Medicalized Female Genital Mutilation/Cutting: Contentious Practices and Persistent Debates
Current Sexual Health Reports
Medicalized Female Genital Mutilation/Cutting: Contentious Practices and Persistent Debates
EDITORS) 0 1
Samuel Kimani 0 1
Bettina Shell-Duncan 0 1
0 Departments of Anthropology and Global Health, University of Washington , Box 353100, Seattle, WA 98105-3100 , USA
1 Africa Coordinating Centre for Abandonment of FGM/C (ACCAF), University of Nairobi , Nairobi , Kenya
Purpose of Review Female genital cutting/mutilation (FGM/C) performed by health care professionals (medicalization) and reduced severity of cutting have been advanced as strategies for minimizing health risks, sparking acrimonious ongoing debates. This study summarizes key debates and critically assesses supporting evidence. Recent Findings While medicalization is concentrated in Africa, health professionals worldwide have faced requests to perform FGM/C. Whether medicalization is hindering the decline of FGM/C is unclear. Factors motivating medicalization include, but are not limited to, safety concerns. Involvement of health professionals in advocacy to end FGM/C can address both the supply and demand side of medicalization, but raises ethical concerns regarding dual loyalty. Ongoing debates need to address competing rights claims. Summary Polarizing debates have brought little resolution. We call for a focus on common goals of protecting the health and welfare of girls living in communities where FGM/C is upheld and encourage more informed and open dialog.
Female genital mutilation; Female genital cutting; Medicalization; Harm reduction; Health care providers
In December 2012, the United National General Assembly
adopted a Resolution to ban female genital mutilations
worldwide, “whether committed within or outside a medical
institution” [A/RES/67/146]. It reiterated a stance outlined at the
first UN-sponsored conference on female genital mutilation/
cutting (FGM/C) held in Khartoum over 40 years earlier .
While the position of UN agencies has been unambiguous and
unwavering over this period [
], proposals and strategies for
improving the safety of FGM/C have been forwarded time and
time again. In some settings, these strategies have been
adopted quietly and privately, whereas in others, proposed
policies have attracted the spotlight of media, sparking
emotionally charged protests, re-opening longstanding fierce
debates, and launching new controversies.
What issues are at stake? What belies the tenacity of these
Female genital mutilation/cutting, also known as female
circumcision, encompasses a wide range of procedures involving
partial or total removal of the external female genitalia for
nontherapeutic reasons. The range of cutting practices has been
classified into four types of FGM/C: type I, also known as
clitoridectomy, is defined as partial or total removal of the
clitoris and/or the prepuce (although it is actually the glans
and/or the body of the clitoris that is cut); type II, excision,
includes partial or total removal of the clitoris and the labia
minora, with or without excision of the labia majora; type III,
infibulation, involves narrowing of the vaginal orifice
(introitus) with creation of a covering seal by cutting and
appositioning or sewing of the labia minora and/or the labia
majora, with or without excision of the clitoris; and other forms,
include pricking, piercing, incising, scraping, or cauterizing the
skin near the clitoris for non-medical reasons, are categorized
as type IV [
Surveys conducted across parts of Africa, the Middle East,
and Southeast Asia document FGM/C prevalence rates
ranging from 1% (Uganda, Cameroon) to more than 95% (Guinea
and Somalia) [
]. Although survey data are lacking, FGM/C
has been described in countries including Colombia, Iran,
India, Malaysia, Oman, Pakistan, Russia, and Thailand, as
well as in migrant communities throughout the world [
Worldwide, more than 200 million women and girls are
estimated to have undergone some form of FGM/C, while each
year, another 3.6 million may be at risk of being cut .
