Under Debate: Female Circumcision

The American Academy of Pediatrics (AAP) was in a tough spot. In late April, its bioethics committee released a revised version of a 12-year-old policy on the ceremonial cutting of a girl’s genitals performed in some African and Asian cultures. The committee included two controversial paragraphs discussing the possibility of allowing American doctors to perform “ritual nicks” on young immigrant girls, in hopes that the parents wouldn’t pursue more damaging and disfiguring procedures for their daughters. But anti-cutting activists weren’t open to discussion. They denounced the new policy, accusing the AAP of endorsing female circumcision. Within a month, the stunned and embarrassed AAP retracted the policy.

Amidst the flood of criticism, a long-standing debate has resurfaced: How does a society put an end to a practice that’s sometimes desired but too often brutal?

“What you really have is a disagreement about tactics,” said Dr. Douglas Diekema, a bioethics professor at the University of Washington in Seattle and a physician at Seattle Children’s Hospital, who chaired the AAP’s bioethics committee. “It’s very naïve to think that if you suddenly say [female circumcision] is wrong, people will stop doing it.”

The World Health Organization (WHO) estimates that between 100 and 140 million women and girls worldwide have been circumcised, often as a coming-of-age tradition or a misguided attempt to preserve virginity. The procedure takes different forms among different cultural groups. Some girls are merely pricked. For others, their entire clitoris is removed or their labia cut. In the most extreme forms, all of a girl’s external genitalia is carved away — sometimes with a razor blade or a broken shard of glass — and her vulva stitched shut. The pain and trauma that follow a circumcision have motivated some advocacy groups, such as Equality Now and Intact America, to organize campaigns against it. But the custom, despite grassroots education and national legislation, hasn’t died out.

In 1996, the United States government passed a law making it illegal to perform circumcision on a girl. Fourteen years later, an estimated 228,000 women and girls living in the United States are at risk for circumcision — up from 168,000 in 1990 — according to a study, based on 2000 census data, by the African Women’s Health Center in Boston, Mass.

When the AAP’s bioethics committee convened in 2005 to redraft its original 1998 policy on female circumcision, it did not intend to incite controversy. In fact, its members wanted to correct the language of the document, which referred to female circumcision as “female genital mutilation,” or FGM, a term they saw as inflammatory and culturally insensitive.

“We felt that [FGM] really was a term that stopped dialogue and education rather than promoted it,” said Dena Davis, a legal consultant to the AAP committee and a professor of law and bioethics at Cleveland State University. “If you go to Somalia or Sudan, almost 100 percent of the [female] population has had the procedure, and they don’t think of themselves as mutilated. If you ask them, ‘Gee, how do you feel about being mutilated?’, it’s not the best way to get a conversation started.”

The committee settled on calling the procedure “female genital cutting,” or FGC, and in the process of revising, rewording and rethinking its policy, it considered an approach for minimizing harm first proposed by doctors at Harborview Medical Center in Seattle. In the mid-1990s, some of them were attending pregnant women from Seattle’s Somali community. “If your baby is a boy, do you want him circumcised?” they would ask. Some of Somali mothers-to-be would reply, “Yes, and also if it’s a girl.”

The Harborview doctors proposed that the hospital offer these mothers a “clitoral nick” for their daugthers — a needle prick, really — in the small hood of tissue that covers the clitoris. “We’re talking about something far less extensive than the removal of foreskin in a male,” a common procedure in the United States, said Dr. Diekema. Such a compromise, the doctors argued, would discourage parents from sending their girls back to their native countries for unregulated and unsanitary procedures.

“They weren’t trying to propagate FGC,” said Dr. Diekema, who had heard the stories of female circumcision requests from his colleagues at Harborview. “If this nick could prevent harm for a few girls, they wanted to have it in their back pocket as an option.” But when news of the proposal broke, anti-circumcision groups and stunned citizens swiftly put an end to the discussion.

When the AAP resurfaced the idea last month, the public reacted with similar outrage.

“It came as a shock to the many, many people who have been working for decades to end FGM here and around the world,” said Taina Bien-Aime, the director of Equality Now, an anti-FGC group based in New York City. “There is no discussion for a human rights violation. You can’t violate just a little less; you can’t discriminate just a little less,” she said. “FGM is FGM is FGM.”

Bien-Aime, like many anti-FGC advocates, argues that allowing even a mild form of circumcision supports the practice and makes it more difficult to eradicate. She pointed to WHO studies showing that parents unsatisfied with a circumcision will re-circumcise their daughters “over and over again until it’s ‘done properly.’” She added: “Would parents ask for a drop of blood or a teaspoon of blood?”

There is some evidence that medicalization can perpetuate the practice of female circumcision. In 1994, Egypt’s Ministry of Health permitted doctors to perform what it called an “inevitable practice.” In the year that followed, hospitals found that many educated, middle-class families, who otherwise avoided unsanitary surgeries, took up the practice because they now considered it safe.

On the other side, there is evidence that harm-reduction strategies akin to a medicalized “nick,” such as needle exchange, have reduced the spread of AIDS among heroin addicts.

But little has been done to study the communities in the United States that are affected by policies regarding female circumcision.

“I find it very curious that this discussion has come up from very old information and not in consultation with immigrant communities,” said Bettina Shell-Duncan, an anthropologist at the University of Washington. Many of her students come from the city’s Somali community. “They tell me nobody is talking about FGC in the community. It seems that demand for the practice is falling away. It just doesn’t hold the same meaning as it does in Somalia.”

On the day the AAP released its new, now retired, policy, Congressman Joseph Crowley of New York introduced a bill, known as the Girls Protection Act, that would criminalize sending girls overseas for circumcisions. Critics of the act argue that it would be difficult to enforce. “Would you have genital examinations of girls coming in on international flights? Who would you check? Just brown girls? It’s a recipe for racial profiling,” said Shell-Duncan.

Davis of Cleveland State University argues that a more experimental approach to dealing with FGC in the United States might be the better option. She suggests starting a trial program for offering ritual nicks in one state and comparing the results to other states over time. “It would be interesting and useful to look at it in a limited and controlled way and see what we find out,” she said.