, India, and Karachi, Pakistan: the boys are circumcised, and the
girls—in the typical case—have part of their clitoral hood cut or removed in a practice known
khanta, with stated reasons for both kinds of cutting ranging from “religious purposes” to
“physical hygiene and cleanliness” [
40
].
The WHO collects all such (female) practices together under the banner of “FGM” [
41
].
Although some nuance is introduced through seemingly arbitrary divisions into types and sub-
types, the WHO typology is not able to ground a principled distinction between (typically
African, Middle Eastern, or Southeast Asian) so-called “mutilations” and (chiefly European
and North American) so-called “cosmetic” genital procedures. In the second column of Table
1, we present a parallel typology of practices which are standard within FGCSs. The table is
organised to exhibit the commonalities between the component practices.
5
Table 1: Comparing “FGM” and FGCS.
“FGM”
FGCS
Procedures
and typology
Type I: Alterations of the clitoris, within which type
1a is the partial or total removal of the clitoral hood, and
type 1b is the partial or total removal of the clitoral hood
and the (external portion of the)* clitoris.
Alterations of the clitoris, including
clitoral reshaping [42], clitoral
unhooding [43], and clitoridectomy or
cliteroplasty [44] (also common in
intersexsurgeries) [5, 6].
Type II: Alterations of the labia, within which type IIa
is the partial or total removal of the labia minora, type
IIb is the partial or total removal of the labia minora
and/or the (external)* clitoris, and type IIc is the partial
or total removal of the labia minora, labia majora, and
(external)* clitoris.
Alterations of the labia, including
trimming of the labia minora and/or
majora, also known as “labiaplasty”
[42, 43].
Type III: Alterations of the vaginal opening, within
which type IIIa is the partial or total removal and
appositioning of the labia minora, and type IIIb is the
partial or total removal and appositioning of the labia
majora, both as ways of narrowing the vaginal opening.
Alterations of the vaginal opening,
typified by narrowing of the vaginal
opening, variously known as “vaginal
tightening,” “vaginal rejuvenation”
[45], or “hymen repair” [46].
Type IV: Miscellaneous, including piercing, pricking,
scraping, and cauterization.
Miscellaneous, including piercing [47],
tattooing [48], and liposuction [49].
Example
high-
prevalence
geographies
Depending on the procedure: Somalia, Sierra Leone,
Guinea, Djibouti, Egypt, Mali, Sudan, Senegal, Eritrea,
Ethiopia, Mauritania, Liberia, Burkina Faso, Gambia,
Guinea Bissau, Kenya, Nigeria, Chad, Cote dIvoire,
and concomitant diaspora communities [50].
North America, Australia, Europe [51].
Actor
Traditional practitioner, midwife, clinical worker or
paramedic, surgeon.
Surgeon, tattoo artist, body piercer.
Age at
which
performed
Depending on the procedure/community: Typically
around puberty, but ranging from infancy to adulthood
[32].
Typically in adulthood, but increasingly
on adolescent girls [3]; intersex
surgeries (e.g., cliteroplasty) more
common in infancy, but ranging
through adolescence and adulthood
[52]
Legal status
in
the UK and
similar
regimes
Unlawful
Lawful
* NOTE: The WHO wrongly equates the external portion of the clitoris (i.e., the part that protrudes outside the
body) with the entire clitoris, thereby diminishing the anatomical and sexual significance of the latter. Most of the
clitoris, including the majority of its erectile tissues and structures necessary for orgasm, is underneath the
superficial skin layer of the bodylike an icebergand therefore cannot be removed without major surgery
(which does not occur in any recognized form of FGM”). This fact may explain why sexual pleasure and orgasm
are reported at higher than expected rates in women who have experienced various forms of genital cutting [53].
6
Table 1 shows that for each component of the “FGM” typology, there is a close analogue within
the FGCS typology. Alterations of the clitoris, labia, and vaginal opening are observed in both
sets of practices, with considerable variation both between and across cases as to the degree of
tissue damage or removal. Instead of using umbrella terms such as “FGM” or FGCS, then, it
is likely to be more illuminating in most cases to be specific. Thus, one should refer to (1)
particular procedures (e.g., labiaplasty, cliteridectomy, hoodectomy, infibulation); (2) the
extent of the procedure, along with the means by which it is carried out—i.e., with which
instruments and how skilfully—and the associated risk/benefit profile (both medical and non-
medical); and (3) the relevant context: physical, psychological, and social/symbolic. As it
stands, the terms “FGM” and FGCS are proposed as stable categories not on the basis of the
acts that actually fall within them, but instead by the perceived reasons for undertaking those
acts (e.g., “non-medical reasons,” “to oppress women,” and so on).
