Ritual Genital Cutting of Female Minors

The Advocates for Human Rights notes with deep concern the policy statement issued by the Committee on Bioethics on April 26, 2010 on Ritual Genital Cutting of Female Minors. In its statement, the Committee offered the “ritual nick” as a compromise to more intrusive forms of female genital mutilation, and stated that it may be a way to build trust between hospitals and immigrant communities and avoid greater harm to little girls.

United States federal law and many state laws rightly criminalize the practice of female genital mutilation. Far from building trust, the policy statement is likely to increase confusion on this issue for Academy members, and for the immigrant community, who deserve full protection of US laws. This statement will not serve to educate and convince immigrant families that it is time to end FGM; it legitimizes this harmful practice under the guise of cultural sensitivity. Violations of human rights must never be excused in the name of culture. Customary or religious traditions, which often have the subordination of women at their root, may not serve to justify harmful practices.

This principle is supported by a number of human rights instruments, including the United Nations Declaration on the Elimination of Violence against Women, which states:

"States should condemn violence against women and should not invoke any custom, tradition or religious consideration to avoid their obligations with respect to its elimination."

The phrase “ritual nick” de-emphasizes the true nature of this human rights violation. In 2008, a coalition of United Nations organizations issued a joint statement on FGM in which they identified a “ritual nick” as a form of FGM:

"Type IV: All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping, cauterization and inserting harmful substances into the vagina."

In May 2009, the United Nations issued the handbook “Good practices in legislation on ‘harmful practices’ against women.” The handbook notes the trend toward “medicalization” of female genital mutilation, whereby medical professionals perform the procedure, and states that “it is particularly important that any definition of this form of violence clearly condemn the practice whether committed within or outside of a medical institution.” The handbook also emphasizes that the law should not distinguish between the four classifications of FGM, “so as to ensure that all types of female genital mutilation are considered and responded to with the same degree of seriousness.”

The European Parliament issued a resolution on this issue in 2009, in which it:

"Urges firm rejection of pricking of the clitoris and medicalisation in any form, which are being proposed as a halfway house between circumcision and respect for traditions serving to define identity and which would merely lead to the practice of FGM being justified and accepted on EU territory; reiterates the absolute and strong condemnation of FGM, as there is no reason—social, economic, ethnic, health-related or other—that could justify it."

It is particularly important that influential members of society such as pediatricians support the complete elimination of FGM. Experts acknowledge that ending the harmful practice of FGM will be possible only with the cooperation of community leaders. The Academy should train its members to educate the public on the risks of this harmful practice in all its forms.

The American Academy of Pediatrics should represent the best interests of its most vulnerable patients by fully and roundly condemning any and all practices of female genital mutilation.

Conflict of Interest:

None declared

I am forced to write this letter because as an organization, for the last one month since this policy document was released, we have had a major out cry from parents both in Africa and the USA. Girls that had said no to FGM are now interested in the new type of FGM called the "AAP FGM" Your policy has almost destroyed our work in eliminating this culture. Its is ignorant for your argument to indicate that once you "prick" a girl she can be prevented from worse FGM. For your information, FGM is a culture, the cut has nothing to do with it. There are rites, oaths and recitals that go with it. I can assure you that here is no girl that will have her clitoris "pricked" and go back to her village and blabb about her "american prick" why? because she will be grabbed by the villagers and take to the real circumcisior so that she can do the entire rite of passage because a cut without the ritual is nothing. What will you have done to such a girl's life? You will subject her to two cuts. You policy is endagering more girls. Change it! We are not going to rest until the whole world is informed about your uninformed decisions.

Conflict of Interest:

None declared

It is shameful for pediatricians to be more interested in preserving cultural norms than in protecting the health and well-being of children. And yet with this latest position statement, that is exactly what you have done. Where, exactly, would this end? If rape were appropriate in some cultures (which it is), would you condone that? Child abuse? Spousal abuse? Is beating one's child "just a little" appropriate, if it is a method of discipline condone by one's society? If you argue that your new position statement is designed to be sensitive to a certain religious practice, I would argue that just because something is religious does not mean it is sacred. If parents were bringing their children to a religious service that involved handling venomous snakes or drinking strychnine, what would your position be then? That a small snake, or a bit of strychnine, is acceptable? Your position on this topic is absolutely, completely, inarguably untenable, as well as unacceptable for those of us who care more about children than the baseless cultural and religious customs of adults.

Conflict of Interest:

None declared

Genital cutting of girls is criminal child abuse in the US; laws require teachers, physicians, and others to report abuse. Does AAP make that clear to members being urged to be more tolerant of FGC of girls? What about parents who present daughters who have been cut? What of solicitation of a physician to do the cutting? Is there no obligation, not even a moral one, to report it?

During 20 years as a military Judge Advocate, I spent many years overseas where we dealt with child abuse that would have gone to civilian authorities stateside. It takes years to get images of battered children out of one's mind; even more years to erase thoughts of "tween" girls raped by step-fathers or biological fathers, and with lingering thoughts about long-term consequences, one is driven to social advocacy on behalf of children.