Over the last four decades, interventions aimed at ending
FGM/C have combined concerted efforts of international
organizations, national bodies and governments, as well as religious
and civil organizations [
]. Health risk models formed the core
of these intervention strategies. Raising awareness about the
dangers of FGM/C, experts believed, would spur people to
reassess the practice and lead to its abandonment [
Early information and education campaigns commonly
featured didactic messaging about the short-term, long-term, and
obstetrical consequences of FGM/C. Over time, a suite of more
comprehensive strategies have emerged. Alternative rite of
passage programs, for instance, encourages upholding
coming-ofage celebrations but eliminating the cutting aspect of the ritual
]. Compensate-the cutter programs have retrained
traditional circumcisers for different vocations and encouraged
them to “drop the knife” [
]. And holistic community
empowerment programs are designed to foster
communitywide discussions and reappraisal of harmful practices such as
FGM/C . Each of these approaches has, to some extent,
sought to raise awareness of the health consequences of FGM/
C in hope of encouraging abandonment [
]. This may have,
however, inadvertently motivated families to turn to the health
system in search of safer cutting and encouraged health care
providers to comply with their patients’ requests .
Analyses of data on FGM/C prevalence from 29 countries
(27 African countries plus Yemen and Iraq) showed that in 15
of the 29 countries, there has been little or no change, while 14
nations showed that FGM/C rates are dropping [
characterized as unacceptably slow has led to calls for
intensification of global efforts to end the FGM/C [
7, 16, 17
]; at the
same time, it has prompted some to propose interim strategies
to reduce potential harm [
What Is Medicalized FGM/C?
Medicalization is the situation in which health care
professionals carry out FGM/C, whether in a health facility or at home
or elsewhere, often using surgical tools, anesthetics, and
antiseptics in the hope of mitigating immediate complications [
]. This term also applies to performing re-infibulation,
reclosure of female external genitalia of women who had been
de-infibulated to allow for sexual intercourse, delivery, and/or
related gynecologic procedures by doctors or nurse-midwives
]. It may also include situations in which medical
professionals administer painkillers or anesthestics, while cutting
is done by the traditional excisor [
]. In countries where health
systems are overburdened and experience shortages of health
professionals, FGM/C may also be performed by employees
who have no formal medical training or clinical knowledge,
such as apprentices or community health extension workers
21, 22, 23
]. This pseudo-medicalization can involve the
use of surgical tools, pain killers, and antiseptics, and thus
may appear to patients to be provided by trained health
professionals. Hence, self-reported survey data on medicalized
cutting may conflate these two very different groups.
What Are the Major Patterns and Trends in Medicalization?
A recent overview of data from 25 countries found that rates
of medicalization (FGM/C performed by a doctor, nurse,
midwife, or other health professional) among women aged 15–49
are highest in five countries: Egypt (38%), Sudan (67%),
Guinea (15%), Kenya (15%), and Nigeria (13%) [
(Table 1). Elsewhere, medicalized cutting is rare and restricted
to geographically defined pockets. All told, the majority of
women (74%) report being cut by traditional practitioners.
The remaining 26%—totaling nearly 16 million
women—reported medicalized cutting [
Among women exposed to medicalized cutting, 93% live
in just three countries: Egypt, Sudan, and Nigeria; more than
half (51%) reside in Egypt alone (Fig. 1) [
]. Notably, these
figures do not include Indonesia, a highly populous country
where FGM/C is known to be practiced, but where nationally
representative data on prevalence of FGM/C among women
and rates of medicalization are lacking.
Among daughters, rates of medicalized cutting are
substantial (10% or higher) in eight countries: Djibouti, Egypt, Guinea,
Iraq, Kenya, Nigeria, Sudan, and Yemen. Mother-daughter
comparisons show that medicalization is increasing in each of
these countries except Nigeria [
]. This trend is sharpest in
Egypt where, according to the 2014 data, rates have more than
doubled between women and daughters (38 and 82%,
]. This increase is likely linked to the fact that in the
1990s, Egypt enacted a policy requiring that FGM/C be
performed by a trained medical professional; this policy has now
been reversed (for more details, see below and [
Medicalization, “Harm Reduction,”
and Regulatory Policies
The term “harm reduction” has been used to discuss FGM/C
in two distinct ways. First, it has described the desire to reduce
Prevalence of FGM/C, medicalization, and total number of women (ages 15–49) cut by health professionals
]. Note: some more recent surveys do not provide information on medicalization. This table summarizes data from the most recently
available survey that included information on type of practitioner of FGM/C
the attendant health risks by improving the sanitary conditions
under which FGM/C is performed, improving the competency
of practitioners, and/or limit the severity of cutting [
23 , 25
Second, it describes a specific public health strategy known as
harm reduction that aims to minimize health hazards
associated with risky behaviors by encouraging the safest
alternative, including, but not limited to, abstinence [
strategy arose in the 1980s to curb the growing HIV/AIDS
crisis among IV drug users, and has since informed programs
for reducing teen pregnancy, drunk driving, smoking, and
various other risky behaviors . Harm reduction recognizes
abandonment of or abstaining from a risky behavior as the
ideal outcome because it bears lowest risk of harm, but
recognizes alternative changes short of abstinence. It promotes the
alternative that is culturally or individually acceptable and
bears the lowest risk of harm.