That said, there are some differences between the two categories. The first is that the practices
known as “FGM” are generally not performed in a safe, regulated medical setting (although
they are increasingly being performed in medicalized settings in the communities in which
they are common and customary) [
54
], while those within the FGCS typology are usually
performed by trained professionals in medical or similar facilities (although there are growing
concerns about a lack of regulation) [
55
].
A second potential difference concerns the age at which the cutting is typically performed—
i.e., usually minor girls for “FGM,” usually adult women for FGCS—but there is overlap here
is well. First, in many African societies, female and male genital cutting ceremonies constitute
the very ritual by which adult status is conferred in the community, which complicates the
question of consent as well as adult/child designations [
56
]. And second, staying just within
the USA, UK, and other Western contexts, nontherapeutic genital cutting—e.g., cosmetic
labiaplasty—is increasingly performed on female children and adolescents well before the age
of legal majority [
57
].
The final difference is their status in law: in Western countries “FGM” of any type is illegal
(in the UK and Australia, this is true regardless of the age at which it is performed), while in
these same countries, FGCS is treated as legal despite technically meeting the same criteria
[
58
].
3. The status of the law
7
In this chapter, we take UK law as a case study. However, similar laws apply throughout the
Western world [
59
], where increased migration of FGC-prevalent communities, coupled with
a growing focus on FGC as a contested site of political attention, have led to pressure to address
FGC either in dedicated legislation, or under existing laws.
In England, Wales, and Northern Ireland, the FGM Act 2003 holds that “to excise, infibulate,
or otherwise mutilate any part of a girl’s labia minora, majora or clitoris” is an offense with a
maximum sentence of fourteen years [
60
]. The legislation has two puzzling features. First, it
stipulates that “Girl includes woman” and therefore equates the consent capacities of adult
women to those of children. Second, the legislation contains a caveat to permit genital
alterations where they are deemed necessary to the “mental health” of a person, while noting
that it is “immaterial” for purpose of making such assessments whether the person requesting
the alteration “or any other person believes that the operation is required as a matter of custom
or ritual.”
These rather confusing qualifications were evidently inserted to ring-fence access to FGCS, by
portraying such procedures as necessary to the mental health of some women (as judged by
their cosmetic surgeons), while preventing “traditional” FGC, which is more readily
interpreted as being performed for reasons that qualify as customary or ritualistic, from
slipping through under the mental health clause. Dustin [
61
] suggests that the cosmetic surgery
lobby may have played a key role in securing the future of FGCS when the legislation was
being drafted.
Yet one could argue that FGCS also qualifies as being motivated by custom or ritual. As noted
by Crouch and colleagues, it is difficult to see how FGCS could be anything other than
cultural” [
62
]. For as Edwards argues, “any woman’s choice to have a procedure on her genitals
cannot be separated from the culture in which this decision is made” [
63
]. Highly restrictive
aesthetic ideals, widespread anatomical ignorance about the range of “normal” appearances for
the vulva, marketing campaigns designed to prey on bodily insecurities, and normatively
questionable social pressures undoubtedly threaten “mental health” and thus play a role in
motivating requests for FGCS [
64
]. In short, “the rationale [for cutting] cannot be separated
from cultural associations” regardless of the culture in which it occurs [63].
Similarly, it is plausible that there may be potentially severe adverse consequences to the
mental health of a person who is “denied” FGC if she lives within an FGC-prevalent
8
community, identifies with the practice, regards modified vulvae as normal or beautiful (or
unmodified vulvae as abnormal or ugly) [7, 9, 56, 86], and so on. But if, as it seems reasonable
to argue, problematic cultural norms or expectations are ultimately to blame for any such
psychological anguish—such that the norms and expectations, rather than female bodies,
should be changed [46]—they are certainly no less to blame for women’s “mental health”
issues in the majority culture, used to justify FGCS.
Perhaps the difference in law can be grounded in the fact that FGCS is medically safer than
FGC? One might indeed contend that the first is safer under current legislation, since it is
usually performed in clinical contexts, while the latter must be performed “underground” in
Western countries because it is unlawful. Yet the division is not so tidy. First, in communities
where FGC is common, the cutting is often performed in medical settings prior to immigration:
according to the WHO, in some FGC-prevalent countries, “one-third or more of women had
their daughter subjected to the practice by a trained health professional” [10]. By contrast,
Western-style “cosmetic” genital piercing, a legal form of FGCS, typically takes place in a
non-clinical environment such as a tattoo parlour and is only minimally regulated [55].
