Is There a Case for Female Genital Alteration?

Hassan Hafez, a barber, mimics the way he used to perform female genital mutilation (FGM) in Minia June 13, 2006. Despite 30 years of advocacy, we have not made dents in the prevalence of the practice in many countries and have been largely unable to change the attitudes regarding the acceptability of female genital alteration. Reuters

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In the most recent Journal of Medical Ethics, U.S. doctors come out in support of some forms of female genital alteration (FGA), a controversial but common practice in many African, Middle Eastern and South-Asian communities.

An estimated 80–140 million women worldwide have had such procedures. And though they're frequently all lumped together as forms of "female genital mutilation," many such procedures are no more problematic than circumcision for male infants or the "elective labiaplasty for which affluent women pay thousands of dollars," the researchers say.

The World Health Organization, the American Academy of Pediatrics (AAP) and the American Congress of Obstetricians and Gynecologists (ACOG) all endorse legal circumcision of male children. Yet "FGA has been deemed a human rights violation by these same organizations as well as by the United Nations, note researchers Kavita Arora and and Allan J. Jacobs in their paper ("Female genital alteration: a compromise solution").

"In fact, the US government has expressly outlawed any procedure that incises or changes a female child's external genitalia in the absence of medical indications."

While well meaning, such positions fail to differentiate between alterations that are purely cosmetic and those that produce significant sexual or reproductive dysfunction. And in making the former illegal, countries could actually worsen outcomes by driving the practice underground, they say.

Arora is a gynecologist at MetroHealth Medical Center in Cleveland and a bioethics professor at Case Western Reserve University. Jacobs is director of gynecologic oncology at Coney Island Hospital in Brooklyn and a professor of bioethics at Stony Brook University.

"We are not arguing that any procedure on the female genitalia is desirable," the are quick to point out. Rather, Arora and Jacobs call for "a compromise solution in which liberal states would legally permit de minimis FGA in recognition of its fulfillment of cultural and religious obligations, but would proscribe those forms of FGA that are dangerous" or cause functional damage.

Promoting minimally invasive FGA is "a compromise that respects culture and religion but provides the necessary protections against child abuse," they conclude, eschewing critics who worry that this compromise weakens efforts to eliminate FGA entirely.

Despite 30 years of advocacy, we have not made dents in the prevalence of the practice in many countries and have been largely unable to change the attitudes regarding the acceptability of FGA. The goal of eradicating procedures that do not cause significant harm is at worst, morally questionable and at best, an invitation to waste resources that could be applied to ends that are more likely to further human well-being.

In order to better protect female children from the long-term harms of [destructive] FGA, we must adopt a more nuanced position that acknowledges that [some FGA procedures] are not associated with long-term medical risks, are culturally sensitive, do not discriminate on the basis of gender and do not violate human rights.

In response to Arora and Jacobs' paper, Arianne Shahvisi, with the University of Sussex Medical School Department of Ethics, argued that they shouldn't "rely on the legitimacy of male circumcision in order to devise a parallel procedure for FGA." While it's fair to say that any society which tolerates male circumcision should permit comparable procedures for females, "it is not at all clear that male circumcision is an acceptable practice to be taken as a yardstick for tolerable levels of harm," Shahvisi writes.

She is also skeptical that FGA-practicing communities will substitute more extreme procedures for those with ritual, but not functional, effects. This "is not compatible with the justifications for performing the procedure to start with," which—while aesthetic in some places—are largely centered on reducing women's potential for sexual pleasure.

Brian Earp, a visiting scholar with the Hastings Center Bioethics Research Institute in New York, worries that legalizing minimal FGA in countries such as the U.S. and Canada would encourage more invasive procedures to be done their guises. Earp also objects to the comparable-to-circumcision argument, not because the two aren't comparable but because he thinks the American approach to male circumcision must face "serious scrutiny."

Physically and symbolically, there is "far more overlap between [FGA and circumcision] than is commonly understood: they should not be discussed, therefore, in hermetically sealed moral discourses," Earp continues.

But he thinks the most "promising way forward would be to argue for an 'autonomy-based' ethical framework" in which children, regardless of sex or gender, should not be subjected to genital procedures.

Elizabeth Nolan Brown is a staff editor at