Child abuse can be violent or sexual, sometimes both at once; boys tend to be victims of violent abuse; girls tend to be victims of sexual abuse. Step-parents tend to be perpetrators more than biological parents. Despite statistical trends, any child can be a victim of any type of abuse by any adult inclined to inflict it. Retrospective statistical studies matter for researchers who ponder prevention. Until now, no one has suggested "experiments" with milder forms of abuse to foster prevention. Flesh cutting experiments on living beings evokes horror, even among some who support such research on "lower" mammals to promote better health for humans. Many call for an end to it and the controversy rages. Is the AAP prepared to venture into an "experiment" to see what effect less female genital cutting will have on possible or potential return to sending cultures where possibly or potentially more genital cutting will take place? Can there be "ethical" approval of such an "experiment"?

Why would the AAP have any interest in this? Is there any evidence of medical benefit from "less" FGC? There have been studies that show some forms of "more" FGC reduce the incidence of HIV/AIDS acquisition among women who have been cut; but no one has suggested such cutting by practicing pediatricians in the US and hopefully no one will. Then who would have thought an AAP committee would urge a look at possibly doing "less" FGC in the interest of promoting cultural sensitivity and preventing "more" FGC?

As party to an international, interfaith marriage, I strongly advocate tolerance of all benign cultural practices and celebration of diversity. But some cultural practices must be abandoned by those who come to the US. There have been recent prosecutions of fathers of underage girls and adult husbands to whom the girls were sold as brides. There are cultures in the world where boys of a certain age are rounded up and taken to a long house for sexual initiation that involves being sodomized by adult men. Should we permit those practices, to prevent children from being taken back for an even worse marriage or initiation? Where I live a man was convicted of animal cruelty after he skinned and roasted his neighbor's dog in the tradition of his sending culture. Should he have been acquitted to show sensitivity for his culture? What is it about cutting children's genitals that makes some of us want to approve it? Why endless ventures to find justification for it?

While preparing for trials, interviewing ER physicians, psychiatrists, and clinical psychologists, I learned much about the effects of abuse on children, including that the effects of abuse are not lessened by good intentions of an abuser. It is the child's perception of abuse that matters. It seems the AAP sees only adult perspectives here, and loses sight of child perspectives when it ventures to the slippery slope and murky water of accommodating child FGC. There is no room for genital cutting of children. Until now it was comforting to know the AAP had an unequivocal policy of disapproving genital cutting, at least for girls. That sense of comfort is lost, unless the AAP retracts its misguided venture into the madness of possible or potential nicks of girls' genitals. Cutting a child's genitals is both violent and sexual abuse; the AAP should have no part in it.

Conflict of Interest:

None declared

This is appalling to me as a woman and a mother. Genitals should have the same rights (and more!!) that every other body part is afforded. I want to believe that pediatricians have the best interest of their patients (infants and children)in mind and heart, but un-necessary surgery on non-consenting persons is not within my area of acceptable behavior towards minors.

Conflict of Interest:

None declared

I am outraged by your policy statement endorsing Type IV FGM as a “comprise to avoid greater harm”.

In the first place, softening the language to “cutting” instead of “mutilation” in the interest of being culturally sensitive is a huge step backward. Cutting the genitalia, IS mutilation. In some cultures, it is considered acceptable for men to beat their wives into submission. Perhaps instead of calling this practice “domestic violence” we should use the more culturally sensitive term “domestic discipline”. That way the wife beaters won’t feel bad or think we don’t respect their cultural practices. Shame on you all!

In the second place, cutting an infant’s genitals for no medical reason, in the “hope” that someone else won’t cut them worse is preposterous. You are CAUSING harm to an infant who cannot consent.

It is unfortunate that a double standard exists for male and female infants in this country. The way to address that would be to move forward towards recommending genital autonomy for an infant of any gender. Instead, you have moved backward in condoning abuse of female infants.

I suggest that you review your own statement, Bioethics Committee 93- 94 on Informed Consent –- “providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses……the pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent.” You have a responsibility to protect infants from their parents’ desires to alter their healthy genitals for non-medical reasons. You have failed.

Conflict of Interest:

None declared

Dear AAP,

I would like to request that this policy statement should be rescinded.

Dr. Davis states that some pediatricians who have a large number of we have good reason to believe that many girls are being sent back to their home countries to undergo FGC. Personally, I doubt that this is true. I have had a lot of Somali patients over the past 4 and a half years because I live and work in Rochester, Minnesota. I have never yet met a Somali parent who requested FGC for his or her daughter. (This makes sense to me, because in general, Somali parents want their children to have a better life here in America than they could have had in Africa.)

