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  Published on: 10 January 2018
• Proposed FGM 'compromise' illuminates medical complicity with non-therapeutic fee-paying surgery on infants
  Susan Bewley
  Published on: 18 May 2017
• Proposed FGM 'compromise' illuminates medical complicity with non-therapeutic fee-paying surgery on infants.
  Susan Bewley
  Published on: 18 May 2017

• Published on: 10 January 2018

  compromise

  • / /, n/a n/a

  Indeed FGA type 1 and 2 would not rob me and so many like me who want to follow our religious rights and adhere to harmless procedures as well which are surely less invasive than male circumcision. Its would not make me feel harrassed by western oppression of allowing the afflent consenting woman undertake the same procedure while condemning me of mine. Since FGA type 1 n 2 are harmless they are on the rise as cosmetic surgeries, so why should my choice of doing it for religious purpose become harmful to be banned. Yes severe forms shouldn't be allowed but surely type 1 or 2 as alternatives can reduce severe forms from happening. Medicalization and strict protocols can be framed to ensure safety from FGA type 1 n 2 procedures as well.

  Conflict of Interest:
  None declared.

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• Published on: 18 May 2017

  Proposed FGM 'compromise' illuminates medical complicity with non-therapeutic fee-paying surgery on infants

  • Susan Bewley, Profesor of Women's Health
  • Other Contributors:
    • London

  The JME's peer reviewers failed to press the clinical issues before publication of this flawed paper(1). The unoriginal idea of a 'ritual nick' performed by health professionals in a harm limitation approach to female genital mutilation (FGM) was proposed by the American Academy of Pediatrics back in 2010(2), who rapidly replaced their statement(3) in the face of worldwide condemnation(4) by the World Health Organisation...

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  The JME's peer reviewers failed to press the clinical issues before publication of this flawed paper(1). The unoriginal idea of a 'ritual nick' performed by health professionals in a harm limitation approach to female genital mutilation (FGM) was proposed by the American Academy of Pediatrics back in 2010(2), who rapidly replaced their statement(3) in the face of worldwide condemnation(4) by the World Health Organisation, and the UK Royal Colleges of Obstetricians and Gynaecologists and Paediatrics and Child Health, amongst others.(5)

  Many mistakes slipped through: (i) the authors say the prevalence of FGM is stable, but provide figures showing it falling; (ii) they claim to medically recategorise all procedures (amateur, accidental or surgical) - matters beyond the scope of ethicists to judge; (iii) they state the impacts of surgery on male and female genitals can be assumed to be similar - they cannot; (iv) likewise, comparisons with adult surgery (including cosmetic female genital surgery) are not relevant to children; (v) there is no such thing as a "nick that heals completely" without leaving scar tissue; (vi) indeed, they later admit that "de minimus" procedures will involve "tissue being removed", the amount being difficult to regulate; (vii) controversially, they describe asymptomatic healthy children as "patients" thus generating an overweaning sense that doctors owe a duty of care regarding social matters; (viii) despite arguing for autonomy they did not suggest leaving parents with responsibility for performing the 'nick'; (ix) far from seriously considering the utilitarian calculus, they have no insight into the damage their proposal has on trust in the medical profession; (x) the concept of 'harm limitation' need not be applied(6) to justify changing the present global consensus, especially without evidence of rising harm in countries where FGM is illegal; (xi) they neglect entirely physicians' conflicted pecuniary interest when surgically altering healthy children's genitals, even if by request of loving parents for socio-cultural benefits; (xii) revealingly, they use a self-referential test for acceptability based on one gynaecologist's previous defence of male circumcision(7).

  Surgeons should respect the basic ethical principles of 'first of all, do no harm' and informed consent to irreversible surgery on the basis of medical necessity, particularly when performed on children. In the USA (but less so in Europe), there may presently remain a 'liberal' tolerance of male circumcision whose protection appears to be the article's real purpose. The weak arguments presented might lead to the opposite conclusion: far from condoning renamed non-therapeutic procedures (no doubt performed for a fee on defenceless girls), why not turn the spotlight onto medically sanctioned traditional 'ritual' practices on male infants?

