A Rose by Any Other Name? Rethinking the Similarities and Differences between Male and Female Genital Cutting

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.

Foreskin restorers: insights into motivations, successes, challenges, and experiences with medical and mental health professionals - An abridged summary of key findings

Demographically diverse surveys in the United States suggest that 5-10% of non-voluntarily circumcised American males wish that they had not been circumcised. Similar data are unavailable in other countries. An unknown proportion of circumcised males experience acute circumcision-related distress; some attempt to regain a sense of bodily integrity through non-surgical foreskin restoration. Their concerns are often ignored by health professionals. We conducted an in-depth investigation into foreskin restorers' lived experiences. An online survey containing 49 qualitative and 10 demographic questions was developed to identify restorers' motivations, successes, challenges, and experiences with health professionals. Targeted sampling was employed to reach this distinctive population. Invitations were disseminated to customers of commercial restoration devices, online restoration forums, device manufacturer websites, and via genital autonomy organizations. Over 2100 surveys were submitted by respondents from 60 countries. We report results from 1790 fully completed surveys. Adverse physical, sexual, emotional/psychological and self-esteem impacts attributed to circumcision had motivated participants to seek foreskin restoration. Most sought no professional help due to hopelessness, fear, or mistrust. Those who sought help encountered trivialization, dismissal, or ridicule. Most participants recommended restoration. Many professionals are unprepared to assist this population. Circumcision sufferers/foreskin restorers have largely been ill-served by medical and mental health professionals.

Global phylogenetic analysis reveals multiple origins and correlates of genital mutilation/cutting

Genital mutilation/cutting is costly in terms of health, survival and reproduction, and the long-term maintenance of these practices is an evolutionary conundrum. Previous studies have suggested a mate-guarding function or various signalling functions of genital mutilation/cutting. Here we use phylogenetic comparative methods and two global ethnographic samples to study the origins and socio-ecological correlates of major types of female and male genital mutilation/cutting. Male genital mutilation/cutting probably originated in polygynous societies with separate residence of co-wives, supporting a mate-guarding function. Female genital mutilation/cutting originated subsequently and almost exclusively in societies already practising male genital mutilation/cutting, where it may have become a signal of chastity. Both have originated multiple times, some as early as in the mid-Holocene (5,000-7,000 years ago), considerably predating the earliest archaeological evidence and written records. Genital mutilation/cutting co-evolves with and may help maintain fundamental social structures, hindering efforts to change these cultural practices.

Harmful cultural practices in the consultation room: Dutch general practitioners' views and experiences

We discuss Dutch general practitioners' responses to patients, mostly women of migrant background, with needs related to Harmful Cultural Practices. Our aim was to discover whether they encounter these kind of health issues and how they respond. We suspected that the patients concerned would not get the care they needed. We found that there is reason for concern, as based on general practitioners' own accounts we conclude that notwithstanding their great commitment to these patients they were disinclined to intervene, because they were cautious to judge other cultures and because they may have over- or underestimated the women's autonomy.

Gender and cultural understandings in medical nonindicated interventions: A critical discussion of attitudes toward nontherapeutic male circumcision and hymen (re)construction

Hymen (re)construction and nontherapeutic male circumcision are medical nonindicated interventions that give rise to specific ethical concerns. In Europe, hymen (re)construction is generally more contested among medical professionals than male circumcision. Yet, from a standard biomedical framework, guided by the principles of autonomy, beneficence, nonmaleficence, and justice, circumcision of boys is, as this article explains, more problematic than hymen (re-) construction. While there is a growing debate on the acceptability of infant circumcision, in the case of competent minors and adults the surgery is not questioned. In the case of hymenoplasty, usually requested by a competent patient, it is recommended to only perform the operation after extensive counseling and if there are compelling conditions. The article further explores why attitudes of medical professionals toward both surgeries diverge and seeks to explain how this is largely informed by gendered and socio-cultural understandings. The article further raises critical questions on medical paternalism and the role of counseling.

Medicalized Female Genital Mutilation/Cutting: Contentious Practices and Persistent Debates

Purpose of Review

Female genital cutting/mutilation (FGM/C) performed by health care professionals (medicalization) and reduced severity of cutting have been advanced as strategies for minimizing health risks, sparking acrimonious ongoing debates. This study summarizes key debates and critically assesses supporting evidence.

Recent Findings

While medicalization is concentrated in Africa, health professionals worldwide have faced requests to perform FGM/C. Whether medicalization is hindering the decline of FGM/C is unclear. Factors motivating medicalization include, but are not limited to, safety concerns. Involvement of health professionals in advocacy to end FGM/C can address both the supply and demand side of medicalization, but raises ethical concerns regarding dual loyalty. Ongoing debates need to address competing rights claims.

Summary

Polarizing debates have brought little resolution. We call for a focus on common goals of protecting the health and welfare of girls living in communities where FGM/C is upheld and encourage more informed and open dialog.

Why UK doctors should be troubled by female genital mutilation legislation

A UK doctor was recently acquitted of charges of reinstating a variety of female genital mutilation after delivering a child. In this paper, I contend that this incident reflects a broader confusion concerning the ethico-legal status of non-therapeutic genital surgeries for children and adults, which are not derivable from tenets of medical ethics, but rather violate them. I argue that medical professionals have an obligation to announce and address this confusion in order to motivate legislative reform, since the inconsistency of the current law entrenches the underlying sexism and ethnocentrism upon which its sense depends. Without convincing arguments for (a) condoning male circumcision and female cosmetic genital surgery and for (b) treating adult women of colour as lacking the capacity to consent, the current legislation stands in need of urgent revision.

