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The Brussels Collaboration On Bodily Integrity. Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024:1-50. [PMID: 39018160 DOI: 10.1080/15265161.2024.2353823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
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.
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Palm C, Elmerstig E, Holmström C, Essén B. The relationship between dominant Western discourse and personal narratives of female genital cutting: exploring storytelling among Swedish-Somali girls and women. FRONTIERS IN SOCIOLOGY 2023; 8:1188097. [PMID: 37497100 PMCID: PMC10366609 DOI: 10.3389/fsoc.2023.1188097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/19/2023] [Indexed: 07/28/2023]
Abstract
Introduction A dominant narrative, referred to as "the standard tale," prevails in popular representations about female genital cutting (FGC) that often contrast with how cut women traditionally narrate their FGC experience as meaningful in contexts where FGC is customary. However, scholarship has increasingly highlighted how global eradication campaigns and migration to countries where FGC is stigmatized provide women with new frames of understanding which may lead to a reformulation of previous experiences. This article subjects the storytelling itself to analysis and explores how participants narrate and make sense of their FGC experience in a post-migration setting where FGC is stigmatized. Methods Semi-structured focus groups (9) and individual interviews (12) with Swedish-Somali girls and women (53) were conducted. Results The article highlights how the participants navigate their storying in relation to "the standard tale" of FGC in their efforts to make sense of their experiences. Navigation was conducted both at an intrapersonal level through continuous identity work, and in relation to the social context in interpersonal encounters, i.e., with service providers and others, among whom the standard tale has become a truth. Discussion The article places the analysis within broader discussions about anti-FGC work and considers the implications in relation to efforts to end FGC.
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Affiliation(s)
- Camilla Palm
- Centre for Sexology and Sexuality Studies, Department of Social Work, Malmö University, Malmö, Sweden
- Department of Women's and Children's Health (IMHm), Uppsala University, Uppsala, Sweden
| | - Eva Elmerstig
- Centre for Sexology and Sexuality Studies, Department of Social Work, Malmö University, Malmö, Sweden
| | - Charlotta Holmström
- Centre for Sexology and Sexuality Studies, Department of Social Work, Malmö University, Malmö, Sweden
| | - Birgitta Essén
- Department of Women's and Children's Health (IMHm), Uppsala University, Uppsala, Sweden
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Agboli A, Richard F, Botbol-Baum M, Brackelaire JL, D’Aguanno A, Diallo K, Mikolajczak M, Ricadat E, Aujoulat I. Changing attitudes towards female genital mutilation. From conflicts of loyalty to reconciliation with self and the community: The role of emotion regulation. PLoS One 2022; 17:e0270088. [PMID: 35727746 PMCID: PMC9212168 DOI: 10.1371/journal.pone.0270088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/05/2022] [Indexed: 12/03/2022] Open
Abstract
The practice of female genital mutilation (FGM) is a social norm embedded in the patriarchal system and is resistant to change due to its roots in the tradition of the practising communities. Despite this difficulty in change, some women succeed in changing their attitudes towards the practice. In trying to understand what makes these women change their attitudes, we identified in a previous study, the critical life events at which change occurs (turning point). These turning points were described with emotions and conflicting feelings based on which we hypothesised that emotion regulation and the resolution of conflicts of loyalty might be possible mechanisms that explain the change of attitudes by the women. In this article, we sought to investigate how the mechanisms interact and how they were at play to explain the change. We, therefore, triangulated our previous data, fifteen women interviewed twice, with the published life stories and public testimonies of 10 women with FGM, and interviews of six experts chosen for their complementary fields of expertise to discuss the emerging concepts and theory, generated by our study. The data were analysed using framework analysis and an element of the grounded theory approach (constant comparison). As a result of our theorisation process, we propose a model of change in five stages (Emotion suppression, The awakening, The clash, Re-appropriation of self, and Reconciliation). This describes the process of a woman’s journey from compliance with FGM and community norms to non-compliance. Our study reveals how the women whose stories were analysed, moved from being full members of their community at the cost of suppressing their emotions and denying their selves, to becoming their whole selves while symbolically remaining members of their communities through the forgiveness of their mothers.