But supposing I am wrong and Dr. Davis is right, doesn't Representative Crowley's proposed legislation criminalizing the transport of girls overseas to undergo FGC make more sense as a solution than the AAP statement's suggestion that FGC should be decriminalized? Dr. Davis was quoted as saying that the Crowley legislation would be difficult to enforce. However, I suspect that just a few well-publicized prison sentences and deportations would suffice to deter a large number of transports.

Moreover, what reason do we have to believe that "nicks" will prevent FGC? How do we know that parents who have had their daughters "nicked" will not want to "finish the job" with infibulation? (By the way, if infibulation includes sewing of the labia, then it is actually not well described by the term "cutting".) Is it not logical to presume that offering "nicks" will lead to an increase in the overall number of girls undergoing FGC (since "nicking" is a form of FGC)? Or have the authors discovered a mechanism by which pediatricians can predict with certainty which girls would otherwise undergo more extensive FGC?

Are there really a substantial number of pediatricians who wish to offer FGC to patients in America in 2010? The statement cites 3 news articles from 1996. 1996 was a long time ago, and before the previous AAP statement was published. What exactly has changed since 1998 that led to the need for a revised statement?

It seems to me that the Committee on Bioethics did not seek or receive sufficient input from pediatricians serving ethnic communities previously practicing FGC. I believe that examination of the empirical evidence will demonstrate that criminalization has been effective in eradicating this custom.

Thank you for your time. Arjun Bamzai MD, FAAP

Conflict of Interest:

None declared

I believe that the AAP was acting with good intentions, regarding this extremely complex issue, in development of its new policy weakening its stand against Female Genital Cutting. However I also believe that this new policy violates the fundamental human right to bodily integrity and freedom from abuse, and raises other ethical and practical concerns.

The ultimate intent of this policy statement is laudable - to end FGC, by educating physicians to better enable them to educate parents about the practice. Certainly education is needed. The AAP should make readily available information about, and contact data for, the organizations, in the US and other countries, that are already working hard to educate about and eliminate FGC. Effectiveness of the education and support provided by these groups, primarily of women, from and in FGC - practicing cultures and countries, has been demonstrated.

However to become complicit by offering a "lesser" procedure, in hope of dissuading the family from seeking a more major FGC procedure in a less safe non-medical setting, is a dangerous step across the line from the physician´s ethical mandate to refrain from doing medically unnecessary procedures. It breaches the guidelines for informed consent in the context of minors, and the responsibility of society in general to protect the human rights of minors. Additionally physician participation implies creditability to the practice of FGC.

This new policy statement is also out of step with: 1) US law prohibiting all genital cutting on female minors, 2) proposed US legislation to prohibit transport of any US minor female out of the country to be subjected to any FGC, 3) many similar international laws, 4) World Health Organization policy on FGC, 5) many other national and international agencies such as CARE, and 6) many grass roots organizations in and from areas and cultures where FGC is practiced. This new AAP policy removing the protection of girls further undermines the medical and ethical credibility of the AAP as the medical organization committed to the physical and mental health and protection of all children.

I therefore recommend that the AAP immediately reinstate its prior policy against all forms of FGC. I believe that the AAP should also act to extend equal protection to male infants by revising the AAP policy on male circumcision to prohibit non-medically indicated circumcision of all male infants and older minors. Thereby it would get in step with the practices of the majority of the world´s countries including: our neighbors Canada and Mexico, plus Europe, South America, Australia, New Zealand, and Asia.

I further recommend and challenge the AAP to use this opportunity to take the lead in providing a forum for real education and enlightenment on the medically, ethically, legally, and culturally complex, and often socially taboo topic of normal genital function and the international practices of genital cutting of both males and females. Education in US medical school and residency curricula about the normal function and anatomy of the genitalia is virtually absent. Most US physicians are as ignorant as the general US population about the cultural and historical practices of genital cutting, appropriate foreskin care and examination of uncircumcised males, and normal age range for retraction of the foreskin.

The AAP is in an excellent position to fill this gap with a special supplement volume to Pediatrics and a plenary session at the next AAP annual meeting. These must be forums for an academically and scientifically honest educational project. There needs to be reviewer diversity. This is no place to continue reviewer bias and elimination of presentations that are in opposition to a narrow perspective. It is also a place for an extensive reference list of existing resources for both physicians and parents: books, pamphlets, organizations, related conferences, documentaries and other movies, laws in other countries, and policy statements of other medical organizations, etc.

This is the opportunity to move forward.

Sincerely, Sarah E. Strandjord, MD, FAAP

Conflict of Interest:

None declared

Conflict of Interest:

None declared

To better understand the American Academy of Pediatrics (AAP) position on female genital cutting (FGC), I encourage you to read the policy statement issued April 26. You can see the full statement at: http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;125/5/1088?rss=1

In the statement, 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.

Conflict of Interest:

President, American Academy of Pediatrics

When health educators prepare to explain to parents from outside the United States why male genital cutting is practiced here but female genital cutting is condemned, they may want to consider the following similarities between cultures that cut male and female genitals.