Policies regulating the way in which FGM/C is carried out
have been described as “temporary transitional measures” for
those not yet ready to stop the practice [
]. Some have
been policies that restrict the type of FGM/C that can be
performed, the persons who are permitted to perform the
procedure, and/or the setting in which it can be conducted. While
the restrictions may have been intended to reduce the risk of
more extensive cutting or having FGM/C performed by an
unqualified practitioner in an unhygienic setting, not all
policies specified a goal of working toward abandonment of
FGM/C. For instance, in Kenya in 1931–1932, two Local
Native Councils (elected bodies that reported to British
colonial administrators) passed resolutions restricting the severity
of allowable forms of excision [
]. While these policies
prohibited more severe forms of cutting, they did not require
circumcisers to encourage abandonment of FGM/C. We
suggest that such restrictions be referred to as regulatory policies
when they do not specifically work toward abandonment of
FGM/C. We suggest that the term “harm reduction” should be
reserved to describe strategies that seek to minimize medical
risk by encouraging the safest acceptable alternative,
including abandonment of FGM/C.
All other countries
Policies Regulating FGM/C
Efforts to medicalize FGM/C or restrict the severity of cutting
have had a long history and have been implemented with
varying degrees of success. Colonial governments in Sudan
and Kenya instituted regulations on the type of cutting
allowed, but were met with strong resistance [
Similarly, in the 1970s, a recommendation by the Somali
Women’s Democratic Organization to replace infibulation
with pricking performed in hospitals was not followed [
Decades later, Islamic scholars have engaged in debating the
religious grounds for different forms of FGM/C [
Although FGM/C is not mentioned in the Koran, it is
mentioned in some hadiths (recorded sayings and practices of the
Prophet Mohamed). One commonly cited hadith attributes the
following statement on FGM/C by Prophet Mohamed: “If you
cut, do not overdo it, because it brings radiance to the face and
is more pleasant for the husband.” Since the authenticity of
this hadith is debated, opinions are divided regarding whether
FGM/C is permitted or required by Islam [
29, 30, 34
Indonesia, for instance, even though FGM/C was banned in
2006, two Muslim organizations reportedly continued to
condone the practice, advising “not to cut too much” [
Indonesian Ministry of Health subsequently issued a 2011
directive for health professionals to perform scraping on girls
]. The government, however, repealed this regulation in
2013 and reiterated support for a 2006 law banning FGM/C.
In Egypt, medicalized cutting is carried out primarily by
doctors, as opposed to other health workers, and is historically
rooted in a 1994 Ministry of Health order requiring state
hospitals to set aside 1 day a week for trained physicians to
perform FGM/C [
]. In the wake of sharp criticism, this
policy was changed, but a loophole allowing for “medically
necessary circumcision” was not closed until 2007 .
In parallel, in the 1990s as European and North American
countries received increased numbers of immigrants from
countries where FGM/C is practiced, several proposals were
drafted recommending offering pricking in lieu of more severe
forms of cutting in children old enough to give consent and for
those families where any prevention strategy did not work.
