Female Circumcision:Nicking or Cutting: Is Either Ethical?
There is some current controversy about an April 26, 2010 statement of policy by the American Academy of Pediatrics (AAP) and published in Pediatrics which suggests to pediatricians that though ritual female circumcision should be continued to be illegal in the United States, the federal government ought to allow physicians to perform simple "nicking" of the female child's genitalia as a nominal acceptance of the family's request for full ritual circumcision and along with education of the family regarding the immediate and long term harms of full circumcision. These actions may reduce the probability that the family will take the child overseas for full circumcision. Read the pdf file from Pediatrics to learn all about female circumcision and the suggestions and recommendations made by the AAP. For a description of the controversy read the article in the New York Times May 6 2010 edition.
Irrespective of the United States current law against any form of a non-medical procedure on a female child's genitalia, is it ethical to disregard the request of the parents for a long established and performed ritual procedure on their daughter, particularly if the ritual circumcision is also performed on the male child? Would simple nicking of the skin be a reasonable substitute for full circumcision if permitted by the parents and be an ethical alternative for the physician to perform?
What are the limits to acceptance of norms from other cultures when requested to be performed in the multi-cultural United States? ..Maurice.
posted by Maurice Bernstein, M.D. @ 9:47:00 PM
22 comments
22 Comments:
The limit to "acceptance of norms from other cultures" is at non-medical mutilation. Acceptance of cultural norms would not extend to amputation of the left pinky at birth, if that happened to be the "cultural norm" somewhere. And don't go bringing in comparisons to male circumcision, a religiously based procedure that has been shown to have beneficial public health effects (reduction in the spread of HIV and other STIs) with no long-term adverse effects, despite the whining of the occasional stray messed-up male.
"Female circumcision" is a nothing but a vicious euphemism used to justify a barbaric procedure intended to subjugate women by destroying their experience of their sexuality.
As for "nicking", any family that can be so easily dissuaded from the "full procedure" (again, using the word "circumcision" is analogous to using the word "pervert" in place of "gay") can in all likelihood be made to understand the inappropriateness of their request.
Nice try, #1 Dinosaur, to immediately throw male circumcision out of the discussion. The AAP states directly and accurately that a ritual nick is less extensive than male circumcision. Any genital cutting of a child that is not medically necessary is unethical. Spare us your cultural bias. All the medical organizations' reviews of the evidence find the surgery is not justified on medical grounds.
The issue is harm reduction. That's why this is so contentious. Should doctors facilitate something that is less wrong to hopefully avoid something much worse? I don't think physicians should have anything to do with medically unnecessary genital cutting. They shouldn't be in the business of ritual cutting.
Circumcision is indeed a vicious euphemism. "Cutting around." That's nice. Usually medical terms are honest and direct. They say what is being done to what. This term does neither. It doesn't indicate that something is being excised, or what it is. It's sugar coating of genital mutilation.
I think a "ritual nick" as harm reduction strategy would be better accepted applied to males, because unlike female genital cutting which is already illegal, it could at least be seen as a step in the right direction.
Fortunately, we have a strong advocate for all children against physicians who could cut their genitals.
INTACT AMERICA BLASTS AMERICAN ACADEMY OF PEDIATRICS’ CALL TO WEAKEN U.S. BAN ON ALL FORMS OF FEMALE GENITAL CUTTING AS OUTRAGEOUS AND UNETHICAL
Petition
By the way, several hundreds of us (so far) are participating in the twitter #i2 campaign for freedom from non-therapeutic circumcision for everybody. Medically unnecessary genital cutting of children has got to stop.
To #Dinosaur
It was once assumed that tonsils
and the appendix had no real function. If evolution had decided
that males needed circumcised,they
would have been born that way.
If you want to advocate,then
advocate for all children!
PT
Amend the law so that it is illegal to perform mutilation on the child regardless of which country it was performed in. That is, if a girl born in the U.S leaves the country intact and returns mutilated, then arrest the parents.