Moreover, depending on the type of cutting, medical training does not guarantee superior skill:
for example, in some communities, FGC—similar to MGC performed by a Jewish mohelis
carried out by a highly-experienced circumciser for whom the cutting is her primary
occupation. Thus, medicalization per se does not eliminate, nor even necessarily reduce, the
risk of complications, as the WHO also notes [10] (but see [
65
]).
Accordingly, many of the complications and risks are similar for FGC and FGCS where the
type (as indicated in Table 1) matches. Even where FGCS of various types are performed by a
licensed surgeon, the following complications are commonly noted: infection, healing
problems, adhesion, dyspareunia, bleeding, and effects on sexual pleasure [
66
]. These are
strongly redolent of the sorts of complications that are often described as following from many
instances FGC, though of course, non-clinical environments and instruments, where
applicable, may render these complications more likely and more severe [
67
].
Finally, as noted earlier, the presumed difference between FGC and FGCS in terms of the age
at which the cutting takes place is not sufficient to ground such divergent laws: some FGC
procedures, such as re-infibulation, are requested by adult women [
68
], while some FGCS
procedures are performed on adolescent girls. Nevertheless, in all Western contexts, FGM
9
is unlawful, while FGCS procedures are presumed to be lawful. The “mental health” caveat
within UK law in particular exemplifies the difficulty in outlawing one set of procedures while
protecting access to a set of procedures that is identical or nearly identical in physical terms.
The difference, in the eyes of the law, then seems to rest on certain stereotypes concerning the
“reason” for which the procedure is undertaken, a matter we will take up in the following
sections.
4. Interrogating inconsistencies
All three of FGCS, FGC, and MGC involve the non-therapeutic modification or removal of
healthy, erotogenic tissue. Whilst there is a lively debate about the average (net) effects of
these practices on health [29, 30, 31,
69
] and sexual pleasure [22, 30,
70
, 86], what is often lost
in such discussions is that no one is an embodied statistical average: genital cutting affects
different individuals differently, depending upon the type and extent of cutting, whether and
what kind of pain control is used, the age at which it is performed, the skill of the practitioner,
one’s mind-set going into the cutting—or later reflecting upon it or its effects—and so on [
71
].
Given such vast individual differences, arguably the more pressing question for ethicists
working within a Western medicolegal context is whether the person in question can consent
to the procedure and thereby exercise bodily autonomy, often characterized as a (human) right
[
72
].
As noted, the capacity of adult women to “choose” FGC or FGCS is sometimes disputed, often
along racial lines, a discussion to which we will return below. But the question of consent is
perhaps most salient in the case of children. Supporters of childhood genital cutting note that
infants and young children are pre-autonomous and therefore incapable of either giving or
withholding their informed consent, not only to genital cutting, but to any significant parental
action that affects them [
73
]. Therefore, they suggest, it is up to the parents to decide whether
to cut the child’s genitals. But such cutting is typically irreversible: depriving a child of the
opportunity to remain genitally intact is also to deprive the eventual adult of the same
opportunity. Plainly, a child’s temporary lack of capacity to make certain informed, mature
decisions about the state or condition of their own body does not create a “blank cheque” for
parents to authorize whatever permanent body alterations they may choose [
74
].
Granting this point, some authors argue that the permissibility of a given act of childhood
genital cutting—usually presumed to fall somewhere beneath an arbitrary and unspecified
threshold of harm [
75
]—depends on the reason for its performance, that is, the conscious or
10
unconscious motive(s) of the parents or wider community [73]. Some motives, at least for
certain kinds of nontherapeutic childhood genital cutting, appear to be regarded as acceptable
in Western societies, while other motives are regarded as unacceptable.
For example, discussants who oppose even “minor” forms of FGC carried out prior to an age
of consent (for example, ritual nicking), while at the same tolerating or even advocating more
physically invasive forms of MGC carried out prior to an age of consent (chiefly, infant male
circumcision), tend to base their arguments on the premise that male circumcision is a religious
requirement, at least for some groups, while FGC is not. The argument then proceeds to claim
that if there is a “religious” motive for childhood genital cutting, then the cutting can be
justified, whether morally or legally.
However, the premise is false, so the argument is unsound. First, FGC is very often regarded
by its supporters as an explicitly Islamic practice with the same or similar scriptural standing
as male circumcision within that religion [7, 65]. Whilst it is true that FGC, like MGC, is not
mentioned in Koranic scripture, both are noted in the Hadith, a record of the teachings of the
Prophet Muhammed. On this basis, some Muslim authorities argue that FGC is in fact
obligatory (though this view is far from universal) [
76
]. Certainly, in Judaism and Christianity,
it is widely held that “binding” religious obligations can stem from extra-biblical sources, such
as rabbinic commentaries or papal encyclicals: the notion that a practice can only be “religious”
if it is grounded in a literal reading of a group’s primary scripture is absurd [65].