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Affiliation(s)
- Afi Agboli
- Institute of Health and Society (IRSS), Brussels, Belgium
- Université Catholique de Louvain, Brussels, Belgium
- * E-mail: ,
| | - Fabienne Richard
- School of Public Health, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Groupe pour l’Abolition des Mutilations Sexuelles (GAMS-Belgium), Brussels, Belgium
| | - Mylene Botbol-Baum
- Institute of Health and Society (IRSS), Brussels, Belgium
- Health, Economics, Ethics, Law, and Social Issues (HELESI), Brussels, Belgium
| | - Jean-Luc Brackelaire
- Institute of Health and Society (IRSS), Brussels, Belgium
- Institute for the Analysis of Change in Contemporary and Historical Societies (IACS), Louvain-La-Neuve, Belgium
- Faculty of Law, Université de Namur (UNamur), Namur, Belgium
| | - Annalisa D’Aguanno
- Groupe pour l’Abolition des Mutilations Sexuelles (GAMS-Belgium), Brussels, Belgium
| | - Khadidiatou Diallo
- Groupe pour l’Abolition des Mutilations Sexuelles (GAMS-Belgium), Brussels, Belgium
| | - Moïra Mikolajczak
- Institute of Health and Society (IRSS), Brussels, Belgium
- Psychological Sciences Research Institute (IPSY), Louvain-La-Neuve, Belgium
| | - Elise Ricadat
- Centre de Recherche Psychanalyse, Médecine et Société (CRPMS), Université de Paris, Paris, France
- Institut de Recherche Saint-Louis, Paris, France
| | - Isabelle Aujoulat
- Institute of Health and Society (IRSS), Brussels, Belgium
- Université Catholique de Louvain, Brussels, Belgium
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Reconsidering the role of patriarchy in upholding female genital modifications: analysis of contemporary and pre-industrial societies. Int J Impot Res 2022; 35:202-211. [PMID: 35701657 PMCID: PMC10159853 DOI: 10.1038/s41443-022-00581-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 04/29/2022] [Accepted: 05/03/2022] [Indexed: 11/08/2022]
Abstract
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.
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Earp BD. Protecting Children from Medically Unnecessary Genital Cutting Without Stigmatizing Women's Bodies: Implications for Sexual Pleasure and Pain. ARCHIVES OF SEXUAL BEHAVIOR 2021; 50:1875-1885. [PMID: 31965452 DOI: 10.1007/s10508-020-01633-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 01/04/2020] [Accepted: 01/08/2020] [Indexed: 05/21/2023]
Affiliation(s)
- Brian D Earp
- Yale-Hastings Program in Ethics and Health Policy, Yale University, New Haven, CT, 06511, USA.
- The Hastings Center, Garrison, NY, USA.
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Hanberger A, Essén B, Wahlberg A. Attitudes towards comparison of male and female genital cutting in a Swedish Somali population. Acta Obstet Gynecol Scand 2021; 100:604-613. [PMID: 33554342 DOI: 10.1111/aogs.14114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION In Sweden, the law treats female genital cutting (FGC) differently from male genital cutting (MGC). However, the comparability of the medical, ethical, and legal aspects of genital cutting of girls and boys are increasingly discussed by scholars, although little is known about how practicing communities view these aspects. This study aimed to explore attitudes towards comparison of genital cutting of girls and boys among Swedish Somalis, and to investigate factors associated with considering the two practices to be comparable. MATERIAL AND METHODS In a cross-sectional questionnaire with 648 Swedish Somali men and women from four Swedish cities, descriptive statistics and logistic regression were used for the analysis. RESULTS Among the Swedish Somalis, 10% considered FGC and MGC to be comparable practices. A majority (98%) of the participants thought FGC could cause long-term health complications, but only 1% considered the physical health disadvantage of MGC would outweigh the physical health benefits. FGC was perceived to be a violation of children's rights by 60%, whereas this proportion for MGC was 3%. Individuals who had a dominant bridging social capital and those who expressed that performing FGC follows religion were more likely to think that FGC and MGC were comparable practices. CONCLUSIONS The increased global attention and emphasis on the comparability of genital cutting of boys and girls was not reflected in this study among Swedish Somalis. Rather, attitudes reflected the common description of the two practices in global public health campaigns, portraying FGC as a harmful practice violating children's rights, while describing MGC as a public health measure. Social interactions and separation of FGC from religion could explain why FGC and MGC were not considered comparable.
