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Response to WHO
  1. Kavita Shah Arora1,
  2. Allan Joel Jacobs2,3
  1. 1 Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland Heights, Ohio, USA
  2. 2 Department of Obstetrics and Gynecology, MetroHealth Medical Center, Brooklyn, New York, USA
  3. 3 Obstetrics and Gynecology, Flushing Hospital Medical Center, Flushing, New York, USA
  1. Correspondence to Dr Kavita Shah Arora, Department of Obstetrics and Gynecology, MetroHealth Medical Center, 1380 Slate Court, Cleveland Heights, Ohio 44118, USA; Kavita.Shah.Arora{at}

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We agree with the WHO and United Nations agencies that elimination of female genital alteration is a desirable goal in those communities where the practice is tied to discrimination and oppression of women.1 To the extent that any practice subjugates or endangers women, of course, its elimination is desirable. As practising physicians, we are appalled by mutilating procedures that kill and maim young women, that impair their ability to have a healthy sexual relationship, and that make childbirth dangerous. Where we disagree, respectfully, is in tactic. Indeed, in most circumstances, respect, collaboration and compromise are more effective in achieving change than censure and condemnation.2

Therefore, we advance a compromise approach rather than a confrontational stance. The supposition that these procedures would ‘normalize, legitimize and perpetuate’ female genital alteration is hypothetical. There is at least one example of a modified female genital alteration procedure serving as an intermediate step to its elimination (Latham S. The Campaign against Female Genital Cutting: Empowering Women or Reinforcing Global Inequity? Ethics and Social Welfare. (forthcoming)).

Furthermore, the absence of a medical justification does not automatically relegate female genital alteration to the category of a cultural practice that violates human rights. Infant girls are subject to the cultural practice of ear piercing in much of the developed and developing world without any known medical benefit. Similar to ear piercing or male circumcision, we would not require that the cultural practice be performed by medical personnel, as such de minimis procedures can be safely performed by trained non-medical personnel. Our point is not whether any form of female genital alteration falls within the appropriate scope of medical practice, and we are not advocating vulvar nicks. We only are asserting that it should be tolerated by a liberal society.

The issues of import, then, are twofold: risks to the child and the overall oppression of women. Under our classification system, we would allow only those procedures that do not pose a physical or psychological risk to the child—a distinction unable to be made by the current WHO categorisation system or nomenclature. Practices that subjugate women or are rooted in this intent should not be tolerated. However, a vulvar nick does not achieve the subjugation of women inherent in diminishing sexual pleasure or making sexual relations painful, nor does it guarantee virginity before marriage. Furthermore, in Iran, men played a large role in the reduction of harmful female genital alteration procedures (Latham S. forthcoming).

Therefore, we disagree with their characterisation of our position as ‘a call to perpetuate’ female genital alteration. Our compromise position is offered solely as a method to reduce harm and improve the health and well-being of women. We agree with Hippocrates that the goal of a physician should be ‘to cure sometimes, to relieve often, to comfort always’. These Hippocratic precepts suggest that concrete measures to prevent harm to actual people, rather than abstract goals set decades in advance, should motivate physicians and policymakers alike. There is little doubt that if every girl who would otherwise be subjected to infibulation next year received instead a vulvar nick, the substitution would be advantageous to their health.


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  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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