Second, male circumcision is often performed for “cultural,” rather than specifically religious,
reasons, and yet it is broadly tolerated even in those cases. Christians in Africa, for instance,
often practice infant male circumcision not because they view it as an explicit requirement of
their own religion, but rather because the practice is widespread in the communities alongside
which they live [
77
]. In the US, circumcision of newborn boys is mostly performed in
accordance with perceived social and aesthetic norms by those who place no religious stake in
the surgery whatsoever, with statements such as “the boy should look like his father” held up
as common explanations [18,
78
]. Even many Jews who circumcise are atheists or otherwise
non-religious, yet choose to continue the tradition for various reasons including a sense of
shared history or ethnic identity [
79
]. In a similar vein, a study in Australia showed that three
times as many parents opted to have their newborn son circumcised to continue a “family
tradition” than to fulfil a perceived religious obligation [
80
].
11
This leads to a dilemma. If male circumcision should be permitted generally and for any reason
because in some groups it is regarded as an explicitly religious practice, then relatively more
mild forms of FGC that are regarded by some groups as religiously required should be given
equal consideration, and should also be tolerated for all groups regardless of the reason. Indeed,
some prominent defenders of ritual male circumcision, aware of the existing double standard
(see Box 2), have recently begun to argue that “mildforms of FGC should in fact be tolerated
in Western law, presumably to ensure that the legal status of male circumcision remains
unquestioned [65,
81
]. Alternatively, one might argue that male circumcision should only be
permitted when it is done for explicitly religious reasons (which would exclude most US
American circumcisions, and might also exclude non-religious Jewish and Islamic
circumcisions that would otherwise be done for “cultural” reasons), in which case, by analogy,
only groups that regard FGC as religiously required would be permitted to perform the cutting,
and all others disallowed. Finally, one could argue that neither male nor female nontherapeutic
childhood genital cutting should be permitted, regardless of the religious motives of the parents
[
82
].
Whichever option one favours, the common emphasis in this discourse on “religion” versus
“culture” is telling. The apparent assumption is that religious norms are categorically different
from, and more important than, “merely” cultural norms. However, it is not obvious that there
is a firm line—whether in practice or conceptually—between what is religious and what is
cultural [77], nor is it obvious that one should be elevated above the other as “legitimate”
grounds for cutting the genitals of a child [
83
].
Box 2. Double standards: a case study
This apparent double standard is playing out as we write this chapter. Four members of the Dawoodi
Bohra, a small Muslim sect with members in Detroit, Michigan, and other US cities, have recently
been indicted on charges of “Female Genital Mutilation” – the first such case under federal law in the
United States [
84
]. As even opponents of the practice from within the community acknowledge [40],
the form of cutting typically practiced by the Bohra on their daughters, namely, pricking or excision
of a portion of the foreskin (“hood”) of the external clitoris—often by a doctor in a clinical setting, as
in the Detroit case being prosecuted—is significantly less physically invasive than the form of cutting
practiced by the very same community on their sons, namely, complete removal of the penile foreskin
(“circumcision”). The two forms of cutting may be done at similar ages, for similar reasons; both are
regarded as a religious obligation by the Bohra based on similar readings of the same passages of
Muslim scripture (in this case, the Hadith the sayings of the Prophet Mohammed); and both are
referred to with the same word, khatna. Yet, though the male procedure is more severe, only the female
procedure has triggered criminal proceedings under federal law [69].
12
Even more peculiar, the false dichotomy is inconsistently applied. For example, it is often
argued that (adult) FGCS is more acceptable than (adult) FGC because the former are not
motivated by a strong cultural imperative [
85
]. That is, FGCS is presented as a procedure which
is chosen by those who request it, which makes it at least plausibly permissible, whereas FGC
is presented as an obligation for those who request it (by virtue of being a ritual or custom)
which then renders it impermissible because it is presumably not “freely” chosen. But if
common defences for male circumcision are to be accepted, one could equally hold that since
FGC is “mandated” by strong religious or cultural pressures in some groups, it is something
that Western societies ought to tolerate, whereas since FGCS is a not mandated in a similar
way, it should not be granted this shortcut to tolerance. Either way, the status quo is incoherent.