While intended to be compromise solutions, balancing respect
for cultural values, host countries laws, medical and ethical
principles while minimizing health risks [
28, 39, 40
despite having been reviewed (in the Florence case) by a
Bioethics Committees that “judged the proposals to be ethical,
legal, deontological, efficacious and fair” [40, p. 8], each of
these proposals ignited public outrage and were never
Stances of Governments and International and Professional Organizations
Numerous medical associations condemn medicalization,
including the World Medical Association, the American College
of Obstetricians and Gynecologists, the American Medical
Association, and the International Federation of Gynecology
and Obstetrics [
]. A dissenting view was expressed by
the American Association of Pediatrics, whose 2010 policy
statement called for allowing pediatricians to perform nicking/
pricking . A firestorm of protest led to the subsequent
retraction of this statement. Recently, following a 2017
summit in Egypt, public statements opposing medicalization
were issued by professional medical associations from
Djibouti, Egypt, Somalia, Sudan, and Yemen. Thus, policies
by professional organizations around the globe are now
aligned with opposition to all forms of medicalization.
On December 20, 2012, the United Nations General
Assembly passed a Resolution on Intensifying Global
Efforts for the Elimination of Female Genital Mutilation
[A/RES/67/146]. Its adoption reflects agreement that FGM/
C constitutes a violation of human rights and that all countries
should take action to end FGM/C and its medicalization, “take
all necessary measures including enacting and enforcing
legislation to prohibit FGM” [A/RES/67/146]. Over 40 countries
have banned FGM/C by law or constitutional decree. In at
least six of these countries (Burkina Faso, Cote d’Ivoire,
Egypt, Eritrea, Mauritania, and Senegal), the criminal code
specifies an elevated penalty (prison and/or fine) specifically
for medical personnel who perform FGM/C, in addition to the
possibility of suspending their licenses .
Ongoing Debates Surrounding
A wide range of debates on medicalization have been
critically, and sometimes bitterly, interrogated in a voluminous body
of scholarly literature, as well as in the media and political
arenas. Many of these debates have centered on three broad
concerns: (1) the effects of medicalization on effort to end
FGM/C, (2) understanding what drives medicalization and
how it can be discouraged, and (3) reconciling competing
rights claims surrounding FGM/C.
Does Medicalization Counteract Efforts to End FGM/C?
At the heart of opposition to medicalization rests a central
assumption: that medicalization will counteract efforts to
eliminate FGM/C. Medicalization, critics fear, can create the
impression that FGM/C can be performed safely and is
condoned by respected medical professionals, thus reducing
motivation of families to abandon the practice [
19, 23 , 44
Others have speculated that medicalization or less severe
cutting can be an interim step toward abandonment [
Current evidence is conflicting, a finding that is perhaps not
surprising since FGM/C regulations have not been instituted
as formal harm reduction policies aimed at encouraging
A statistical overview of data from 25 countries showed no
association (non-significant correlation) between medicalized
FGM/C among daughters and rates of decline in prevalence of
]. In countries where measurement has been
repeated in surveys roughly 5 years apart, substantial changes
in both medicalization and prevalence rates are detectable
only in Kenya, with FGM/C prevalence rates declining sharply
while medicalization remained high. Therefore, at least in this
setting, medicalization has not completely counteracted the
process of abandonment of FGM/C. By contrast, two
countries with the highest rates of medicalization, Egypt and
Sudan, show persistently high rates of FGM/C, with change
visible only in the youngest age cohorts [
medicalization is hindering this decline is unclear and is best
investigated in focused studies.
A recent mixed-methods study (using survey and in-depth
interviews) in Egypt reported that doctors did not consistently
discourage FGM/C, even when mothers sought advice and
expressed concerns for their daughter’s safety [44 ].
Another study analyzing the 2008 Egypt DHS data found that
households were less likely to opt for FGM/C when
medicalization was used more widely among their daughter’s peers;
the author suggested that medicalization might be associated
with changing norms surrounding FGM/C, opening
possibilities for abandonment . This interpretation was not
supported by a new study in Kenya, where families who adopt
medicalized cutting do not consider this to be a step toward
]. Further research is needed to reconcile
these conflicting findings.
Research on whether medicalization is associated with
reduction in severity of cutting also shows mixed results.
