Gendered genital modifications in critical anthropology: from discourses on FGM/C to new technologies in the sex/gender system

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.

Rethinking the Definition of Medicalized Female Genital Mutilation/Cutting

In 2015, the international community agreed to end Female Genital Mutilation/Cutting (FGM/C) by 2030. However, the target is unlikely to be met as changes in practice, including medicalized female genital mutilation/cutting (mFGM/C), challenge abandonment strategies. This paper critically reviews the current World Health Organization (WHO) definition of mFGM/C to demonstrate that mFGM/C, as currently defined, lacks detail and clarity, and may serve as an obstacle to the collection of credible, reliable, and comparable data relevant to targeted FGM/C prevention policies and programs. The paper argues that it is necessary to initiate a discussion on the revision of the current WHO definition of mFGM/C, where different components (who-how-where-what) should be taken into account. This is argued by discussing different scenarios that compare the current WHO definition of mFGM/C with the actual practice of FGM/C on the ground. The cases discussed within these scenarios are based on existing published research and the research experience of the authors. The scenarios focus on countries where mFGM/C is prevalent among girls under 18 years, using data from Demographic Health Surveys and/or Multiple Indicator Cluster Surveys, and thus the focus is on the Global South. The paper places its arguments in relation to wider debates concerning female genital cosmetic surgery, male genital circumcision and consent. It calls for more research on these topics to ensure that definitions of FGM/C and mFGM/C reflect the real-world contexts and ensure that the human rights of girls and women are protected.

Changing gender norms around female genital mutilation/cutting (FGM/C): a key role for social work in the Global North

"Female genital mutilation/cutting" (FGM/C) refers to procedures that involve altering the external female genitalia with the aim of reinforcing gendered body norms. The literature has consistently shown that, like various forms of discrimination, the practice is rooted in systems of gender inequality. As a result, FGM/C has increasingly come to be understood in terms of social norms that are by no means fixed. And yet, in the Global North, interventions remain primarily medical in nature, with clitoral reconstruction having emerged as a common means of dealing with related sexual issues. And although treatments can vary greatly depending on the hospitals and physicians involved, sexuality tends to be considered from a gynecological perspective, even when multidisciplinary care is offered. By contrast, gender norms and other socio-cultural factors receive little attention. In addition to highlighting three critical shortcomings in current responses to FGM/C, this literature review also describes how social work can play a key role in overcoming the associated barriers by (1) adopting a holistic approach to sex education, one capable of addressing those aspects of sexuality that lie beyond the scope of a medical consultation; (2) supporting family-based discussions on matters of sexuality; and (3) promoting gender equality, especially among younger generations.

"La Perla Del Mar": A Case Report on Subcutaneous Penile Implants

The purpose of this report is to alert and inform the medical community about the presence and practice of subcutaneous penile implants (SPIs), which are used with the intent of increasing sexual pleasure. This case aspires to deflect plausible misconceptions in the specific populations who use the SPIs. This case study was performed in January 2023 at a tertiary care center in Miami, Florida. A 61-year-old Cuban male admitted for a routine hernia repair with an incidental finding of a benign SPI was interviewed and examined; an extended collection of historical information regarding the patient's penile implant was ascertained. The patient stated that there was a tradition among the men and adolescent individuals living along coastal cities/towns of Cuba such as Havana and Matanzas who would elect to have pieces of stones or gems or any solid objects shaped and molded into round objects that are used for the intent of increasing sexual pleasure. The patient referred to the implant as "La Perla Del Mar," which translates directly into "Pearl of the Sea." Upon visualization of the nodule on examination, a differential diagnosis may include infection (such as syphilis), granulomas, sarcoidosis, dermatofibroma, epithelial inclusion cyst, or malignancy. However, an appropriate workup informed us about the penile implant. Clinicians should employ caution in investigating a penile nodule by taking a detailed social and sexual history and physical exam from the patient if possible. This case and the literature review cited to bolster the notion of a lack of chronic symptoms due to the inserted objects. Several provocations for the implantation of an artificial penile nodule, in this case, maybe extrapolated, such as the desire for a prospective partner's pleasure/displeasure, group identification, or masculine embodiment. The main takeaways from this case report are the considerations that should be taken in the older Caribbean population for patients with the "Perla Del Mar" implantation and bolstering the notion of complete sexual education for clinicians regarding specific populations to enhance patient care.

Health outcomes and female genital mutilation/cutting: how much is due to the cutting itself?