Simply put, the reasoning employed in defence of pre-consensual male circumcision and
against pre-consensual FGC is sharply at odds with the reasoning employed in defence of adult
FGCS and against adult FGC. In the case of motivations for ritual male circumcision, it is
commonly argued that the strength of the associated background norm, whether religious or
“merely” cultural, is a reason for respecting or tolerating the practice, despite the fact that
young male children and especially newborn boys are manifestly incapable of providing their
own consent. Yet in the case of FGC, the strength of what is in some communities an equally
robust and often highly similar background norm is seen as consent-undermining, not only for
female minors but also mature adult women—irrespective of their agency or autonomy as
might be demonstrated in other contexts.
On one side, then, we have MGC, one form of which is of great religious significance to some
groups, while for others it is “merely” cultural but is not necessarily any less valued. Although
it is typically performed on the most intimate part of a child’s body before consent can possibly
be given or withheld, it is widely accepted and is permitted by Western law. On the other side,
we have FGCS, a set of procedures that have primarily aesthetic value for a small—if
growing—number of individuals and are of no religious significance to anyone. They are
typically performed on adults who are presumed to be competent to provide their own consent
but are also increasingly performed on younger girls with the permission (or at the insistence)
of their parents. They, too, are relatively uncontroversial and are permitted by Western law.
Then in the middle we have FGC, an anatomically overlapping set of procedures performed at
various ages, sometimes on adults or older adolescents who are typically presumed, in this
case, to be non-competent to provide consent, but most often on younger girls with the
permission (or at the insistence) of their parents. Certain forms are of great religious
13
significance to some groups and have aesthetic value for those who embrace them [
86
,
87
],
but all forms are seen as entirely unacceptable, and no form is permitted by Western law.
5. Explaining the inconsistencies
Perhaps the difference in attitudes and legislation toward male versus female forms of ritual
genital cutting—and between FGC and FGCS—stem not from the religious or cultural
significance of one or the other, but from other differences. One common candidate for such a
distinction is that FGC—but not FGCS—is performed for reasons that are purely or primarily
misogynistic, aiming to curb the sexual lives of girls and women, while male circumcision has
no such limiting intention towards boys. As noted recently in the African Journal of
Reproductive Health [
88
]:
Female circumcision has been presented somewhat stereotypically as a practice in
which men control female sexuality and female reproduction. The manner in which
women have been depicted as victims of a brutal male practice has created sharp
reactions, not the least from circumcised women. They have not commonly perceived
themselves as victims of a violent male practice but have seen female circumcision as
a female custom that is necessary to maintain order [and] to make or create true women.
Consistent with this view, in nearly every culture where FGC occurs it is organized and carried
out exclusively by women, with men being barred from participation and often far more likely
to report a desire for abandonment of the practice than their female counterparts. Moreover,
there is no known community that practices FGC without also practicing MGC, often in
parallel and for similar reasons: girls are nowhere being singled out for cutting [9, 56,
89
]. By
contrast, there are many groups that practice MGC without practicing FGC, such as within
Judaism, some but not other sects of Islam, and generally in the USA: in those cases, boys are
singled out for cutting, while girls are strictly protected. Nevertheless, where the two practices
do co-occur, prevailing motivations are often close conjugates: ostensible health benefits,
aesthetics, religious adherence, hygiene, symbolic entry into adulthood, enhancing one’s
expected sex appeal, reduction of promiscuity, and feminization or masculinization of the
genitals [
90
].
Depending on the community in question, any number (or combination) of these and other
motivations may apply simultaneously across the gender divide [77]. And while sexual control
is sometimes a motivating factor, as we shall discuss, this rationale is not confined to the female
rites. In the context of hazing ceremonies, for example, it has been proposed that MGC may
be a means by which older males exert sexual dominance over adolescent boys, saying in
14
essence: “We can hurt your penis now, so just think what we can do if you misuse it against
us—a warning, if only in symbolic form, of possible castration” [
91
].
Moreover, in some groups, MGC is explicitly intended to reduce a male’s capacity for sexual
pleasure. Among the Nso people in Cameroon, for example, one recognized purpose of
circumcision is to “tame and moderate the sexual instinct” of men [
92
]. In addition, the
widespread popularity of circumcision in the United States traces directly to historical attempts
to curtail masturbation in male children as a form of sexual discipline and “moral hygiene”
[
93
,
94
]. And even today, Western-funded campaigns to circumcise millions of African boys
and men as a “surgical solution” to the spread of HIV are premised in part on the belief that
such men cannot be trusted to control their own sexual behavior (hence the “need” for surgery):
Lurking just below the surface in many HIV discussions—especially of HIV in sub-
Saharan Africa—is the perception that people in certain countries or regions are more
promiscuous, more callous, less empathic, or less moral. Some imply that people living
with HIV should abstain from or minimise sexual activity, including reproductive
desires.
Thus, some authors have warned that the aggressive Western “marketing” of male
circumcision in such contexts risks reinforcing colonial-era stereotypes about the “sexually
promiscuous African male” [
95
].