Introduce jail terms if they are not already in place.
Lets not tiptoe around this issue because the word "culture" is tied up with it.
NP
Causing irreparable physical harm to another human being without that person's consent should not be tolerated, period. Doctors should not be performing any surgery, cutting, etc. that does not serve a valid medical purpose that will benefit the individual.
Opening the door to unnecessary and dangerous or harmful procedures to appease people in the name of "cultural sensitivity" is not acceptable. There is a reason FGM is not legal in this country, and it should remain so.
Recent studies have shown that, on average, at least 100 baby boys per year are dying in their first month of life due to complications resulting from circumcision. The actual number is probably far higher due to deaths being attributed to other causes and complications that are not immediately apparent as resulting from the surgery. Exposing girls to these risks and potential complications (how often might a knife slip and a "nick" turn into an amputation, hemorrhage, or permanent disfigurement?) is a horrifying thought.
Instead of lending any legitimacy to the procedure, more effort should be put into educating those considering such "rituals".
WS
For an insight into the incidence and popular views of "female circumcision" in the Sudan click the link below and read the 2001 publication in International Family Planning Perspectives>. ..Maurice.
"is it ethical to disregard the request of the parents for a long established and performed ritual procedure on their daughter, particularly if the ritual circumcision is also performed on the male child?"
Absolutely! Footbinding is a long established and performed ritual procedure. (There is some suggestion it survives in pockets in China.) Or how about breast-ironing?
Even a ritual nick is an attack on a girl's autonomy, a symbol of her powerlessness and the adults' potential for absolute control over her sexuality. (If not, what is it?)
And if you want to couple that with male circumcision, feel free. They're equally indefensible, and for the same reasons.
IBD,
In some ways I think the misapplication of terminology leads to comparing apples to oranges; "circumcision" as applied to males is usually a far less drastic, and not anywhere near as physically disfiguring, procedure than the procedures called this that are done to females. (Barring horrific accidents of course.) A lack of a foreskin doesn't, under most circumstances, lead to problems with normal bodily functions (unless you have the uncommon case where scar tissue develops excessively); the more extreme forms of female circumcision lead to problems with any of several physiological functions, e.g., menstruation, coitus, childbirth, and sometimes even non-reproductive functions like walking or urination. There is no comparison.
The other underlying issue: the reasons for male circumcision are not, at least in modern times, tied up in warped sociological constructs like "controlling sexuality" or "keeping them (i.e., women) faithful in marriage". Female "circumcision" is, and therein lies the chasm of difference between these procedures. I would not subject any child of mine to this procedure, no matter what their gender, personally. And if that's perceived as a cultural bias, so be it.
Ethicist Ken Kipnis from the Department of Philosophy of the University of Hawaii and who has written to this blog previously, gave me permission to reproduce the following posting which he originally wrote to a bioethics listserv yesterday discussing the same topic. .Maurice.
A while ago I did some research on sub-Saharan practices: female genital "cutting" or "circumcision" or "mutilation". What we call it plays a role in what we think of it.
First, the practice is, it seemed at the time, driven by women, and the belief that it cuts down on women's desire for sexual intimacy, making daughters more desirable as faithful spouses. I heard an interview with a Somali social services field worker (?) who had been working with teams, meeting with women in the villages and talking about the rather severe sequelae of the procedure; genito-urinary problems that the local women knew well. I got the sense from the interview that women's opinions were changing on the desirability of the practice, and that this was being driven internally within the culture. Like male circumcision here, it is a contested practice there.
The problem arises, esp. in the US and France. where Africans want their children to have the procedure.
First, no one should ever do evil thing E because otherwise (as in what is essentially a threat) some one else will do evil thing E+. To accept such reasoning is potentially to place yourself in the power of evil people. It is ok to obliterate Los Angeles if someone reliably promises to obliterate Los Angeles, Minneapolis, and New York if you don't. It is ok to kill a prisoner painlessly if otherwise he will face a botched execution.
