In defence of genital autonomy for children

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.

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.

The need for a unified ethical stance on child genital cutting

The American College of Nurse-Midwives, American Society for Pain Management Nursing, American Academy of Pediatrics, and other largely US-based medical organizations have argued that at least some forms of non-therapeutic child genital cutting, including routine penile circumcision, are ethically permissible even when performed on non-consenting minors. In support of this view, these organizations have at times appealed to potential health benefits that may follow from removing sexually sensitive, non-diseased tissue from the genitals of such minors. We argue that these appeals to "health benefits" as a way of justifying medically unnecessary child genital cutting practices may have unintended consequences. For example, it may create a "loophole" through which certain forms of female genital cutting-or female genital "mutilation" as it is defined by the World Health Organization-could potentially be legitimized. Moreover, by comparing current dominant Western attitudes toward female genital "mutilation" and so-called intersex genital "normalization" surgeries (i.e. surgeries on children with certain differences of sex development), we show that the concept of health invoked in each case is inconsistent and culturally biased. It is time for Western healthcare organizations-including the American College of Nurse-Midwives, American Society for Pain Management Nursing, American Academy of Pediatrics, and World Health Organization-to adopt a more consistent concept of health and a unified ethical stance when it comes to child genital cutting practices.

Male or female genital cutting: why 'health benefits' are morally irrelevant

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.

In Vivo Imaging-Based 3-Dimensional Pelvic Prototype Models to Improve Education Regarding Sexual Anatomy and Physiology

BACKGROUND

Myths, misconceptions, and taboos about sexual anatomy and physiology are common and can affect sexual health and maintain harmful practices and beliefs.

AIM

To construct a female and a preliminary male 3-dimensional (3D) pelvic model on the basis of in vivo imaging, which could be studied in sex education and clinical practice.

METHODS

We retrospectively studied the images of 200 female pelvic magnetic resonance examinations and reviewed the literature to choose the optimum magnetic resonance imaging (MRI) protocol for the study of the clitoris and surrounding organs. We also conducted a cross-sectional study of 30 women who were undergoing a pelvic MRI. 15 women had undergone female genital mutilation/cutting involving the clitoris and 15 had not. The best-quality MRI images of 3 uncut and 1 cut clitoris, together with the principal surrounding pelvic organs, were selected to generate 3D reconstructions using dedicated software. The same software was used to reconstruct the anatomy of the penis and the principal surrounding pelvic organs, based on contrast-enhanced computer tomography images. Images of both models were exported in .stl format and cleaned to obtain single manifold objects in free, open source software. Each organ model was sliced and 3D printed. A preliminary feedback was collected from 13 potential users working in urology, gynaecology, sexual medicine, physiotherapy, and education.

OUTCOMES

The main outcomes of this study are a kit of 3D pelvic models, 2-dimensional figures of female and male sexual anatomy, and files for 3D printing.

RESULTS

We present a kit containing 3D models and 2-dimensional figures of female and male sexual anatomy, based on in vivo imaging and, feedbacks and suggestions received from potential users.

CLINICAL TRANSLATION

Our kit can be used in anatomy and sex education among and by health professionals, teachers, sex educators, students, and the general population.

STRENGTHS & LIMITATIONS

The strengths are that the models were based on in vivo imaging, can be dismantled/reassembled, and show analogous anatomic structures of the clitoris and the penis. The female models represent diversity, including women with female genital mutilation/cutting. The limitations are that the male model is preliminary and can be improved if based on an MRI; that imaging-based anatomic representations can differ from anatomic dissections; and that the models represent the sexual organs at rest or during an unknown state of arousal only.

CONCLUSION

Our kit can be studied in anatomy, biology, and sex education, as well as in clinical practice. Abdulcadir J, Dewaele R, Firmenich N, et al. In Vivo Imaging-Based 3-Dimensional Pelvic Prototype Models to Improve Education Regarding Sexual Anatomy and Physiology. J Sex Med 2020;17:1590-1602.

Current critiques of the WHO policy on female genital mutilation

In recent years, the dominant Western discourse on "female genital mutilation" (FGM) has increasingly been challenged by scholars. Numerous researchers contest both the terminology used and the empirical claims made in what has come to be called "the standard tale" of FGM (also termed "female genital cutting" [FGC]). The World Health Organization (WHO), a major player in setting the global agenda on this issue, maintains that all medically unnecessary cutting of the external female genitalia, no matter how slight, should be banned as torture and a violation of the human right to bodily integrity. However, the WHO targets only non-Western forms of female-only genital cutting, raising concerns about gender bias and cultural imperialism. Here, we summarize ongoing critiques of the WHO's terminology, ethicolegal assumptions, and empirical claims, including the claim that non-Western FGC as such constitutes an extreme form of discrimination against women. To this end, we highlight recent comparative studies of medically unnecessary genital cutting of all types, including those affecting adult women and teenagers in Western societies, individuals with differences of sex development (DSD), transgender persons, and males. In so doing, we attempt to clarify the grounds for a growing critical consensus that current anti-FGM laws and policies may be ethically incoherent, empirically unsupportable, and legally unsustainable.