1.Cultural bias prevents recognition of the sexual and psychological harm of local practices. 2. Local medical doctors support genital cutting. 3. The anatomy and physiology of the cut parts are not generally known. 4. The practices are defended with reasons such as tradition, religion, aesthetics, cleanliness, and health. 5. The practices are believed to have no effect on normal sexual functioning. 6. The decision to cut may be motivated by underlying psychosexual reasons. 7. The practices are accepted and supported by those who have been subjected to them. 8. Critical public discussion is generally taboo. 9. The adverse effects are hidden by repression and denial. 10. Genital cutting is typically done by force on children who are seen as not having rights to their bodies.

The fact that cutting children’s genitals is defended with some of the same reasons in our culture as in others raises additional doubts about the validity of these reasons and underscores the power of cultural influence on personal beliefs and attitudes. In this way, learning about another culture’s practice can help mutual understanding.

The Policy acknowledges that “ritual nicks” are less extensive than newborn male circumcision and are illegal. These facts and the emotional discomfort some may feel with this existing double standard argue for opposing male circumcision, not for accepting female “ritual nicks.”

Cultural bias appears to have contributed to a few flawed or contradictory statements in the Policy. The primary principle of medical ethics, “do no harm” is not equivalent to “do less harm.” It is a principle of absolute behavior, not relative behavior. Defending doing less harm because others could do more harm (the “greater evil”) is the kind of flawed ethical thinking that has rationalized a wide range of harmful and destructive human activities, including wars. There can be no exceptions to ethical principles if they are to mean anything.

The Committee on Bioethics has not attempted to satisfy the burden of proof that a “ritual nick” has no risks of physical and psychological harm. Its assumption that a “ritual nick” is not physically harmful is debatable. If the harm if relatively minor, it is still harm. Certainly, there is physical harm or risk of physical harm any time a cutting instrument contacts sensitive genital tissue.

The Policy then ignores the potential psychological harm of a forced “ritual nick” on a child of any age. Imagine your own emotional response to being subjected to the same experience. Children are more vulnerable than adults to trauma, and they deserve our empathy. Psychologists know that adults who cannot feel often project their lack of feeling onto children and assume that children do not feel. As a psychologist who has studied early trauma, I understand the dangers of minimizing or ignoring psychological harm to young children. The Policy states that “potential psychological harms associated with FGC violate the principle of nonmaleficence (a commitment to avoid doing harm).” Clearly, a forced “ritual nick” with associated potential psychological harm violates this principle. Consent on the part of an older child (who may be subjected to parental pressure) does not necessarily prevent potential psychological harm.

Finally, the Policy recommends opposing “all forms of FGC that pose risks of physical or psychological harm.” Considering the previous statements, there are no forms of FGC that do not pose such risks. If the AAP stands for protecting the physical and mental health of girls, it must oppose all forms of genital cutting.

Ronald Goldman, Ph.D., Executive Director, Circumcision Resource Center, http://www.circumcision.org, author of Circumcision: The Hidden Trauma

Conflict of Interest:

None declared

Cultural Sensitivity: The AAP has proposed genital nicks or piercings for baby girls to satisfy cultural customs in a less harmful way, with no evidence that it would work. This shows a lack of concern for the patient, which is more suitable for the veterinary profession.

Patients Rights: The owner of a tattoo & piercing shop responded to a request to pierce the ears of a baby girl thus: “Absolutely not! Bring her back when she can talk. If she wants her ears pierced, with no parental pressure. I will tell her that it will hurt... If she still wants her ears pierced, I will gladly do so.” This layman’s reaction is worth consideration by the AAP and the entire medical profession

Recommendation: The AAP should protect all patients’ both male & female from unnecessary, painful, and / or harmful procedures.

Jim Moore NOCIRC of Ohio - Cincinnati

Conflict of Interest:

None declared

You are quite right that we, the authors of the policy statement, should have made explicit our commitment to requiring assent from any child old enough to give it. As for "Do No Harm," our commitment to that principle remains unchanged. Since we have good reason to believe that many girls are now sent back to their home countries for truly terrible and life-threatening genital cutting, it is our belief that a limited experiment offering the compromise of a "nick" might result in a dramatic reduction of harm.

Conflict of Interest:

None declared

We, the international members of Doctors Opposing Circumcision, were horrified to read that the American Academy of Pediatrics has proposed advocating genital ‘nicks’ to girls, using the disingenuous excuse that pediatricians would thus be protecting the child from FGM. This is political correctness taken past logic deep into human rights abuse, aside from being self-serving, as well as patently illegal under current US law.

The task of the AAP is to protect children, not to act as cultural apologist or broker for primitive rites deserving of summary abandonment without regret. There is not the slightest evidence that counseling parents about the harmful effects of genital tampering would not be all the AAP needs to do.