Now some more specific observations.
First, no one is suggesting in this thread that medical doctors do the procedure as it is done in Africa. That is not on the table.
Second, a key issue -- unsettled so far -- is whether the attenuated procedure is minor (a pin-prick, comparable to piercing a young girl's earlobes in the mall) or if it is capable of adversely affecting the potential for adult sexual intimacy. If the latter, we have a violation of the precept "Above all, do no harm." Case closed. If the former, it would likely be less consequential than male circumcision which, though intensely debated, is still widely undertaken by doctors. (It is a separate questions whether we should be OK with male circumcision if the ritual "briss" is done by a "mohel". Should it be considered child abuse?)
Finally, there is the question whether health care professionals should be complicit or directly involved. Here in Hawaii, I am aware of nurses (with the knowledge of doctors) including certain herbal medications when patients are tube-fed, if the family/patient insists. And moxibustion, widely used in Asia, has been permitted in hospital settings notwithstanding the very minor burns it can produce and the irritation sometimes caused by the smoke. Patients have been known to smoke marijuana on hospital grounds. There is a point to hospitals being as open as possible to complementary and alternative practices, provided that patients are not harmed and that conventional medical treatments are not compromised.
So unless someone can clarify what is going on with the "pin-prick", and whether the procedure has consequential sequelae, I can't agree with the objections.
Is there anything ethically wrong with the following?: no physicians should perform any procedure on male or female genitalia unless there is a disease or disorder which requires the procedure to correct or cure. That is simple enough. What am I missing? Is there really a significant economic or emotional or religious reason for physicians to consider or perform such procedures? ..Maurice.
Dr. Bernstein, you've got it just about right.
The key is consistency. A single ethical standard general enough to apply to any body part, and to every child.
We do not practice that now.
No physician will remove a child's lips just because the parents prefer it. No physician will cut off a child's finger because the father is missing his, too. Yet those reasons are presently accepted for removal of the perfectly normal and healthy foreskin.
We must stop making a special exemption to the rules of medical ethics for male circumcision.
IntactByDefault, then may I also say that no physician should perform any procedure on any patient unless there is a disease or disorder which requires the procedure to correct or cure?? No more cosmetic breast surgery in women with non-pathologic breasts based simply on their own personal request. No hair transplants for men for appearance sake or in fact any surgery for cosmetic purposes?
I'll carry the ethical restriction even further: no medical professional participation in procedures involved in the legal execution of a criminal or even physician assisted suicide. Actually, I am for all that! Who might society want to do all these and other procedures without physicians? Someone else: a "mohel" or other skilled religious or cultural ritualist or society-trained non-physician technicians. And if there are none of these technicians available, maybe the procedure never should have been considered. ..Maurice.
My comments have applied to minors, who cannot consent for themselves. I am not making any argument against the practice of an informed and consenting adult modifying their own body however they choose, or a physician performing such a modification.
AMAZINGut
!!!! When religions anc cultural differences enter the picture,ted we all succumb to romanticism about respecting "fellow cultures", I've been in France, and I've seen Muslim women who wantailted the French laws to prevail, and girls taken awaybecause of our infatuation with "cultural diversity" we really don´t know what a procedure really entails. These ignorant parents should really have the girls taken away.
? What the hell is that post supposed to mean amazingut?
I am not sure that I can explain clearly what Anonymous of 3:50 pm today was trying to express, perhaps the writer or someone else can clarify.
Though our America is multi-cultural in its history and current life, we still need to set certain limits to the cultural norms of others but on the other hand we should be more careful and selective in setting those limits with attention not to be fully destructive of those cultural norms. Perhaps that is what the "nick" permission by AAP for physicians is all about. ..Maurice.
