Defending an inclusive right to genital and bodily integrity for children

Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed?

When is it ethically permissible for clinicians to surgically intervene into the genitals of a legal minor? We distinguish between voluntary and nonvoluntary procedures and focus on nonvoluntary procedures, specifically in prepubescent minors ("children"). We do not address procedures in adolescence or adulthood. With respect to children categorized as female at birth who have no apparent differences of sex development (i.e., non-intersex or "endosex" females) there is a near-universal ethical consensus in the Global North. This consensus holds that clinicians may not perform any nonvoluntary genital cutting or surgery, from "cosmetic" labiaplasty to medicalized ritual "pricking" of the vulva, insofar as the procedure is not strictly necessary to protect the child's physical health. All other motivations, including possible psychosocial, cultural, subjective-aesthetic, or prophylactic benefits as judged by doctors or parents, are seen as categorically inappropriate grounds for a clinician to proceed with a nonvoluntary genital procedure in this population. We argue that the main ethical reasons capable of supporting this consensus turn not on empirically contestable benefit-risk calculations, but on a fundamental concern to respect the child's privacy, bodily integrity, developing sexual boundaries, and (future) genital autonomy. We show that these ethical reasons are sound. However, as we argue, they do not only apply to endosex female children, but rather to all children regardless of sex characteristics, including those with intersex traits and endosex males. We conclude, therefore, that as a matter of justice, inclusivity, and gender equality in medical-ethical policy (we do not take a position as to criminal law), clinicians should not be permitted to perform any nonvoluntary genital cutting or surgery in prepubescent minors, irrespective of the latter's sex traits or gender assignment, unless urgently necessary to protect their physical health. By contrast, we suggest that voluntary surgeries in older individuals might, under certain conditions, permissibly be performed for a wider range of reasons, including reasons of self-identity or psychosocial well-being, in keeping with the circumstances, values, and explicit needs and preferences of the persons so concerned. Note: Because our position is tied to clinicians' widely accepted role-specific duties as medical practitioners within regulated healthcare systems, we do not consider genital procedures performed outside of a healthcare context (e.g., for religious reasons) or by persons other than licensed healthcare providers working in their professional capacity.

Exploring opposition to ritual female genital cutting since the first U.S. federal prosecution: the 2017 detroit case

In the U.S., the 1996 federal law banning medically unnecessary female genital cutting (FGC) of minors was rendered unconstitutional in 2018 in the Nagarwala case. This paper highlights legal developments at the federal and state levels in the U.S. since this trial. It looks at anti-FGC frameworks in other Western countries such as Australia, the UK, France, and Switzerland for comparison. The Australia High Court ruled in favor of a broader interpretation of the words "mutilate" (as in "female genital mutilation" or FGM) and "clitoris" in 2019. In the UK in 2019, a mother of a three-year-old became the first person convicted of "FGM.". In the U.S., 2020 federal legislation strengthened opposition to FGC of minors. Twenty-one U.S. states have developed legislation since 2017 that was enacted to oppose such FGC. The 14th Amendment to the U.S. Constitution affords equal protection under the law without regard to sex or gender, prompting increased inclusion of neonatal male circumcision and normalizing surgery for children with intersex traits in the FGC legislation debate. More widely, the principle of equal application of the law raises questions about the legality of adult female genital cosmetic surgery where adult "FGM" is banned. Tensions between state law and religious law introduce complexities to allowing religious and cultural communities to practice their preferred way of life when this conflicts with human and civil rights afforded to individuals within secular liberal democracies. For consistency, the anti-FGC framework in the U.S. may need to shift towards calls to protect all children, regardless of sex characteristics (i.e., including male and intersex children) from medically unnecessary, non-consensual genital cutting.