Clitoral Reconstruction After Female Genital Mutilation/Cutting: A Review of Surgical Techniques and Ethical Debate

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.

False beliefs predict increased circumcision satisfaction in a sample of US American men

Critics of non-therapeutic male and female childhood genital cutting claim that such cutting is harmful. It is therefore puzzling that 'circumcised' women and men do not typically regard themselves as having been harmed by the cutting, notwithstanding the loss of sensitive, prima facie valuable tissue. For female genital cutting (FGC), a commonly proposed solution to this puzzle is that women who had part(s) of their vulvae removed before sexual debut 'do not know what they are missing' and may 'justify' their genitally-altered state by adopting false beliefs about the benefits of FGC, while simultaneously stigmatising unmodified genitalia as unattractive or unclean. Might a similar phenomenon apply to neonatally circumcised men? In this survey of 999 US American men, greater endorsement of false beliefs concerning circumcision and penile anatomy predicted greater satisfaction with being circumcised, while among genitally intact men, the opposite trend occurred: greater endorsement of false beliefs predicted less satisfaction with being genitally intact. These findings provide tentative support for the hypothesis that the lack-of-harm reported by many circumcised men, like the lack-of-harm reported by their female counterparts in societies that practice FGC, may be related to holding inaccurate beliefs concerning unaltered genitalia and the consequences of childhood genital modification.

Baseline data from a planned RCT on attitudes to female genital cutting after migration: when are interventions justified?

OBJECTIVES

To present the primary outcomes from a baseline study on attitudes towards female genital cutting (FGC) after migration.

DESIGN

Baseline data from a planned cluster randomised, controlled trial. Face-to-face interviews were used to collect questionnaire data in 2015. Based on our hypothesis that established Somalis could be used as facilitators of change among those newly arrived, data were stratified into years of residency in Sweden.

SETTING

Sweden.

PARTICIPANTS

372 Somali men and women, 206 newly arrived (0-4 years), 166 established (>4 years).

PRIMARY OUTCOME MEASURES

Whether FGC is acceptable, preferred for daughter and should continue, specified on anatomical extent.

RESULTS

The support for anatomical change of girls and women's genitals ranged from 0% to 2% among established and from 4% to 8% among newly arrived. Among those supporting no anatomical change, 75%-83% among established and 53%-67% among newly arrived opposed all forms of FGC, with the remaining supporting pricking of the skin with no removal of tissue. Among newly arrived, 37% stated that pricking was acceptable, 39% said they wanted their daughter to be pricked and 26% reported they wanted pricking to continue being practised. Those who had lived in Sweden ≤ 2 years had highest odds of supporting FGC; thereafter, the opposition towards FGC increased over time after migration.

CONCLUSION

A majority of Somali immigrants, including those newly arrived, opposed all forms of FGC with increased opposition over time after migration. The majority of proponents of FGC supported pricking. We argue that it would have been unethical to proceed with the intervention as it, with this baseline, would have been difficult to detect a change in attitudes given that a majority opposed all forms of FGC together with the evidence that a strong attitude change is already happening. Therefore, we decided not to implement the planned intervention.

TRIAL REGISTRATION NUMBER

Trial registration number NCT02335697;Pre-results.

Factors associated with the support of pricking (female genital cutting type IV) among Somali immigrants - a cross-sectional study in Sweden

Background

Pricking, classified as female genital cutting (FGC) type IV by the World Health Organization, is an under-researched area gaining momentum among diaspora communities. Our aim was to explore factors associated with being supportive of pricking among Somalis in Sweden.

Methods

In a cross-sectional design, attitudes and knowledge regarding FGC, and measures of socioeconomic status, acculturation, and social capital, were assessed by a 49-item questionnaire in four municipalities in Sweden. Data were collected in 2015 from 648 Somali men and women, ≥ 18 years old, of which 113 supported the continuation of pricking. Logistic regression was used for the analysis.

Results

Those more likely to support the continuation of pricking were older, originally from rural areas, and newly arrived in Sweden. Further, those who reported that they thought pricking was: acceptable, according to their religion (aOR: 10.59, 95% CI: 5.44–20.62); not a violation of children’s rights (aOR: 2.86, 95% CI: 1.46–5.61); and did not cause long-term health complications (aOR: 5.52, 95% CI: 2.25–13.52) had higher odds of supporting pricking. Religion was strongly associated with the support of pricking among both genders. However, for men, children’s rights and the definition of pricking as FGC or not were important aspects in how they viewed pricking, while, for women, health complications and respectability were important.

Conclusions

Values known to be associated with FGC in general are also related to pricking. Hence, there seems to be a change in what types of FGC are supported rather than in their perceived values.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-017-0351-0) contains supplementary material, which is available to authorized users.