None of this detracts from the fact that FGC has, in many cases, become tightly bound up in
the regulation of female sexuality, among so many other methods by which such regulation is
pursued globally (including FGCS, as we shall argue in a moment). Thus, in some
communities, for example in parts of the Sudan, the prizing of female chastity and the
subjection of girls and women to the presumed sexual and aesthetic preferences of men are
among the primary motivations for FGC [
96
,
97
]. In other communities, “the belief that girls
with intact genitalia will be stubborn, promiscuous, or unable to control their sexual desires,”
or that “genital cutting is necessary [to] prove virginity” may be widespread [20]. In still others,
the motives are not primarily anti-sexual, for either the females or males [37].
Such variation is only to be expected. As noted by the non-partisan Public Policy Advisory
Network on Female Genital Surgeries in Africa, “the vast majority of the world’s societies
can be described as patriarchal, and most either do not modify the genitals of either sex or
modify the genitals of males only. There are almost no patriarchal societies with customary
genital surgeries for females only” [9]. Finally, motivations may even differ from family to
family. The temptation to universalise over a given motivation should therefore be resisted:
15
the variety of reasons for—and types of—both FGC and MGC across their disparate
geographical regions of prevalence frustrate such reductive explanations [9, 37].
Nor should FGCS be permitted to evade critique on this front. Such “cosmetic” procedures are,
by all accounts, largely motivated by a desire for genitals that are perceived to be (a)
aesthetically appealing according to restrictive norms propagated within pornography and
aided by trends toward total pubic hair removal (which render the genitals more visible), and
(b) “enhanced” in terms of sexual function, which often amounts to the creation of a “tight
receptacle for penile penetration” [4]. If there are motivations for FGCS that do not derive from
these two main sources, they have not been as well-reported. To the extent that both the global
pornography industry, and the instrumentalisation of female genitals for penile penetration, are
reflections or instantiations of misogyny, it may well be that the motives for FGCS are more
universalisable than those for FGC, with as much or more to answer for on this point.
If not health reasons, religious motivations, or misogyny, what is it that makes FGC sufficiently
distinct from its close cousins, FGCS and childhood male circumcision, so as to warrant such
extreme legislative differences? One possible answer lies beyond medicine or ethics, and
instead focusses on the way in which FGC is positioned politically within Western discourses.
Some scholars argue as follows: While male circumcision is more common than FGC within
Islam, and there are more circumcised men globally who are Muslim than Jewish, FGC has
found itself associated with Islam in ways that have caused the practice to inherit the fears and
anxieties created by Islamophobic trends across the Western world [
98
]. The strength of this
association is likely encouraged by the widespread belief that FGC is always performed for
sexist or “patriarchal” reasons, which has contributed to, and meshed with, the vilification of
Islam as an inherently misogynistic religion. This framing allows fear of the “Other” to adopt
the more beneficent mask of concern for the welfare of women and girls.
Moreover, unlike the stereotypically imagined recipients of male circumcision (chiefly, Jewish
or US American boys) and FGCS (chiefly, white/Western women), FGC is mentally associated
almost exclusively with women-of-colour from the Global South. In accordance with the
discourses of historical colonial “civilising missions” and more recent examples of military
imperialism, these women are portrayed as lacking autonomy, and as subjugated to the will of
their men-folk, thereby impelling Western intervention [
99
]. The intervention comes in the
form of draconian legislation whose primary function is to reassure the public that the
16
perceived “civilizational threat” is held at bay, and that the perceived misogyny of foreign
cultures will not be tolerated.
Meanwhile, because the force of this legislation derives from political rather than ethical
narratives, and therefore concentrates on charges of “barbarism” rather than violations of
bodily autonomy per se, male infants as well as intersex children are left unprotected. Further,
because these political considerations replace more nuanced inflections within feminist theory
and anthropology, cultural norms around female bodies are not brought into the same narrative,
leaving FGCS largely free of critique.
In the shadows of these moral lacunae are the women and girls of FGC-prevalent communities,
whose diverse needs and perspectives are often lost in the focus on criminality and realpolitik.
Unsurprisingly, attitudes towards FGC are as varied as its typology and geographical
distribution [20]. Whilst in many regions, a growing minority of women strongly oppose the
practice to which they were subjected as children, the more general pattern is that the majority
of women within populations of prevalence who have themselves been cut report their
continuing support for the practice [
100
]. Of course, ethics and morality do not reduce to a
tally of votes, and beliefs and values can change. But if campaigns to eliminate FGC are ever
to be successful, they must take seriously—not condescend toward—the women who do value
their cutting traditions, and who regard their modified vulvae as normal or enhanced as
opposed to mutilated or otherwise harmed. Meeting such women on their own terms, rather
than automatically discounting their perspective or dismissing them as victims of false
consciousness, would be a good place to start.