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Affiliation(s)
- Adam Hanberger
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Akademiska Sjukhuset University Hospital, Uppsala, Sweden
| | - Birgitta Essén
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Akademiska Sjukhuset University Hospital, Uppsala, Sweden
| | - Anna Wahlberg
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Akademiska Sjukhuset University Hospital, Uppsala, Sweden
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Earp BD. Male or female genital cutting: why 'health benefits' are morally irrelevant. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106782. [PMID: 33462078 DOI: 10.1136/medethics-2020-106782] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 12/03/2020] [Accepted: 12/08/2020] [Indexed: 06/12/2023]
Abstract
The WHO, American Academy of Pediatrics and other Western medical bodies currently maintain that all medically unnecessary female genital cutting of minors is categorically a human rights violation, while either tolerating or actively endorsing medically unnecessary male genital cutting of minors, especially in the form of penile circumcision. Given that some forms of female genital cutting, such as ritual pricking or nicking of the clitoral hood, are less severe than penile circumcision, yet are often performed within the same families for similar (eg, religious) reasons, it may seem that there is an unjust double standard. Against this view, it is sometimes claimed that while female genital cutting has 'no health benefits', male genital cutting has at least some. Is that really the case? And if it is the case, can it justify the disparate treatment of children with different sex characteristics when it comes to protecting their genital integrity? I argue that, even if one accepts the health claims that are sometimes raised in this context, they cannot justify such disparate treatment. Rather, children of all sexes and genders have an equal right to (future) bodily autonomy. This includes the right to decide whether their own 'private' anatomy should be exposed to surgical risk, much less permanently altered, for reasons they themselves endorse when they are sufficiently mature.
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Affiliation(s)
- Brian D Earp
- Yale-Hastings Program in Ethics and Health Policy, Yale University and The Hastings Center, New Haven, CT 06511, USA
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Interrogating the politicization of female genital cutting (FGC) within conditions of asymmetrical cultural convergence. A case study of Northern Ireland. WOMENS STUDIES INTERNATIONAL FORUM 2020. [DOI: 10.1016/j.wsif.2020.102391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Sharif Mohamed F, Wild V, Earp BD, Johnson-Agbakwu C, Abdulcadir J. Clitoral Reconstruction After Female Genital Mutilation/Cutting: A Review of Surgical Techniques and Ethical Debate. J Sex Med 2020; 17:531-542. [PMID: 31932257 DOI: 10.1016/j.jsxm.2019.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 11/14/2019] [Accepted: 12/04/2019] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Clitoral reconstruction (CR) is a controversial surgical procedure performed for women who have undergone medically unnecessary, often ritualistic genital cutting involving the clitoris. Such cutting is known by several terms; we will use female genital mutilation/cutting (FGM/C). Treatments offered to women affected by complications of FGM/C include defibulation (releasing the scar of infibulation to allow penetrative intercourse, urinary flow, physiological delivery, and menstruation) and CR to decrease pain, improve sexual response, and create a pre-FGM/C genital appearance. AIM In this study, our aim is to summarize the medical literature regarding CR techniques and outcomes, and stimulate ethical discussion surrounding potential adverse impacts on women who undergo the procedure. METHODS A broad literature review was carried out to search any previous peer-reviewed publications regarding the techniques and ethical considerations for CR. MAIN OUTCOME MEASURE The main outcome measure includes benefits, risks, and ethical analysis of CR. RESULTS While we discuss the limited evidence regarding the risks and efficacy of CR, we did not find any peer-reviewed reports focused on ethical implications to date. CLINICAL IMPLICATIONS CR can be indicated as a treatment for pain and potential improvement of associated sexual dysfunction when these have not responded to more conservative measures. Women must be appropriately informed about the risks of CR and the lack of strong evidence regarding potential benefits. They must be educated about their genital anatomy and disabused of any myths surrounding female sexual function as well as assessed and treated in accordance with the current scientific evidence and best clinical practices. STRENGTH & LIMITATIONS This is the first formal ethical discussion surrounding CR. This is not a systematic review, and the ethical discussion of CR has only just begun. CONCLUSION We present a preliminary ethical analysis of the procedure and its potential impact on women with FGM/C. Sharif Mohamed F, Wild V, Earp BD, et al. Clitoral Reconstruction After Female Genital Mutilation/Cutting: A Review of Surgical Techniques and Ethical Debate. J Sex Med 2020;17:531-542.
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Affiliation(s)
- Fatima Sharif Mohamed
- Department of Obstetrics and Gynecology, Maricopa Integrated Health System, Phoenix, AZ, USA
| | - Verina Wild
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Brian D Earp
- Yale-Hastings Program in Ethics and Health Policy, Yale University and The Hastings Center, New Haven, CT, USA
| | - Crista Johnson-Agbakwu
- Department of Obstetrics and Gynecology, Maricopa Integrated Health System, Phoenix, AZ, USA; Office of Refugee Health, Southwest Interdisciplinary Research Center, Arizona State University, Phoenix, AZ, USA
| | - Jasmine Abdulcadir
- Department of Woman, Child and Adolescent, Division of Gynecology, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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Wahlberg A, Påfs J, Jordal M. Pricking in the African Diaspora: Current Evidence and Recurrent Debates. CURRENT SEXUAL HEALTH REPORTS 2019. [DOI: 10.1007/s11930-019-00198-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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