Studies in Nigeria and Kenya reported that health
professionals who performed FGM/C promoted nicking in lieu of
clitoridectomy in order to reduce the chance of complications
and drawing attention to their practice [46, 47]. Conversely,
research in Indonesia documented that while traditional
practitioners tended to perform scraping of the clitoris (type IV),
health care providers more commonly performed more severe
type I FGM/C . Surveys on FGM/C do not always collect
information on type of FGM/C, but the limited available data
show a shift to less severe nicking/pricking forms of cutting
(defined as “cut, no tissue removed”) in countries where
medicalization is spreading [
]. Whether there is any causal role
is, however, unclear.
What Motivates Medicalization of FGM/C and What Can Be Done to Discourage It?
While medicalized FGM/C is found in greatest concentration
in three countries (Egypt, Sudan, and Nigeria), health
professionals in countries around the world have been approached
with requests to cut girls and women [49–53]. These include
countries in Africa, Asia, and the Middle East where FGM/C
has long been practiced, as well as those that have received
migrants, refugees, and asylum seekers from FGM/C
practicing communities [
The demand for medicalized cutting appears to be driven
by a number of factors. First, heightened concerns over
potential health complications have motivated parents to seek
medicalized and/or less severe cutting [
19, 21, 23 , 25 , 44 , 55
At times, medicalized cutting has been driven by policies
restricting traditional practitioners, but allowing health
professionals to perform FGM/C (e.g., Egypt in the 1990s, and more
recently, Indonesia). Additionally, in some instances,
medicalized cutting has been offered as part of routine neonatal care
options, even in settings where FGM/C is considered to be a
relatively benign procedure [22, 56].
Attention has also focused on understanding the supply side
of medicalization. Financial gain is a recurring theme across
], although it is not always the primary motivating
factor. Some health care providers themselves come from
FGM/C-practicing families and support its continuation [
] and are willing to honor the values and wishes of their
23 , 25 , 55, 57
]. Knowledge of criminal statutes or
professional guidelines has been shown to be incomplete ,
and legal bans at times run counter to the professional norms
shared by communities of providers [
21, 36, 55, 57
]. This is
particularly evident in setting where health professionals justify
performing FGM/C in order to prevent it from being performed
by an unskilled practitioner, without pain management, or
under unsanitary conditions [
Improving education on FGM/C has become prioritized
not only for improving clinical care for affected women,
but also preparing health providers to be involved in
advocacy. While some countries now require health
professionals to educate patients on FGM/C, in others, this duty
is considered untenable given the already heavy workloads
and time constraints faced by medical providers [
Moreover, because few training institutions have
comprehensive components on FGM/C in their curricula, health
care professionals continue to report having insufficient
knowledge on the issue .
A number of countries also require health care providers to
track and/or prevent FGM/C. An overview of policies in 30
countries (11 countries where FGM/C is practiced and 19 that
host migrants from FGM/C-practicing countries) found that
16 countries mandate a “duty to report” cases in which a
patient has undergone FGM/C, while 18 countries require
formal action to be taken when health professionals suspect
that FGM/C will be carried (duty to avert) [
reporting requirements raise the ethical dilemma of dual
loyalty, where health care providers have an obligation to protect
the confidentiality of their patients at the same time as having
a duty to report to the state [
]. Whether mandated actions to
prevent FGM/C on a girl or her siblings are offset by concerns
regarding violating confidentiality, eroding trust between
providers and their patients, and setting off protection orders that
remove a girl from her home and/or lead to the imprisonment
of her parents are matters of grave concern [
Those calling for stricter enforcement of bans on
medicalized FGM/C have encouraged sanctioning health care
institutions that do not enforce such policies and criminally
prosecuting violators. Legal charges have been issued against
medical professionals accused of performing FGM/C in countries
including Egypt [
], the UK [
], and the USA [
Complexities in these cases include determining whether legal
restrictions apply to nicking, pricking or scraping, and
determining when FGM/C is “medically necessary.” Additionally,
the extent to which high-profile cases deter other medical
professionals from performing FGM/C or drive the practice
underground is poorly understood.
