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Doctors Push Controversial Strategy to Fight Female Genital Mutilation

ENGLISH Mart 31, 2016
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Two doctors are advocating for a different approach to lower global rates of female genital cutting, still common in some regions although banned in numerous countries.
 
In a paper published today in the Journal of Medical Ethics, the physicians argue that female genital “nicks” and other such cuts that respect cultural and religious traditions but cause minimal harm should be legally permitted. This strategy, which has previously faced backlash, would better protect girls and young women from the long-term consequences of more severe forms of genital cutting, they say.
 
“We are not arguing that any procedure on the female genitalia is desirable,” Dr. Kavita Shah Arora and Dr. Allan Jacobs say in the paper. “Rather, we only argue that certain procedures ought to be tolerated by liberal societies . . . In order to reduce the prevalence of the extensive forms of FGA (female genital alteration), we propose a compromise solution that is ethical, culturally sensitive and practical.”
 
Female genital mutilation, as it’s more commonly known, involves the removal of part or all of the external female genitalia or other injury to these organs. The World Health Organization estimates more than 125 million girls and women alive today have undergone genital cutting, mainly in Africa and the Middle East, though migration from these areas has spread the practice. The majority of girls are cut before the age of 15.
 
In response, more than 40 countries have banned FGM, including the United States, and it’s internationally recognized as a human rights violation.
 
‘Soberingly Small’ FGM Decline
 
The paper’s authors say attempts to stamp out FGM with legislation have largely failed and risk driving the practice underground. While there have been some encouraging drops in the practice in countries such as Kenya and Liberia, they say overall the decline has been “soberingly small.”
 
“Despite over 30 years of advocacy, the prevalence of female genital alteration remains high and is largely unchanged in regions where it is largely practiced,” study co-author Arora, an obstetrician-gynecologist and bioethicist who teaches at Case Western Reserve University in Cleveland, told Women’s eNews.
 
New Recommended Categories of Genital Cutting
 
Part of the proposal in today’s Journal of Medical Ethics involves creating a new system to categorize genital cutting. Currently, the World Health Organization identifies four types of FGM based on the kind of procedure. But the paper’s authors say it makes more sense to base these categories on the procedure’s effects on the young woman instead and to legalize the categories that cause minimal harm. Here’s their recategorization:
Category 1: Includes procedures that should have no long lasting effects on the appearance or function of the genitalia, if performed properly. For example, a small nick in the vulvar skin. These should be allowed.
Category 2: Includes procedures that change the appearance slightly but are not expected to have any lasting effects on reproductive capacity or sexual fulfillment. Examples include pulling back the hood of the clitoris and procedures resembling elective labiaplasty (a cosmetic genital surgical procedure). These should be allowed.
Categories 3-5: Includes procedures, such as clitoris removal and vaginal cauterization, that maim or harm and impair sexual fulfillment, pregnancy and childbirth. These should be banned.
Given this limited success, the authors suggest a more nuanced approach be considered, one that upholds cultural and religious traditions without sacrificing the health and well-being of girls and young women. To do this, they say, we must acknowledge the wide spectrum of cutting and allow small surgical “nicks” or other “minimal” forms of cutting that may slightly change the look of external genitalia but don’t adversely affect sexual satisfaction or reproduction. The hope is this would prevent more harmful and severe forms of FGM that lead to long-term complications, which should remain banned and be actively discouraged, the authors say.
 
“A small nick on the vulva would have fewer risks than male circumcision and no long-term medical side effects. This would seem to be a reasonable compromise procedure versus infibulation [the most severe type of cutting], which is associated with numerous medical, sexual, social and psychological short- and long-term risks,” Arora says. “Even if one girl can be saved from a more extreme FGA procedure and have a de minimis procedure as we outline, then our strategy would be worthwhile.”
 
The idea isn’t new. In 2010 the American Academy of Pediatrics made a similar suggestion in a policy statement, saying: “It might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick as a possible compromise to avoid greater harm.” But the policy was met with major backlash and the AAP quickly changed its position to oppose all forms of female genital cutting.
 
Backlash Again
 
This paper is also facing opposition. Equality Now, an international group fighting to end female genital cutting, was critical of the AAP in 2010 and is still against this approach.
 
“This unfortunate proposal comes at a time when countries and international organizations–including the United Nations and the African Union–have noted the increasing dangers of the medicalization of FGM,” Mary Wandia, FGM program manager at Equality Now, told Women’s eNews.
 
Dr. Nawal Nour, director of the African Women’s Health Center at Brigham and Women’s Hospital in Boston, also has issues with this strategy. For one, she says, it overlooks the psychological side of cutting. “From my experience, the psychological impact varies and does not seem to be associated with the amount of tissue removed,” she said in an interview. “You can’t draw that line saying a small nick is harmless.”
 
Also, she says, before pushing any new approaches, we must first involve those in affected communities. “Why is the African voice excluded in a discussion so relevant?” she asks. “What message are we sending African countries that have had grassroots organizations working for decades to stop this practice? If we state that it is alright to practice this then what impact are we making to those countries that are trying to abandon it?”
 
Three commentaries also published in today’s Journal of Medical Ethics respond to the proposal and also raise concerns. These range from legal and regulatory challenges to questions of if the approach would work to misgivings over using male circumcision to justify forms of female genital cutting. In her response piece, bioethicist Ruth Macklin of Albert Einstein College of Medicine in New York points out that genital cutting, in whatever form, is used as a way to control women.
 
“Whether it be controlling their sexual behavior in the most extreme form by sewing up the vaginal opening, or the lesser version of clitorodectomy to eliminate women’s sexual pleasure, or the social requirement of making it a condition of being marriageable, as a cultural rite it signifies a means of making girls and women physically, aesthetically or socially acceptable to men,” she says in the commentary.
 
Arora and Jacobs make clear they’re not condoning oppression but, rather, suggesting a compromise that may have more success than our current anti-FGM strategy.
 
“Our immediate goal is to generate discussion,” Arora says. “Any change would have to be a partnership.”
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