A better use of the AAP’s time would be to lobby to make the current U.S. FGM law ‘extra territorial’, that is, applicable even to U.S. residents who fly their child to Mogadishu for a summer-vacation ‘circumcision.’ Return with a mutilated daughter; go to jail ---or be deported.

Word would get around fast, and ancient cultures in need of a little updating would be quick to fall in line. Indeed, there is lots of anthropological evidence that cultures can easily abandon FGM and survive. We demean them to assume they cannot be brought, swiftly, into a 21st century where eery child's genitalia is safe from tampering.

John V. Geisheker, J.D., LL.M. Executive Director, General Counsel, Doctors Opposing Circumcision DoctorsOpposingCircumcision.org Seattle, Washington USA

Conflict of Interest:

The author is the Executive Director of the charity, Doctors Opposing Circumcision. whose members advocate genital integrity for all children, everywhere.

As a second year Biology student hoping to go to medical school one of the first things I learned was that everyone in the medical profession must adhere to the maxim Primum non nocere, "first, do no harm." I find it ironic then that under these guidelines one of the "first" things done to a helpless young girl would be to “harm” her for no real medical benefit. The risk of infection from even the slightest “prick” is in no way worth the possible benefits proffered from the use of this barbaric procedure. Further without consent from the young patient, what right gives any medical professional worth the name permission to forcibly pierce a child’s genitals in this or any civilized nation? Most disturbingly however this recommendation supports the practice of mild female genital mutilation without placing an age limit on its use. While the report seems to imply that “nicks” to the clitoris would only be performed on infants it is not expressed outright. The thought of a young woman or girl in this nation being held down against her will while an older (possibly male) doctor pierces her genitals is absolutely horrifying. The United Nations, United States Federal Government, and the World Health Organization all seem to be perfectly clear on the point that the genital mutilation of children for any reason is wrong. The AAP needs to come into line with the laws of the civilized world on this issue, not distort them to harm young girls. I am not one to believe in absolutes but the solemn oath to do no harm is one of the few I can stand for without exception.

Conflict of Interest:

None declared

A longer version of this comment has been posted at bioethicsforum.org (The Hastings Center)

http://www.thehastingscenter.org/Bioethicsforum/Post.aspx? id=4641&blogid=140

Doctors need to get out of the infant 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).

Conflict of Interest:

None declared

We have reviewed the AAP’s latest policy statement on female genital cutting (FGC) and we are shocked to see such an ethically and medically incoherent document issue from your venerable organization. What truly is paradoxical is for the nation’s leading organization of doctors treating children to weaken its opposition to a practice proven to cause substantial, irreparable, lifelong harm to children.

Moreover, your proposed, seemingly innocent “ritual nick” almost certainly violates the Federal Prohibition of Female Genital Mutilation Act, whose criminal provisions became effective in March 1997.

We trust that lightening your opposition to female genital cutting is not being done to help set up a parallel move toward diluting your 1999 statement on male circumcision (MGC). Flawed as the latter statement was, it did acknowledge the lack of medical benefit to the procedure on males. It is imperative that both statements be maintained or strengthened.

The AAP has no business brokering cultural procedures, even those that may support future revenue streams for some of its members. In this time of reduced resources, more than ever, it is imperative that medical organizations such as the AAP focus on what matters most—promoting the safety of our children, and working to eradicate—not condone or justify—harmful, non-beneficial, unethical practices such as FGC and MGC.

J. Steven Svoboda Attorneys for the Rights of the Child

Conflict of Interest:

None declared

The National Organization of Circumcision Information Resource Centers (NOCIRC) joins Intact America, Equality Now, Forward, Attorneys for the Rights of the Child, and all organizations working to protect the genital integrity rights of infants and children in condemning the American Academy of Pediatrics' Policy Statement Ritual Cutting of Female Minors. This statement significantly weakens the AAP's previous commitment to the health and well-being of infants and children.

We call upon the AAP to retract the portion of their policy statement that endorses Type IV FGM as a "possible compromise to avoid greater harm." Genital "nicking" of female minors is harmful, traumatic, and painful to a child. No form of female genital cutting is without harm and none is acceptable!

Legitimizing female genital cutting by medicalizing a lesser form of the practice does not protect infants and children from harmful traditional practices, it condones them, breaching the rights of the child. Any cutting subjects infants and children to antibiotic resistant infections, whether in the hospital or in the community. Healthcare professionals are both responsible for and obligated to protecting the rights of the child. They must not undermine, condone, or profit from human rights violations.

Federal and state laws were passed to protect the female child. The new AAP policy statement suggests pediatricians practice an illegal and unconscionable act, leaving their membership open to litigation.

Why does the American Academy of Pediatrics, or any other medical organization, need a policy statement to counter the federal government's claim that female genital cutting is an unlawful act?

Personal preference, cultural conditioning, and religious affiliation do not override a child's right to his or her own body and to self- determination. Circumcision, genital mutilation, and genital cutting are harmful traditional practices...and we need to bring them to an end!

