Cultural Rite, Medical Wrong
Human Bodies
Elizabeth Reis, 05/11/2010

Cultural Rite, Medical Wrong

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Did you ever experience one of those moments when you agreed with someone’s arguments on an issue through point A, point B, and point C, but then somehow arrived at a different conclusion? It’s disconcerting, as if someone told you that 1 + 1 + 1 = 2.

This happened to me recently when I read the new policy statement from the American Academy of Pediatrics about female genital cutting. This rite occurs mostly in African countries and in some communities in the Middle East and Asia (between 4 and 5 million procedures are done annually on infants and young girls). It is illegal in the United States for ritual practitioners to perform it on infants or children under the age of 18. Pediatricians in the U.S., though, are sometimes asked by parents raised in these countries to carry out the surgical rite on their daughters. How should doctors respond to parents who request this procedure?

The pediatrics group believes that female genital cutting is a harmful and medically unnecessary practice. The organization has mandated that doctors counsel and educate parents about the damage that can ensue. It further urges them to make the broader point that female genital cutting violates the human rights of their daughters to bodily integrity.

Some parents are not persuaded. Those from cultures that practice the procedure argue that it confers enormous social and cultural benefits. In some societies, a woman’s circumcision guarantees that she will be marriageable; if parents deny this to their daughter, they are essentially consigning her to a lifetime of isolation and misery because she will never be able to have a family life that can support her materially or emotionally.

Since most American physicians do not share these experiences and cultural values, the American Academy of Pediatrics believes that “protection of the physical and mental health of girls should be the overriding concern of the health care community.” Therefore, it has concluded that doctors should never perform clitorectomy, excision (removal of some or all of the clitoris and part of the labia minora), or infibulation (removing the clitoris and labia minora and stitching together the labia majora with only a small hole for urine and menstrual flow).

Some critics might see a double standard here: If doctors are so concerned with the protection of children’s physical and mental health, why, then, are so many in this country willing to perform neonatal male circumcision? Why should doctors do for boys what they are unwilling to do for girls? One could argue that male circumcision is not medically necessary, and that it violates the infant boy’s bodily integrity.

Because of the way that male circumcision became medicalized in this country in the nineteenth century, most Americans feel differently about this procedure than they do about female genital cutting. Many men argue that it’s not a big deal, that their sex lives are just fine, and that aesthetically a circumcised penis is cleaner and more appealing (obviously, there are many men who disagree with all of these statements).

Whatever justification one might use for perpetuating neonatal male circumcision (even a medical reason that posits the decrease in the spread of HIV), it is all but impossible to contradict the fundamental point that the operation violates the infant boy’s bodily integrity. In a circumcision, the most sensitive part of a baby’s anatomy is cut. It’s as simple as that. And doctors should not be doing it.

Here is where I strongly disagree with the academy’s policy statement: In an effort to promote cultural sensitivity and foster good relationships between physicians and parents from cultures that practice female genital cutting, the academy ruled that pediatricians can satisfy cultural requirements by substituting ritual “nicks” for the more severe cuts. To discourage parents from sending their daughters back to Africa, Asia, or the Middle East to get the “real thing,” the American Academy of Pediatrics is allowing doctors to show respect for parental decision-making (an argument they make with male circumcision as well) and save girls from undergoing more severely disfiguring procedures.

Doctors need to get out of the genital cutting business entirely, whether for boys or girls. Doctors are supposed to help patients, not harm them.  If the “nick” they’re talking about is really no more than an ear pierce, then, frankly, it doesn’t require a doctor’s skilled hands. A ritual circumciser can draw a tiny bit of blood.

Doctors should not do anything that hurts their patients, either the baby girls or the baby boys. If people cannot get these procedures at their doctors’ offices, then gradually they will become demedicalized and be seen for what they are: medically unnecessary cultural or religious rituals. Many Jewish parents, for example, want their sons circumcised for religious and cultural reasons. A ritual circumciser, a mohel, does the procedure, and it is legal. The same process can be instituted for the ritual “nick” for girls and performed within strict guidelines: no clitorectomies, no excisions, no infibulations. The rite could be legal but not performed by doctors, our culture’s healers.

Right now, nonmedical procedures performed on the genitals of female minors are illegal, but perhaps doctors and female genital cutting advocates could work together to decriminalize mere nicks. Doctors can then reach out to families not by offering a nick themselves, but by counseling them about the dangers of female genital cutting and at the same time recommending people in the community who are willing to perform the minor incision. It’s not a perfect solution, but as a compromise it’s a start. At least doctors wouldn’t be contributing to the notion that genital cutting is a medical necessity.

Why not just criminalize all of it? Though personally I am against all forms of ritual cutting, I do not think that criminalization is helpful. It denies the values that some cultures hold dear, and probably will not have the intended effect of stopping the procedures. Cultures can be changed in other ways, compassionate education being one of them. I admired the American Academy of Pediatrics statement in this regard because it included precise written and visual details of the different kinds of female genital cutting. I would like to see the same education provided to parents of baby boys when they’re considering neonatal male circumcision. Parents should understand exactly what it is they’re signing on to when they agree to any cutting of their children’s genitals.

All children can make these decisions for themselves when they become adults. True, it might be more difficult to do later in life, but the choice should be theirs.

Elizabeth Reis is an associate professor of women’s and gender studies at the University of Oregon and the author of Bodies in Doubt: An American History of Intersex (Johns Hopkins University Press, 2009).

UPDATE: On May 27, the American Academy of Pediatrics withdrew its policy statement on female genital cutting and reaffirmed its strong opposition to the practice.

Posted by Susan Gilbert at 05/11/2010 11:36:19 AM | 

As lead author of the AAP policy statement, I appreciate Prof. Reis's thoughtful commentary, but I would like to respond to some points.

First, it is important to understand that the AAP did not "rule" that doctors can perform ritual "nicks," since those nicks would be illegal under federal law. Rather, the AAP spoke in a cautiously positive way about the possibility of a change in the law that would allow for such a practice. The idea of the "nick" is not even one of the statement's recommendations.

Second, I share Prof. Reis's frustration about the difficulty of achieving parity and consistency between policies about male and female genital cutting of minors. I am not a member of AAP and have no idea of the content in the soon-to-be-released policy statement on male circumcision, but I hope that at least it contains a strong mandate for education of parents, and an equally strong mandate for proper pain control during the procedure. Speaking for myself, I do not think it acceptable for uncertified mohels to perform this surgery. In my state, even the woman who washes my hair needs to be certified--but not the person who would cut a newborn boy's genitals? Clearly, the dissonance between the government's laissez-faire attitude toward male genital cutting and complete criminalization of female genital cutting (of minors) raises important constitutional questions of equal treatment of religion, and equal protection of girls and boys.

Finally, I appreciate Prof. Reis's concern about doctors seeming to give a medical imprimatur to female genital cutting by presiding over a "nick." On the other hand, most critics of our policy fear that, once any cutting at all is allowed, parents will want much more than a nick. Having medical personnel do the procedure makes it more likely that the nick will remain just that--a tiny nick. Yes, this does not seem like the sort of thing doctors should be doing. But if the goal is to "do no harm," and the alternative is the very real likelihood that the girl will be taken back to her home country for a terrible and life-threatening procedure, I think performing the "nick" is a way to defend the health of children.

Dena S. Davis, J.D.,Ph.D.
Cleveland-Marshall College of Law
Cleveland State University
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