While Female Genital Mutilation/Cutting (FGM/C) continues to garner global attention, FGM/C-affected migrant communities, who are often racialized minorities in the U.S., face additional challenges which may impact their physical and mental health and well-being. It has been proposed that an overly narrow focus on the female genitalia or FGM/C status alone, while ignoring the wider social experiences and perceptions of affected migrant women, will result in incomplete or misleading conclusions about the relationship between FGM/C and migrant women's health. A cross-sectional study was conducted across two waves of Somali and Somali Bantu women living in the United States, (n = 879 [wave 1], n = 654 [wave 2]). Socio-demographics, self-reported FGM/C status, perceived psychological distress, and self-reported FGM/C-related health morbidity was examined against self-reported experiences of everyday discrimination and perceived psychosocial support. In statistical models including age and educational attainment as potentially confounding socio-demographic variables, as well as self-reported FGM/C status, self-reported discrimination, and perceived psychosocial support, self-reported discrimination was the variable most strongly associated with poor physical health and psychological distress (i.e., FGM/C-related health morbidity and psychological distress), with greater perceived psychosocial support negatively associated with psychological distress, when controlling for all the other variables in the model. FGM/C status was not significantly associated with either outcome. Discrimination, more frequently reported among 'No FGM/C' (i.e., genitally intact or unmodified) women, was most frequently perceived as linked to religion and ethnicity. Our findings are consistent with views that discrimination drives negative outcomes. In this population, discrimination may include the 'quadruple jeopardy' of intersecting relationships among gender, race, religion, and migration status. We find that self-reported experiences of discrimination-and not FGM/C status per se-is associated with adverse physical and mental health consequences in our sample drawn from Somali migrant communities living in the United States, and that social support may help to mitigate these consequences. Our findings thus reinforce calls to better contextualize the relationship between FGM/C and measures of health and well-being among Somali women in the United States (regardless of their FGM/C status), taking psychosocial factors more centrally into account.Clinical Trials.Gov ID no. NCT03249649, Study ID no. 5252. Public website: https://clinicaltrials.gov/ct2/show/NCT03249649.

Reconsidering the role of patriarchy in upholding female genital modifications: analysis of contemporary and pre-industrial societies

According to the World Health Organization (WHO), customary female genital modification practices common in parts of Africa, South and Southeast Asia, and the Middle East are inherently patriarchal: they reflect deep-rooted inequality between the sexes characterized by male dominance and constitute an extreme form of discrimination against women. However, scholars have noted that while many societies have genital modification rites only for boys, with no equivalent rite for girls, the inverse does not hold. Rather, almost all societies that practice ritual female genital modification also practice ritual male genital modification, often for comparable reasons on children of similar ages, with the female rites led by women and the male rites led by men. In contrast, then, to the situation for boys in various cultures, girls are not singled out for genital modification on account of their sex or gender; nor do the social meanings of the female rites necessarily reflect a lower status. In some cases, the women's rite serves to promote female within-sex bonding and network building-as the men's rite typically does for males-thereby counterbalancing gendered asymmetries in political power and weakening male dominance in certain spheres. In such cases, and to that extent, the female rites can be described as counter-patriarchal. Selective efforts to discourage female genital modifications may thus inadvertently undermine women-centered communal networks while leaving male bonding rites intact. Scholars and activists should not rely on misleading generalizations from the WHO about the relationship between genital cutting and the social positioning of women as compared to men. To illustrate the complexity of this relationship, we compare patterns of practice across contemporary societies while also highlighting anthropological data regarding pre-industrial societies. Regarding the latter, we find no association between the presence of a female initiation rite and a key aspect of patriarchy as it is classically understood, namely, social endorsement of a gendered double-standard regarding premarital sexual activity. We situate this finding within the broader literature and discuss potential implications.

Genital Cutting as Gender Oppression: Time to Revisit the WHO Paradigm

The World Health Organization (WHO) condemns all medically unnecessary female genital cutting (FGC) that is primarily associated with people of color and the Global South, claiming that such FGC violates the human right to bodily integrity regardless of harm-level, degree of medicalization, or consent. However, the WHO does not condemn medically unnecessary FGC that is primarily associated with Western culture, such as elective labiaplasty or genital piercing, even when performed by non-medical practitioners (e.g., body artists) or on adolescent girls. Nor does it campaign against any form of medically unnecessary intersex genital cutting (IGC) or male genital cutting (MGC), including forms that are non-consensual or comparably harmful to some types of FGC. These and other apparent inconsistencies risk undermining the perceived authority of the WHO to pronounce on human rights. This paper considers whether the WHO could justify its selective condemnation of non-Western-associated FGC by appealing to the distinctive role of such practices in upholding patriarchal gender systems and furthering sex-based discrimination against women and girls. The paper argues that such a justification would not succeed. To the contrary, dismantling patriarchal power structures and reducing sex-based discrimination in FGC-practicing societies requires principled opposition to medically unnecessary, non-consensual genital cutting of all vulnerable persons, including insufficiently autonomous children, irrespective of their sex traits or socially assigned gender. This conclusion is based, in part, on an assessment of the overlapping and often mutually reinforcing roles of different types of child genital cutting—FGC, MGC, and IGC—in reproducing oppressive gender systems. These systems, in turn, tend to subordinate women and girls as well as non-dominant males and sexual and gender minorities. The selective efforts of the WHO to eliminate only non-Western-associated FGC exposes the organization to credible accusations of racism and cultural imperialism and paradoxically undermines its own stated goals: namely, securing the long-term interests and equal rights of women and girls in FGC-practicing societies.