Conflict of Interest:

Executive Director of a non-profit educational organization protecting the genital integrity rights of male, female, and intersex infants and children.

My suggested TO-DO list for the AAP:

* The AAP must immediately retract this Policy Statement, and declare its basic content, presentation, and conclusion to be fundamentally misguided. It is interesting to note that the word "consent" appears nowhere in the Policy Statement (nor "coerced"!); nor does the discussion of the "ritual nick" nor of its possible legalization appear at all in its abstract. These two "errors" alone make the Policy Statement suspect.

* The AAP must immediately issue a statement that the AAP agrees with and urges compliance with World Health Organization practices, summarized at http://www.who.int/mediacentre/factsheets/fs241/en/ and that the AAP essentially defers to the WHO as having *vastly* greater experience with the issue of FGM.

* The AAP must draw its members' attention to serious legal risks in treating FGM as anything but child abuse in general terms, and specifically illegal on its own; and that cultural sensitivity cannot excuse ethical or legal complicity. The recent legal trend toward US courts being surprisingly sympathetic toward claims against doctors for having performed mere routine (in US) infant male circumcision is an obvious sign that mishandling a situation that in any way involves FGM will put the physician in extreme legal peril.

* The AAP must develop, and provide for its members, culturally appropriate ways to express that any degree of FGM is legally and morally impermissible under any circumstances. Traditional though it may have been, it is being abandoned rapidly across the world; the parents should be told this, since the parents should not want to have the shaming distinction of being among the last to cling to the practice of committing FGM on their girl. Countless Chinese families for nearly a millennium practiced foot-binding, for many of the same reasons that FGM is committed. The former practice has vanished without a trace, and the second must join it immediately. Parents have a basic instinct to not vivisect their child, and I think that a "no buts" appeal to that can be both culturally appropriate, and a cultural universal.

* And finally, the AAP must immediately dismiss all the current members of the Committee on Bioethics. The members of the committee that produced this Policy Statement obviously can't be trusted to produce a Policy Statement on the bioethics of swatting a mosquito.

Conflict of Interest:

None declared

Statement on “Policy Statement Ritual Genital Cutting of Female Minors,” Committee on Bioethics, American Academy of Pediatrics, published April 26, 2010.

by Gerry Mackie, Associate Professor of Political Science, University of California at San Diego, May 8, 2010. http://www.polisci.ucsd.edu/~gmackie/

I am an academic who, since 1996, has studied, published, and advised international agencies on female genital cutting (FGC) and its abandonment. I have written on the sociology of the practice, the morality of its continuation or abandonment, and policies helping to organize its end. See the FGC tab on my webpage, URL above.

The AAP Policy Statement is wholly premised on assumptions about the sociology of the practice, but cites none of the central literature on that subject: Gerry Mackie, “Ending Footbinding and Infibulation: A Convention Account, American Sociological Review 61:999-1017 (1996); Ellen Gruenbaum, The Female Circumcision Controversy: An Anthropological Perspective (University of Pennsylvania Press, 2000); Bettina Shell-Duncan and Ylva Hernlund, eds., Female “Circumcision” in Africa (Lynne Rienner, 2000); Rogaia Mustafa Abusharaf, ed., Female Circumcision (University of Pennsylvania Press, 2006); Hernlund and Shell-Duncan, eds., Transcultural Bodies (Rutgers University Press, 2007). It does not cite the most authoritative international-organization documents on the practice: Changing a Harmful Social Convention: Female Genital Mutilation/Cutting (UNICEF, Innocenti Digest, 2005); the “Platform for Action: Towards the Abandonment of Female Genital Mutilation/Cutting (FGM/C),” by the Donors Working Group (9 country development agencies, 11 UN agencies, and others). It even fails to cite the most important article on harm reduction and FGC: Shell-Duncan, “The Medicalization of Female 'Circumcision': Harm Reduction or Promotion of a Dangerous Practice?“, Social Science and Medicine 52:1013-1028 (2001). These references are easily discoverable by elementary search methods.

Misunderstanding of the sociology of the practice begins in the title of the policy statement: “ritual genital cutting.” Why do people do FGC? Because it is a “ritual”? That begs the question as to its causation, and moreover is assumed with no supporting theory or evidence of any kind. Do Americans get orthodontia for their children because they are compelled to do so by ritual? Why is that when Africans do something it is a ritual, but when Americans do something it is for reasons?

This faulty premise is the basis of the policy recommendation. What is the evidence that “substituting ritual ‘nicks’ for more severe forms” would ameliorate or end the practice?