Ethical and Sociocultural Aspects of Sexual Function and Dysfunction in Both Sexes

AIMS

This study aimed to highlight the salient sociocultural factors contributing to sexual health and dysfunction and to offer recommendations for culturally sensitive clinical management and research as well for an ethically sound sexual health care, counseling and medical decision-making.

BACKGROUND

There are limited data on the impact of sociocultural factors on male and female sexual function as well as on ethical principles to follow when clinical care falls outside of traditional realms of medically indicated interventions.

METHODS

This study reviewed the current literature on sociocultural and ethical considerations with regard to male and female sexual dysfunction as well as cultural and cosmetic female and male genital modification procedures.

RESULTS

It is recommended that clinicians evaluate their patients and their partners in the context of culture and assess distressing sexual symptoms regardless of whether they are a recognized dysfunction. Both clinicians and researchers should develop culturally sensitive assessment skills and instruments. There are a number of practices with complex ethical issues (eg, female genital cutting, female and male cosmetic genital surgery). Future International Committee of Sexual Medicine meetings should seek to develop guidelines and associated recommendations for a separate, broader chapter on ethics.

Female genital alteration: a compromise solution

Despite 30 years of advocacy, the prevalence of non-therapeutic female genital alteration (FGA) in minors is stable in many countries. Educational efforts have minimally changed the prevalence of this procedure in regions where it has been widely practiced. In order to better protect female children from the serious and long-term harms of some types of non-therapeutic FGA, we must adopt a more nuanced position that acknowledges a wide spectrum of procedures that alter female genitalia. We offer a revised categorisation for non-therapeutic FGA that groups procedures by effect and not by process. Acceptance of de minimis procedures that generally do not carry long-term medical risks is culturally sensitive, does not discriminate on the basis of gender, and does not violate human rights. More morbid procedures should not be performed. However, accepting de minimis non-therapeutic f FGA procedures enhances the effort of compassionate practitioners searching for a compromise position that respects cultural differences but protects the health of their patients.

Addressing polarisation in science

Ploug and Holm argue that polarisation in scientific communities can generate conflicts of interest for individual researchers. Their proposed solution to this problem is that authors should self-report whether they are polarised on conflict of interest disclosure forms. I argue that this is unlikely to work. This is because any author with the self-awareness and integrity to identify herself as polarised would be unlikely to conduct polarised research to begin with. Instead, I suggest that it is the role of (associate-level) editors of journals to detect and report on polarisation. One consequence of this view is that they need to be sufficiently familiar with the field of research they are evaluating to know whether polarisation is at stake.

Not a surgical vaccine: there is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia

OBJECTIVE

To conduct a critical review of recent proposals that widespread circumcision of male infants be introduced in Australia as a means of combating heterosexually transmitted HIV infection.

APPROACH

These arguments are evaluated in terms of their logic, coherence and fidelity to the principles of evidence-based medicine; the extent to which they take account of the evidence for circumcision having a protective effect against HIV and the practicality of circumcision as an HIV control strategy; the extent of its applicability to the specifics of Australia's HIV epidemic; the benefits, harms and risks of circumcision; and the associated human rights, bioethical and legal issues.

CONCLUSION

Our conclusion is that such proposals ignore doubts about the robustness of the evidence from the African random-controlled trials as to the protective effect of circumcision and the practical value of circumcision as a means of HIV control; misrepresent the nature of Australia's HIV epidemic and exaggerate the relevance of the African random-controlled trials findings to it; underestimate the risks and harm of circumcision; and ignore questions of medical ethics and human rights. The notion of circumcision as a 'surgical vaccine' is criticised as polemical and unscientific.

IMPLICATIONS

Circumcision of infants or other minors has no place among HIV control measures in the Australian and New Zealand context; proposals such as these should be rejected.

Female Genital Mutilation/Cutting in the UK

Debates about female genital mutilation/cutting (FGM/C) have polarized opinion between those who see it as an abuse of women’s health and human rights, to be ‘eradicated’, and those who may or may not oppose the practice, but see a double standard on the part of western campaigners who fail to challenge other unnecessary surgical interventions — such as male circumcision or cosmetic surgery — in their own communities and cultures. This article interrogates these debates about FGM/C in the context of measures to reduce it in the UK over recent decades. It does not suggest that FGM/C is a legitimate practice, seeing it, rather, as an abuse of women’s and children’s rights that should be combated using a combination of measures. However, it argues that reduction strategies are undermined by inconsistencies in the law and the failure to back up the law with research and education.

Health and human rights in today's fight against HIV/AIDS

The development of the health and human rights framework coincided with the beginning of the rapid spread of HIV/AIDS. Since then, the international community has increasingly turned to human rights language and instruments to address the disease. Not only are human rights essential to addressing a disease that impacts marginalized groups most severely, but the spread of HIV/AIDS itself exacerbates inequality and impedes the realization of a range of human rights. Policy developments of the past decade include the United Nations (UN) Committee on Economic, Social and Cultural Rights' General Comment on the 'Right to Health', the UN Declaration of Commitment on HIV/AIDS, and the UN's International Guidelines on HIV/AIDS and Human Rights, among others. Rights-related setbacks include the failure of the Declaration and its 5-year follow-up specifically to address men who have sex with men, sex workers, and intravenous drug users, political restrictions placed on urgently needed US President's Emergency Plan for AIDS Relief (PEPFAR) funds, and the failure of many countries to decriminalize same-sex sex and outlaw discrimination against people living with HIV/AIDS. Male circumcision as an HIV prevention measure is a topic around which important debate, touching on gender, informed consent and children's rights, serves to illustrate the ongoing vitality of the health and human rights dialogue. Mechanisms to increase state accountability for addressing HIV/AIDS should be explored in greater depth. Such measures might include an increase in the use of treaty-based judicial mechanisms, the linking of human rights compliance with preferential trade agreements, and rights requirements tied to HIV/AIDS funding.