  References (1) Arora KS, Jacobs AJ. J Med Ethics Published Online First: 22nd February 2016 doi:10.1136/ medethics-2014-102375 (2) American Academy of Pediatrics. Ritual genital cutting of female minors. Pediatrics 2010; 125: 1088-93. (3) American Academy of Pediatrics. Policy statement: ritual genital cutting of female minors. Pediatrics 2010; 126: 191. (4) MacReady N. AAP retracts statement on controversial practice. Lancet 2010; 376: 15. (5) Joint RCOG/RCPCH statement on the AAP policy statement on FGM. 12 May 2010

  https://www.rcog.org.uk/en/news/joint-rcogrcpch-statement-on-the-aap- policy-statement-on-fgm/ (6) Pearce AJ, Bewley S. Medicalization of female genital mutilation. Harm reduction or unethical? Obstet Gynaecol Reprod Med 2014;24(1):29-30 (7) Jacobs AJ. The ethics of circumcision of male infants. Isr Med Assoc J. 2013;15:60-5.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

  • Back to top
• Published on: 18 May 2017

  Proposed FGM 'compromise' illuminates medical complicity with non-therapeutic fee-paying surgery on infants.

  • Susan Bewley, Professor of Complex Obstetrics

  The JME's peer reviewers failed to press the clinical issues before publication of this flawed paper(1). The unoriginal idea of a 'ritual nick' performed by health professionals in a harm limitation approach to female genital mutilation (FGM) was proposed by the American Academy of Pediatrics back in 2010(2), who rapidly replaced their statement(3) in the face of worldwide condemnation(4) by the World Health Organisation...

  Show More

  The JME's peer reviewers failed to press the clinical issues before publication of this flawed paper(1). The unoriginal idea of a 'ritual nick' performed by health professionals in a harm limitation approach to female genital mutilation (FGM) was proposed by the American Academy of Pediatrics back in 2010(2), who rapidly replaced their statement(3) in the face of worldwide condemnation(4) by the World Health Organisation, and the UK Royal Colleges of Obstetricians and Gynaecologists and Paediatrics and Child Health, amongst others.(5)

  Many mistakes slipped through: (i) the authors say the prevalence of FGM is stable, but provide figures showing it falling; (ii) they claim to medically recategorise all procedures (amateur, accidental or surgical) - matters beyond the scope of ethicists to judge; (iii) they state the impacts of surgery on male and female genitals can be assumed to be similar - they cannot; (iv) likewise, comparisons with adult surgery (including cosmetic female genital surgery) are not relevant to children; (v) there is no such thing as a "nick that heals completely" without leaving scar tissue; (vi) indeed, they later admit that "de minimus" procedures will involve "tissue being removed", the amount being difficult to regulate; (vii) controversially, they describe asymptomatic healthy children as "patients" thus generating an overweaning sense that doctors owe a duty of care regarding social matters; (viii) despite arguing for autonomy they did not suggest leaving parents with responsibility for performing the 'nick'; (ix) far from seriously considering the utilitarian calculus, they have no insight into the damage their proposal has on trust in the medical profession; (x) the concept of 'harm limitation' need not be applied(6) to justify changing the present global consensus, especially without evidence of rising harm in countries where FGM is illegal; (xi) they neglect entirely physicians' conflicted pecuniary interest when surgically altering healthy children's genitals, even if by request of loving parents for socio-cultural benefits; (xii) revealingly, they use a self-referential test for acceptability based on one gynaecologist's previous defence of male circumcision(7).

  Surgeons should respect the basic ethical principles of 'first of all, do no harm' and informed consent to irreversible surgery on the basis of medical necessity, particularly when performed on children. In the USA (but less so in Europe), there may presently remain a 'liberal' tolerance of male circumcision whose protection appears to be the article's real purpose. The weak arguments presented might lead to the opposite conclusion: far from condoning renamed non-therapeutic procedures (no doubt performed for a fee on defenceless girls), why not turn the spotlight onto medically sanctioned traditional 'ritual' practices on male infants?

  References (1) Arora KS, Jacobs AJ. J Med Ethics Published Online First: 22nd February 2016 doi:10.1136/ medethics-2014-102375 (2) American Academy of Pediatrics. Ritual genital cutting of female minors. Pediatrics 2010; 125: 1088-93. (3) American Academy of Pediatrics. Policy statement: ritual genital cutting of female minors. Pediatrics 2010; 126: 191. (4) MacReady N. AAP retracts statement on controversial practice. Lancet 2010; 376: 15. (5) Joint RCOG/RCPCH statement on the AAP policy statement on FGM. 12 May 2010

  https://www.rcog.org.uk/en/news/joint-rcogrcpch-statement-on-the-aap- policy-statement-on-fgm/

  Conflict of Interest:

  I was involved in setting up an FGM clinic 1996, have publications on FGM, and received a fee for expert advice in the UK's first FGM trial 2014.

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  Conflict of Interest:
  None declared.

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