Should There Be Zero Tolerance of All Forms of FGM/C and Medicalization?
Ongoing debates have addressed how to distinguish
acceptable risk from intolerable harm, or who has the right to make
such distinctions. These are interpretive issues, linked to legal,
ethical, medical, and human rights claims about the limits of
individual autonomy and tolerance of multiculturalism.
The Platform for Action developed at the 1995 Fourth
World Conference on Women laid a blueprint for framing
FGM/C as a human rights violation [
]. Drawing on these
principles, the UN advanced a “zero tolerance” approach for
opposing all forms of FGM/C, a position that reflected a break
from the earlier health framework and vexing questions it
spurred about whether or how health risks might be
]. Strategies to promote and protect these rights have
faced the challenge of simultaneously addressing competing
rights claims: how can rights of the child, women’s rights to
freedom from discrimination, freedom from torture, and the
right to bodily integrity and health be reconciled with a right to
culture or religious freedom [
The strictest application of the zero tolerance stance
prohibits any non-therapeutic procedure involving the female
genitalia. However, when prohibition is linked to the concept
of harm, as is stipulated in certain criminal codes ,
questions arise as to whether restrictions also apply to type IV
procedures (nicking, pricking, or scraping of the clitoris or
clitoral hood) that do not produce anatomical changes [
In the mid-1990s in the Netherlands, a recommendation called
for differentiating “tissue impairing and non-tissue impairing
circumcision and non-mutilating ritual incision,” and
suggested that doctors be allowed to perform an anesthetized
prick of the clitoral covering [
] (p. 285). Similar proposals
were also considered in Seattle, Washington [
Florence, Italy . Two decades later, medical ethicists
endorsed “de minimis” forms of FGM/C, such as pricking, that
were said to bear no long-term medical risks [
question the veracity of the claim that the long-term
consequences are rare [
], as well as the merits of using harm as
grounds for defining acceptable versus unacceptable forms of
FGM/C. Irrespective of harm, critics charge, FGM/C is rooted
in the gender discrimination and therefore violates the
fundamental human rights of girls and women [
Debates have also lingered over unresolved questions on
consent. Social pressures in societies where FGM/C is widely
practiced were argued to limit women’s ability to provide
meaningful consent [
] and justify protectionist
measures. Critics, however, questioned whether such measures
compound restrictions on women’s autonomy, possibly
advancing an image of women as victims who are incapable of
reasoned decision-making regarding acceptable risk [
Moreover, perplexing contradictions arise from banning
FGM/C while upholding permissive standards regarding
female genital cosmetic surgeries, some of which bear striking
similarity to certain form of FGM/C (labia reduction, clitoral
reductions, and a form of labial adhesion known as “The
72, 75, 76
]. While this concern first arose in
Europe and North America, it now extends to Egypt, where
some doctors who perform FGM/C have adopted a discursive
change, calling it a “cosmetic procedure” [
In the case of minors, the issue of consent regarding FGM/
C is tied parental authority. Because children below a certain
age have “diminished capacity” to make medical decisions
], the “best interest” principle grants parents (or legal
guardians) latitude to make decisions on a child’s behalf
]. However, the state at times intervenes, such as when
parents have refused medical treatment for life threatening
conditions on the basis of religious beliefs [
]. For FGM/C,
the calculus of acceptable risk rests on weighing competing
rights enshrined in the Convention on the Rights of the Child:
a child’s right to practice her culture or religion (Article 23),
and a child’s right to health (Article 30). The Joint UN Policy
Statement on FGM/C recognizes that parents “who take the
decision to submit their daughter to female genital mutilation
perceive the benefits to be gained from this procedure to be
outweighed by the risks involved” [
] (p. 9). Yet, it firmly
concludes that “this perception cannot justify a permanent
and potentially life-changing practice that constitutes a
violation of a girls’ fundamental human rights” [
] (p. 9). This
position is endorsed in criminal statutes that restrict not only
type III, but also types I and II among minors. However, where
statutes pose restrictions based on harm, rather than zero
tolerance, the legal status of nicking, pricking, piercing, and
scraping (type IV) are less clear .