The recommendation claims that a WHO document supports the premise (footnote 2). The URL provided for the document redirects to a list of 18 separate documents. A google search for the exact title of the cited document yields only links back to the AAP Policy Statement. I could not verify the citation. Among the documents posted by WHO is an interpretation of the Helsinki declaration, under the bolded headline “Health care providers should not perform FGM”: “Its performance by medical personnel may wrongly legitimize the practice as medically sound or beneficial for girls and women’s health. It can also further institutionalize the procedure as medical personnel often hold power, authority, and respect in society.” http://www.who.int/reproductivehealth/topics/fgm/helsinki_declaration.pdf An additional concern is that harm reduction for this generation may perpetuate the practice through future generations and thus result in greater overall harm compared to strategies aimed at organizing complete abandonment of the practice in the present. Substitution of a milder cutting is a controversial topic in the international policy discussions I have attended, and is almost never advocated.

What is the remaining evidence for the premise? No randomized prospective study, no clinical study, no ethnography, remarkably, no study of any kind by anyone. The whole of the evidence supporting the recommendation is a few sentences of reporter’s interview with two Somali immigrants published 13 years ago in a Seattle newspaper (footnote 33), and the opinions of “some physicians” (unreferenced) who “emphasize the significance of a ceremonial ritual in the initiation of the girl or adolescent…and advocate only pricking or incising the clitoral skin as sufficient to satisfy cultural requirements.” If those are the same physicians who proposed the nick for Seattle Somalis 13 years ago, note that the normal age of cutting among Somalis is around 5 to 8. Are they adolescents? No. What groups in the world “initiate” 6-year old girls? None. Do Somalis perform ceremonial ritual upon cutting? No. Thus, the proposed mechanism of harm reduction is implausible on its face.

In principle, I could support controversial harm-reduction strategies in public health. Any such strategy should be based on well-informed theory, and ultimately on the accumulation of supporting evidence. The Policy Statement fails on both counts, and should be retracted.

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Conflict of Interest:

None declared

To the Author of the "article" from the Department of Bioethics of the AAP regarding your recently posted stance on Female Genital Mutilation, or as you so simply put it, "cutting"

While I've read your stated position several times (each more bewildered than the last), I fail to see more than a political cowering on policy concernnig a human travesty on such an unacceptable global scale, I sometimes am amazed that so many people are unaware of the entire scope of the problem. In fact, it seems you are trying to appease everyone by minimizing and trivializnig such a traumatic and unneccesary procedure in such a way to appear cilnically detached. I would think it was easy to sit behind a desk and type out such a prefunctory, muffled description of something at it's best is a violation of human rights, and at it's worst is a horror that rivals a slaughterhouse, with vast phycical, emotional and mental trauma that leaves a shell of the person in it's wake.

I've talked to many of these women, I've heard their stories, I've listened to them and felt their pain, some of them are good friends of mine, and your "window dressed" article is a collective slap in their faces. I've heard the screams, seen the crying faces, felt the emptiness and the pain inside them even YEARS later because the families that are supposed to care and protect them submit them to this. If you can turn a blind eye to the after effects and to the wishes of the children who have their own human right to remain intact, then you have a conscience with low standards

As physicians and surgeons and members of the respected medical profession, you are meant to hold most dear the oath you took. The Hippocratic Oath may not be important to your average layperson, but I was previously led to understand that "above all, do no harm" was sacred among your profession. Perhaps in the future, it should be "do no harm unless the price is high enough"? After all, what are "bioethics", if backed up by an oath that has come to mean nothing, to men and women willing to ignore it at will, by people who seek to medicalize a tradition and cultural travesty for the sake of lining their pockets with extra money?

More than 130 million women in the world have been butchered in this way. How many more per day will be by your practically "green lighting" this with your position?

I call on the AAP to do the right thing and reverse this position. DO NO HARM

Conflict of Interest:

Common Sense vs. Barbarity

To the Esteemed Members of the Bioethics Committee:

Have you all gone nuts? Just a little female circumcision?!?! There's no reason to do this procedure and to condone any form of it is not acceptable. To simply state that without our participation the parents will likely seek a more "severe & dangerous" procedure is not enough of a reason to get caught up on that slippery slope of cross- cultural gobbledy-gook.

The paper states that the little nick "is no more of an alteration than ear piercing". Yeah, right. When the authors offer up their genitals for piercing, I'll believe them.

Further on, the policy statment indicates that acceptance of the "ritual nick" may build trust between hospitals and immigrant communities. I can think of some other ways of doing this without cutting genitals. To offer up some baby's clitoral hood because you want a hospital to strengthen a relationship with a community is child abuse; for what, market-share?

It's odd to me that the writers chose a compromise, when in their own article they cite the Scandinavian experience (ie the outlawing of the practice lead to abandonment of the practice by the Somali immigrant community).

There can be no wavering or compromise. A little "nick" is like a little domestic violence; the procedure is an absolute wrong with no redeeming value to the child. The child gains no health benefits & learns nothing from the procedure.

Certain behaviors are universal wrongs and despite the good intentions of those arguing in favor of a little "nick" we cannot condone this practice in any way, shape or form if we are to present ourselves as professionals dedicated to protecting children's well-being.