In line with this, despite the variation in typology and culture between regions of prevalence,
successful abandonment campaigns share several core features. Amongst them: centring
affected women, engaging local religious or cultural leaders, accommodating the
interdependence of communities and their decision-making, showing appropriate respect for
cultures and reinforcing their positive aspects, and focussing on local values and aspirations
[100,
101
]. In other words, initiatives which positively engage communities and allow
abandonment to be led from within are most likely to be successful. Blanket criminalisation
based on double-standards, by contrast, is unlikely to foster an atmosphere of cooperation and
mutual understanding. Such a realization has recently led to calls for legal reform—on practical
grounds—even among steadfast anti-FGC advocates [
102
].
17
6. Conclusion
The prevailing view that there is a categorically valid, morally significant difference between
the set of acts described as “FGM” and those known as FGCS is inconsistent with the available
evidence concerning both the range of physical interventions constituting such practices, and
the cultural and individual motivations behind them. On closer inspection, it is clear that the
categories are functional, rather than “scientific”; they are defined not by the acts they contain
(since the physical realities of these acts have considerable overlap), but by the perceived
rationales for which they are sought. FGCS acts are sought for purportedly aesthetic reasons
(which are themselves rooted in wider cultural norms that deserve scrutiny); FGC acts are
sought to adhere to religious or cultural norms (which similarly should be subjected to
critique), within which aesthetics is often also a consideration. Even the “rationale”
demarcation is thus evidently blurry.
The more closely one studies the two sets of practices, especially in light of further overlaps
with MGC, the greater the apparent similarities between them. Yet acts understood to
constitute “FGM” are criminal, while those within the FGCS category are not. As discussed,
one reason for this discrepancy is that the stereotypical reasons for seeking “FGM” are
perceived to be indefensible, while the reasons for seeking FGCS are regarded as less
problematic. Moreover, “FGM” is believed to be primarily (but is not always actually)
performed upon children, who cannot give consent, while FGCS is believed to be primarily
(but is not always actually) sought by adults, who (contestably) can. But even if such presumed
distinctions were more strongly rooted in reality, they would be undermined by the fact that
religious or cultural male circumcision—which is more physically invasive than at least some
prohibited forms of FGC—is legal almost everywhere, often unregulated, and primarily
performed upon infants and newborns who are least capable of consenting.
Given such inconsistencies, it is increasingly being argued that the laws concerning genital
alteration are not based in “objective” or universally valid distinctions, but are rather heavily
shaped by certain social and political discourses regarding race and gender [83]. This creates
a confusing situation for medical professionals, whose work requires a clear understanding of
the differences between the two practices, yet the (largely unexplained) division offered by the
law is not derivable from, nor consistent with, the tenets of medical ethics [
103
].
Changes to legislation around genital alteration in Western contexts could be approached in
several ways. Some would argue that, in liberal, multicultural societies, it is important to permit
18
pluralism in the law in order to accommodate the practices of minority ethnic and religious
groups, even if those practices involve irreversible modifications to the bodies of children. On
that view, one might argue that the law around FGC (perhaps with certain typological
restrictions) should be brought into line with its parallel practice, MGC [65]. Others would
contend that the only defensible distinction is that between those who have the capacity to
consent, and those who do not, and that if pluralism in the law should be upheld, it should be
reserved for the bodies of adults [82]. Such a view motivates changes to the law according to
which non-therapeutic genital alterations are unlawful for all children, and lawful for all adults
[33, 61]. This would allow genital surgeries to be chosen, if desired, on the basis of one’s own
mature preferences and values, regardless of race or gender, and to be offered within regulated
clinical conditions with due attention to possible complications and follow-up care.
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... This is true not only in Asia, as mentioned, but also in parts of Africa and the Middle East. Depending on the community, the form(s) of cutting it has adopted, and the extent to which the practice has been medicalized, either the male or female version of the ritual may be more substantial or risky, with variable implications for health and sexuality (Shahvisi & Earp, 2019). ...
