Is just a little bit of female genital mutilation OK?
American bioethicists wrestle with an inflammatory issue.

Michael Cook
21 May 2010
Reproduced with Permission

Take two of the most combustible issues of our time, feminism and Islam. Mix. Shake. Pour. Duck.

This is more or less what happened last week when the bioethics committee of the American Academy of Pediatrics revised its long-standing opposition to female genital mutilation. Up to now, the AAP's position was simple: never. In the United States, as in many other countries, opposition has been reinforced with legislation. One American father has been sentenced to 10 years in jail for cutting his two-year-old daughter.

But after years of experience with emigré communities from places like Somalia and Sudan, the AAP decided that absolute refusal to cooperate could do more harm than good. Parents have taken their daughters back to the home country where the procedure might be done in septic conditions without anaesthetic, sometimes with scissors or a shard of glass.

Therefore the AAP's bioethicists recommended a compromise. Doctors should attempt to persuade parents that cutting is medically unnecessary and dangerous. But if parents insist, they could offer limited cooperation. "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". The nick, they say, would be no more painful or damaging than an ear-piercing. Basically they were using a consequentialist argument: the sum of the plusses and minuses is a plus.

The reaction was was, um, ear-piercing. "There is no limit to the depravity of the cultists who worship at the altar of multiculturalism," wrote a contributor in the conservative FrontPage magazine. At the other end of the political universe, the Huffington Post, a contributor asked if torturing girls just a little bit is OK now: "Was there an American Association of Pediatrics 'let's get high on crack' meeting that took place where they came up with this idea?"

This is a bioethical conundrum. On the one hand, FGM does no good whatsoever and is sometimes harmful. On the other hand, it is done to women by women. Parents think their daughters need it. And some educated women even regard it as a liberating rite of passage. For instance, a feminist scholar from Sierra Leone at the University of Chicago, Fuambai Ahmadu, wrote that Westernised "feminist sisters insist on denying us this critical aspect of becoming a woman in accordance with our unique and powerful cultural heritage." Dr Admadu actually returned to her native country to have the procedure and wrote about it in rhapsodic terms.

The problem for progressive bioethicists is this: how can one condemn a harmful practice which women want? For instance, most doctors would assent to a woman's right to choose abortion with all its physical and psychological risks. Many would approve of gender reassignment surgery, which is far more mutilating. Vaginal rejuvenation is medically unnecessary, but has become a tidy little earner for cosmetic surgeons without any audible huffing and puffing from bioethicists. If there are forms of FGM which entail no permanent damage and if there is informed consent, how can they possibly say that FGM is wrong?

Let's begin with the name of the procedure. The AAP declined to term it "female circumcision", because that would associate it with a procedure which is widely acceptable, male circumcision. It couldn't be called "female genital mutilation" because that would be culturally insensitive to women who have experienced it and feel proud of it. A more neutral term is "female genital cutting", which hasn't caught on because it is neutral. The United Nations now uses the awkward term "Female Genital Mutilation/Cutting". The AAP bioethicists settled on "ritual genital cutting of female minors".

Then there is the question of who does it. According to the United Nations Population Fund (UNFPA), three million women and girls undergo the procedure every year and 100 to 140 million have already undergone the practice. Most of these women live in 28 countries in Africa and Western Asia, with pockets elsewhere.

What the UNFPA is too delicate to say is that nearly all of these women are Muslims who feel that FGM is a religious obligation. However most Muslims do not. In Saudi Arabia, the bulwark of conservative Islam, the practice is almost unknown. In 2007 the Al-Azhar Supreme Council of Islamic Research, the highest religious authority in Egypt decreed that cutting has no basis in Islamic law. Nonetheless, in Egypt about 90 percent of married women between the ages of 15 and 49 have been cut. The problem is the same as with suicide bombing; there is no single authoritative voice for Islam on moral issues. It depends on the local imam's interpretation of Islamic scriptures.

Most importantly, there is the question of what exactly we are talking about. The World Health Organization has classified FGM into four types. Type III, or infibulation, creates a kind of surgical chastity belt. It is the worst. Other types include the AAP's "nick". The most invasive types are linked to complications in childbirth and even maternal deaths. Other side effects include severe pain, haemorrhage, tetanus, infection, infertility, cysts and abscesses, urinary incontinence, and psychological and sexual problems.

The moral dimension stems from the implicit insult to women. Horrified Westerners regard FGM as the most extreme form of gender oppression. "Female genital mutilation has been recognized as discrimination based on sex because it is rooted in gender inequalities and power imbalances between men and women and inhibits women's full and equal enjoyment of their human rights," says the UN. It has a point. In many societies FGM is used as a way of ensuring virginity and marital fidelity. In some societies, a girl who has not undergone the procedure is not marriageable.

With this in mind, critics of FGM are adamant that the AAP's concession to this barbaric practice, however small, was completely immoral. In the UK, the Royal College of Obstetricians and Gynaecologists and the Royal College of Paediatrics and Child Health issued their own statement: "To suggest that a qualified medical practitioner is involved in this practice as a 'compromise' does not make it less brutal and has the danger of giving legitimacy to FGM. Two wrongs do not make a right. The main objective for all civilised societies has to be the complete eradication of an unacceptable practice."

These are high-minded sentiments indeed. But a couple of years ago the RCOG was issuing statements lamenting the shortage of abortion doctors in the UK. It is hard to see consistency in its moral reasoning. On one issue, it argues that there are some things which are always and everywhere wrong, like FGM. On the other, it assumes that the wrong depends on the circumstances, intentions and outcomes. At least the Americans are consistent in their relativism.

Isn't a better way to approach the problem to get the facts about whether FGM seriously harms a girl? If so, the physician's duty is not to cooperate. From this point of view, the "nick" is not a serious harm. As the AAP says, "the ritual nick suggested by some pediatricians is not physically harmful and is much less extensive than routine newborn male genital cutting [ie, circumcision]."

However, there is another weighty consideration. Opponents of FGM have pointed out that when Egyptian doctors began to cooperate in FGM, the procedure becomes medicalised. Even well-educated parents felt relaxed about having it done to their daughters. Now more than three-quarters of FGM procedures in Egypt are performed by doctors, nurses and medical technicians. "While the medicalization of the practice began as a way to reduce complications, it had the effect of institutionalizing it," says the UNFPA. Instead of fading away, it became a source of income for doctors.

Furthermore, the analogy with male circumcision is misleading. There is only one form of this procedure but there are several forms of FGM. Only the "nick" is comparable. The other forms are unspeakably brutal.

So the likely result of legalising the "nick" would be to entrench the practice and thus make it worse. Parents might feel that if the "nick" can be done safely, why not request the more severe forms of FGM? Doctors would almost certainly promote the practice to generate more patients. It is, therefore, a very bad idea.

But the reason why the AAP made the wrong decision is not because it was truckling to Muslims or authorising the torture of young girls. It simply did not think the issue through.