he fierce discord over the topic of female genital cutting begins even with the question of what to call it. Among other names, it’s referred to as female circumcision, female genital mutilation, or, in medical parlance, infibulation: cutting away all or part of a girl’s external genitalia and stitching together the labia.
The World Health Organization calls it a human rights violation. Both the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics also oppose the practice.
Still, despite decades of condemnation, the practice remains well entrenched around the world, said gynecologist Dr. Kavita Shah Arora, assistant professor of reproductive biology and bioethics at Case Western Reserve University. “After 30 years of advocacy, the incidence of this is largely unchanged,” she said.
Weighing into this medical and cultural debate, then, she and co-author Allan Jacobs suggest a compromise: allowing doctors to perform a small cut, or nick, while banning more radical procedures that are dangerous or “produce significant sexual or reproductive dysfunction.” The authors argue that this compromise would minimize the physical and psychological harm to a girl while satisfying her family’s desire for a procedure in keeping with religious or cultural norms.
The paper, published Monday in the Journal of Medical Ethics, surveys studies showing the limited change in FGM prevalence in various countries. The percentage of girls who underwent any procedure that altered external genitalia fell from 77.8 percent to 71.6 percent from 2006 to 2011. In Somalia, the country with the highest prevalence of FGM, one study found 81 percent of women had undergone the procedure.
The minimalist cutting procedure would come with a new description. Calling it an “alteration” instead of the more loaded “mutilation,” Arora said, is less likely to alienate or stigmatize the families who practice it.
“We do this all the time with things like whether you homeschool your child or whether you allow your child to eat meat,” Arora said. “We should be thinking about finding a balance between the government’s responsibility to protect minors with the parental right to raise kids the way they see fit.”
The position is, however, a contentious one. A series of editorials published alongside the paper raise a host of concerns about the idea of allowing minimal nicks to serve as substitutes for conventional FGM.
“A cultural tradition designed to control women — even in its least harmful form — is best abandoned,” responded biomedical ethicist Ruth Macklin of Albert Einstein College of Medicine.
“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,” wrote Brian D. Earp, visiting scholar at the Hastings Center.
Dr. Nawal Nour, director of the African Women’s Health Center at Brigham and Women’s Hospital in Boston, raised a further concern in an interview: such a compromise would not be enough for many families.
“It’s rare that parents will agree to a nick,” she said. “This claim that they will consider that, there’s no data on that. And there’s no data that girls who undergo the nicking won’t later undergo a more severe procedure. The parents will just think the nicking didn’t really count.”
It’s not the first time this has come up. In 2010, the American Academy of Pediatrics’s Committee on Bioethics wrote, “It might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick [to the clitoris] as a possible compromise to avoid greater harm.” But after backlash from the medical and academic communities, the AAP retracted the policy statement, instead banning all forms of genital cutting on girls.
Nour is concerned that a compromise could hinder efforts to protect girls, both within families and around the world.
“This will rattle the human rights community, who are in the all-or-nothing way of thinking about this,” she said. “What message are we sending to countries that are trying to end this practice? ‘Well, they’re nicking in America, so why are you trying to stop us?'”
Arora admits that the compromise will not bring about a complete turnaround from more severe practices.
“There are a lot of shortcomings,” she said. “But it’s good if even one girl can be saved from an extreme procedure.”