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Defenders of male circumcision increasingly argue that female ‘circumcision’ (cutting of the clitoral hood or labia) should be legally allowed in Western liberal democracies even when non-consensual. In his target article, Richard Shweder (2022) gives perhaps the most persuasive articulation of this argument to have so far appeared in the literature. In my own work, I argue that no person should be subjected to medically unnecessary genital cutting of any kind without their own informed consent, regardless of the sex characteristics with which they were born or the religious or cultural background of their parents. Professor Shweder and I agree that Western law and policy on child genital cutting is currently beset with cultural, religious and sex-based double standards. We disagree about what should be done about this. In this commentary, I argue that ‘legalising’ childhood FGC so as to bring it into line with current treatment of childhood MGC is not an acceptable solution to these problems. Instead, all medically unnecessary genital cutting of non-consenting persons should be opposed on moral and legal grounds and discouraged by all appropriate means.
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The word "circumcision" comes from Latin circum (meaning "around") and caedere (meaning "to cut"). Cultural and religious justifications are employed to convince members of the community as well as outsiders that circumcision is reasonable and just. The purpose of the discussion is to suggest some cardinal changes to the practice of male circumcision in order to make it more humane and less painful to its subjects. Balancing between group rights and the rights of the child, it is essential to avoid unnecessary suffering. It is one of the liberal state's obligations to protect the best interests of vulnerable third parties. The article opens with some preliminary data about male circumcision and then explains its importance in Judaism. It examines the medical reasons for male circumcision and the risks involved in the practice; subsequently, it discusses the critique of male circumcision. The article also highlights the points of agreement and disagreement between those supporting and opposing the ritual and insists that male circumcision should be performed by using anaesthesia. The final part of the article includes a proposal for humane male circumcision that considers religious sentiments and the rights of the child, aiming to strike a reasonable balance between competing interests. I hope the proposal will be debated in parliaments in the western world. If we are to achieve a richer culture, rich in contrasting values, we must recognize the whole gamut of human potentialities, and so weave a less arbitrary social fabric, one in which each diverse gift will find a fitting place.
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Health of refugee women encompasses a range of health conditions across their reproductive health and includes obstetrics and gynecological health as well as general preventive and psychosocial health. For refugee women, cultural and/or religious beliefs around sexual behavior, prenatal care, breastfeeding, cancer screening, contraception, intimate partner violence, and such traditional practices as female genital mutilation/cutting (FGM/C) may influence decisions that they make regarding their healthcare. Moreover, low socioeconomic status, malnutrition, infectious diseases, and poor social support may have a deleterious impact on their reproductive and overall health. Intimate partner violence (IPV) is also a concern in refugee women. Refugee women are a vulnerable population for whom culturally informed care and a trusting patient-provider relationship can promote health and wellness. Healthcare providers should be prepared to address unique challenges in caring for women refugees. This chapter reviews general health, mental health, reproductive health, breastfeeding, family planning, and IPV in refugee women. FGM/C and its management in refugee women is also discussed.
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Purpose of Review To summarize and critically evaluate the moral principles invoked in support of zero tolerance laws and policies for medically unnecessary female genital cutting (FGC). Recent Findings Most of the moral reasons that are typically invoked to justify such laws and policies appear to lead to a dilemma. Either these reasons entail that several common Western practices that are widely regarded to be morally permissible and are currently treated as legal—such as intersex “normalization” surgery, female genital “cosmetic” surgery performed on adolescent girls, or infant male circumcision—are in fact morally impermissible and should be discouraged if not legally forbidden; or the reasons are being applied in a biased and prejudicial manner that is itself unethical, as well as inconsistent with Western constitutional requirements of equal treatment of individuals before the law. Summary In the recent literature, only one principle has been defended that appears capable of justifying a zero tolerance stance toward medically unnecessary FGC without relying on, exhibiting, or perpetuating unjust cultural or moral double standards. This principle holds that, in countries whose ethicolegal traditions are shaped by a foundational concern for individual rights, respect for bodily integrity, and personal autonomy over sexual boundaries, all non-consenting persons have an inviolable moral right against any medically unnecessary (or medically deferrable) interference with their genitals or other private anatomy. In such countries, therefore, all non-consenting persons, regardless of age, race, ethnicity, parental religion, assigned sex, gender identity, or other individual or group-based features, should be protected from medically unnecessary genital cutting, regardless of the severity of the cutting or the expected level of benefit or harm.
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Four members of the Dawoodi Bohra sect of Islam living in Detroit, Michigan have recently been indicted on charges of female genital mutilation (FGM). This is the first time the US government has prosecuted an “FGM” case since a federal law was passed in 1996. The world is watching to see how the case turns out. A lot is at stake here. Multiculturalism, religious freedom, the limits of tolerance; the scope of children’s—and minority group—rights; the credibility of scientific research; even the very concept of “harm.” To see how these pieces fit together, I need to describe the alleged crime.
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In this article numerous changes have been made which are listed below. In addition to these, a number of typographical and grammatical corrections have been made throughout. All errors have been corrected online and in print.