A parallel debate questions whether double-standards are
being used to oppose type I and type IV (nicking, pricking,
and scraping, in particular) FGM/C while condoning routine
male neonatal circumcision. Commentators calling for equal
treatment differ in terms of concluding whether both male and
female genital cutting on minors should be allowed or
]. Earp has argued that all forms of genital
cutting on minors, regardless of health consequences, may
form an “intimate violation” [
], and he instead advances
the idea of “genital autonomy,” wherein decisions are delayed
until children reach an age at which they can provide valid
]. This position, however, sets decision-making
regarding FGM/C apart from other widely accepted domains
of parental decision-making authority that may influence a
child’s mental, moral, and spiritual development [
However, Earp’s view aligns with a 2012 opinion of a
Higher Regional Court in Cologne, Germany that classified
circumcision of boys as “bodily harm” and ruled that the
“fundamental rights of the child to bodily integrity outweigh
the fundamental rights of the parents” [
]. Vocal protests
from Jewish and Muslim groups characterized the Court’s
opinion as “an unprecedented intrusion of the right to
selfdetermination of religious communities” [
], and prompted
the German government to pass legislation allowing ritual
male circumcision when performed by a medical professional
]. An upcoming criminal trial in the USA may soon be
asked to render a similar decision in a case on FGM/C [
While controversies have long surrounded the issue of FGM/
C, some of the most vexing and tenacious debates have
centered on its medicalization and regulations on the severity of
cutting. The intractability of these debates rest, in part, upon
the tendency to conflate moral and medical arguments [
as well as the slow generation of sound scientific data to test
empirical claims [
19, 66, 89, 90
]. Recent decades have
witnessed a dramatic increase in scientific evidence on health
risks associated with FGM/C and behavior change. Yet, there
are still gaps in knowledge, particularly on risks associated
with type I and type IV forms of FGM/C, and there remains
a pressing need to reconcile the evidence base with ethical,
moral, and legal standards.
Growing consensus on defining FGM/C as a human rights
violation underscores that concerns are not limited to
minimizing health risks, but rather extend to broader concerns on child
protection and well-being, consent, bodily integrity, and
discrimination against women. Medical ethicists, legal experts,
and policymakers alike have been forced to confront
competing rights claims, including the right to health, right to bodily
integrity, rights of the child, right to culture, and right to
religious freedom. The lack of clear cut, definitive answers
regarding the priority of competing claims have given fuel to ongoing
debates surrounding medicalization, some of which have now
become objects of scrutiny in courts of law around the world.
Polarizing debates have cast each side in a negative light.
Are proposals for less extensive or medicalized cutting
condoning child abuse and willing to undercut efforts to end FGM/C,
or are they compassionate, pragmatic compromise solutions
intended to protect the health of girls? Are zero tolerance
platforms safeguarding the human rights of girls, or staunchly
defending a moral high ground at any cost? We suggest that
these extreme positions deflect focus from the common ground.
The central interest of all parties in these debates, we believe, is
to seek solutions to best protect the health and welfare of girls
living in communities where FGM/C practices are upheld.
Resolution may require calling for more informed and open
dialog to better understand and address the constraints on
bringing a rapid end to FGM/C, and the effects of changes in type of
cutting or choice of providers that are already underway in parts
of the world. While legal action serves to impose regulatory
restriction and punish violators, it is unclear if this will
discourage the supply and demand for medicalization, or drive the
practice underground. It also remains questionable as to
whether nuanced understandings and solutions will arise in the
adversarial context of courts of law. Hence, the best chances for
achieving lasting resolution will likely involve continued dialog
between patients, providers, and all of those working ardently
to change norms and protect the rights and well-being of girls
Funding Funding for this work was provided by UK Aid and the UK
Government through the Department for International Development
funded project, “Evidence to End FGM/C: Research to Help Girls and
Women Thrive,” coordinated by Population Council. Grant
administration through the Center for the Study of Demography and Ecology was
supported by the Eunice Kennedy Shriver National Institute of Health and
Human Development award number 5R24HD042828.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
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