If you are interested in the types of fgm performed go to this link.http://www.ranzcog.edu.au/publications/o-g_pdfs/O&G-Winter-2008/Female-genital-mutilation-Greg-Jenkins.pdf
NP
In a bit of a turnaround the American Academy of Pediatrics sent the following message to their members:
1. AAP Reaffirms Its Opposition to Female Genital Cutting
In airing the controversy on female genital cutting (FGC) in its April 26 policy statement, the American Academy of Pediatrics (AAP) may have left an erroneous impression that a ritual nick is acceptable as a means of avoiding the barbaric and life-threatening FGC procedure. The AAP reaffirms its unalterable opposition to FGC and to female genital 'nicking.'
One wonders why this "clarification" was made. ..Maurice.
One must also wonder why the AAP didn't revise the policy statement. Instead they just made a 'clarification...'
may I also say that no physician should perform any procedure on any patient unless there is a disease or disorder which requires the procedure to correct or cure?
I wouldn't agree with that statement. I think it is far too extreme a position. As you noted yourself, it would exclude cosmetic surgeries from the list of ethical procedures. More importantly, I think, it would also exclude vaccinations (since there is usually no pre-existing condition being treated).
I believe that the correct model for such ethical decisions (and this works equally well in medical and non-medical contexts) is harm avoidance. Put simply, if a procedure would cause a non-trivial net harm (when evaluated in the case of a particular individual), it is unethical (and there may be a case for making it illegal). But procedures that, on balance, are beneficial or neutral are not by themselves unethical, even though they may not be necessary.
To illustrate, let me consider some practical applications of the rule. Suppose we have a cosmetic surgery patient who desires breast enlargement because she's self-conscious about her appearance. We can reasonably presume that the psychological benefits of the surgery will be significant and, assuming she's in reasonable physical health, will outweigh the risks of the procedure. Consequently there's no net harm, so there's no ethical problem.
Now consider a severe form of FGC. Since this causes considerable harms, exposes the patient to considerable risk, and offers no net benefit, there's a net harm, so there is an ethical problem.
Now consider the mildest form of FGC — the "nick" to which the AAP refer. I would suggest that this would carry some risk (there must be a small chance of infection, for example), but it is probably small when conducted in sterile conditions. And since there are no benefits to offset the risk, there is a small net harm. The question is, is this harm significant enough to count as "non-trivial"? I don't know, but my guess is that it's probably not significant enough to justify outlawing it.
I'm not fond of the idea, but that's probably just cultural conditioning against FGC of any kind, and prejudice isn't really a valid objection to anything. Intellectually, I don't think I'd be able to condemn physicians who perform the "nick" or those who refuse.
Jake, your argument is not valid at all when the procedure is done on minors who have no choice in the matter.
NP
Well, now it appears that the AAP has taken its clarification statement or revision statement back and has ended up with the following presumably final comment on the issue. ..Maurice.
AMERICAN ACADEMY OF PEDIATRICS WITHDRAWS
POLICY STATEMENT ON FEMALE GENITAL CUTTING
For Immediate Release: May 27, 2010
CHICAGO -- The American Academy of Pediatrics (AAP) has retired its 2010 policy statement on female genital cutting (FGC). The AAP Board of Directors has approved the following as AAP policy on FGC:
"The AAP reaffirms its strong opposition to FGC and counsels its members not to perform such procedures. As typically practiced, FGC can be life-threatening. Little girls who escape death are still vulnerable to sterility, infection, and psychological trauma.
"The AAP does not endorse the practice of offering a 'clitoral nick.' This minimal pinprick is forbidden under federal law and the AAP does not recommend it to its members.
"The AAP is steadfast in its goal of protecting all young girls from the harms of FGC."
AAP President Judith S. Palfrey, MD, FAAP, said, "Our intention is not to endorse any form of female genital cutting or mutilation. We retracted the policy because it is important that the world health community understands the AAP is totally opposed to all forms of female genital cutting, both here in the U.S. and anywhere else in the world.
"The AAP's goal is to protect the health and well-being of all children," Dr. Palfrey said. "One good thing to emerge is that this discussion has shone a bright light on this issue and raised the world’s awareness about this harm to young women."
Post a Comment
<< Home