Dr. Benjamin Aubey

Conflict of Interest:

None declared

The following letter was sent by mail and included a previous letter, which I can supply if needed.

Dear Sirs and Mesdames:

You should have recently received my letter dated February 9, 2010, cc'd to you that I sent to the Circumcision Task Force in regard to the pending statement on infant circumcision. (enclosed) I have read your recent Policy Statement on the Ritual Genital Cutting of Female Minors and feel the need to write again.

It is no secret that this country views the amputation or cutting of infant and child genitals in two very different ways depending on whether the infant or child is male or female. It is quite unfortunate that this manifests in a difference in the way we protect the rights of children legally, and socially. I fully expect a “medical ethics committee” such as yours to ignore common acceptance of cultural habit, and encourage the highest form of ethics when it comes to the conduct of medical professionals and the services they provide. You have failed us all in this respect.

It appears for several reasons that rather than commenting on the boundaries of medical ethics, you have appointed yourselves guides for cultural practices, and are attempting to influence the growing debate over equal rights because of personal bias, or financial interest.

First, there is no reason for you to use softer language (“cutting” vs. “mutilation”) in general with the pediatricians in this country. You could have simply recommended this change in language be used by the small percentage of physicians who have actual dealings with families who are seeking FGM, rather than trying to soften everyone’s perception of this practice.

Next, you fail to mention in your description of motivations for FGM ANY belief of medical benefit. It’s interesting that even though you are addressing medical professionals that you should fail to mention this common relevant motivation. People who practice FGM are just as convinced that it is medically beneficial as those are who practice MGM (Male Genital Mutilation), as any FGM abolitionist can tell you. Physicians ought to be prepared to respond to this argument if they are truly expected by you to dissuade families from the practice. Omitting this motivation conveniently avoids recognition of the obvious similarity of attempted medical justification of MGM.

While you do mention that physicians may need to address our country’s double standard, I notice that you do not have an actual justification to offer.

The most grievous diversion from your capacity as “medical ethicists” is the arguments made in favor of physicians carrying out a cultural ritual that not only serves no medical purpose, but is a painful breach of human rights, and our law.

Whether or not such involvement of a pediatrician in this ritual would dissuade other mutilations of that child, or others by influence, is simply conjecture, and is quite debatable. The one thing it is guaranteed to do, however, is legitimize the practice.

The only proper response to any request for the genital mutilation or simple cutting of a child’s genitals is one already made by the Committee on Bioethics of 93-94 in the policy on Informed Consent. No doubt this statement was made without the hindrance of taking our own familiarity with genital mutilation into consideration.

"…providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. … the pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent."

Further, your re-classifying of some forms of FGM as non harmful based on our cultural acceptance of a more harmful practice is a failure of logic and is an inappropriate manipulation of perspective. “Harm” is an opinion that can only be decided by the individual, and it is NOT your place to decide that a painful, non-medically indicated cut is not harmful, especially when performed upon a non-assenting patient. No other such cutting is acceptable for a physician.

I expected you to heed my warnings before about the discrepancies between the genital autonomy rights of men and women, but not by attempting to legitimize the abuse of female infants or children! We are reaching a point where these discrepancies are becoming obvious and publicized. As medical ethicists that speak to a changing nation, I suggest you take a lesson from the Bioethics Committee of 93-94 and keep your political agenda, personal preference for altered genitals, or the potential income from those unnecessary procedures out of your evaluations. It would also be a shame to see you change the policy quoted above to corroborate those inappropriate motivations, as you have with the recent FGM policy.

Finally, if there are any who want to remove their name from this policy, or who want to publicly speak against it, please know that you have a lot of support.

Sincerelly hoping you will do the right thing,

Enclosure cc with enclosure: AAP Board of Directors Executive Committee AAP Bioethics Committee of 93-94 William J. Clinton Foundation To be placed in video form at www.youtube.com/user/whatUneverknew

Conflict of Interest:

I'm not sure what qualifies, but I am an activist opposed to forced genital cutting.

This new policy represents an extraordinary weakening of the Academy's former stance that female genital cutting was unacceptable.

The new policy fails to uphold the child's right to autonomy: that every child has a right to make their own decision on whether or not normal tissue should be removed before they are old enough to give or withhold consent in their own right.

The policy flies in the face of the face of the Academy's existing policies on Health Equity and Children's Rights[1]and Informed consent, parental permission, and assent in pediatric practice.[2] It also advocates contravention of US Statute Law.[3]

The Academy is failing children. All children whether female, intersex or male have a right to be protected from genital surgery until they are old enough to choose for themselves.

1. http://pediatrics.aappublications.org/cgi/content/full/125/4/838, accessed 3 May 2010.

2. http://pediatrics.aappublications.org/cgi/reprint/95/2/314, accessed 3 May 2010.

3. http://law.onecle.com/uscode/18/116.html, accessed 3 May 2010.

Conflict of Interest:

Trustee of a charity promoting genital autonomy