Somalia has one of the highest rates of female genital mutilation.
Female genital mutilation (FGM) is a hot topic and a subject that insights anger, confusion and distress.
In many countries, the practice is extremely prevalent and shows little sign of slowing. In Egypt, for instance, between 2006-2011, the percentage of girls undergoing FGM only dropped from 77.8% to 71.6%.
In one study conducted in Somalia, 81% of subjects underwent infibulation (complete excision of the clitoris, labia minora, and most of the labia majora) and only 3% did not have any form of FGM.
A recent paper - written by Dr. Kavita Shah Arora, from the Department of Obstetrics and Gynaecology at the MetroHealth Medical Center, Cleveland, OH, and Allen J. Jacobs, from the Department of Obstetrics and Gynecology, Stony Brook University, NY - puts a new slant on the difficult topic.
The paper, published alongside a series of responses from other experts, is likely to spark impassioned discourse. The main thrust of Dr. Arora's argument is that banning the most minor of FGM procedures is:
"Culturally insensitive and supremacist and discriminatory towards women."
An estimated 200 million girls and women alive today have been subjected to some form of FGM. Many nations in the Middle East, Asia and Africa carry out the procedure as a matter of course.
FGM is, to a certain extent, routed in religion, but it also has cultural significance. The practice, many would argue, is anti-female and misogynistic.
The current state of affairs
In most Western countries, including the US and UK, FGM is banned in all of its forms, but this does not necessarily prevent individuals from countries where FGM is practiced from having their children altered.
Some families take their daughters back to their country of origin to carry out the procedure; others find someone in their local community who will undertake the procedure illegally. Either of these outcomes can be risky at best.
To combat this, Dr. Arora and her colleagues believe that more time and thought needs to be devoted to finding some middle ground.
They argue that some FGM procedures are little more than a nick in the vulvar skin and cause no long-term changes in the form or function of the genitalia.
The authors consider that by categorizing the procedures along a scale of severity and renaming them as "female genital alterations (FGAs)," some of the stigma might be dropped. The authors are careful to make it clear that they "are not arguing that any procedure on the female genitalia is desirable. [...] we only argue that certain procedures ought to be tolerated by liberal societies."
By legalizing only the least intrusive FGM procedures, they believe that some young girls might be saved from the most serious procedures that include clitoral removal and vaginal cauterization. These most disruptive interventions would be classed as "Category 5" and would remain outlawed. On the other hand, so-called "nick" procedures, classed as "Category 1," would become permissible.
According to the authors, Category 1 FGM would be no more invasive - in fact, slightly less invasive - than circumcision, which is widespread in the US. The medical benefits of circumcision are tenuous, and the authors consider that the practice, in many cases, is a religious, cultural intervention with parallels to Category 1 FGM.
Both practices are carried out without the consent of the minor at the sharp end of the scalpel.
'Not all cultural symbols deserve respect'
Dr. Arora's paper is accompanied by a number of commentaries on the topic that argue against many of the points that she makes.
The circumcision argument is rebuffed by Ruth Macklin, of the Albert Einstein College of Medicine, NY, in her commentary entitled "Not all cultural symbols deserve respect." She argues that symbolically, FGM is about subjugation. In its worst form, it seeks to prevent women from having intercourse or, at the very least, prevent them from deriving pleasure from it.
Additionally, in many cultures, FGM is necessary to make your daughter marriageable. Macklin says:
"As a cultural rite, it signifies a means of making girls and women physically, aesthetically or socially acceptable to men."
Macklin also wonders whether a genital nick would suffice for Somalians, whose culture permits and encourages the most extreme versions of FGM. If a father has his sights on a culturally necessary Category 5 operation, Macklin asks whether he would settle for a Category 1 nick.
If Category 1 truly leaves no mark in later life, would this be sufficient to make his daughter marriageable in his eyes?
'In defence of genital autonomy for children'
In another commentary on the controversial subject, entitled "In defence of genital autonomy for children," Brian D. Earp, of The Hastings Center Bioethics Research Institute, NY, makes his stance clear early on in the text:
"Ultimately, I suggest that children of whatever sex or gender should be free from having healthy parts of their most intimate sexual organs either damaged or removed before they can understand what is at stake in such an intervention and agree to it themselves."
Earp goes on to explain the legal issues that would surround making Category 1 FGM permissible. He states "cutting into a child's genitals without a medical diagnosis, and without its informed consent, meets the formal definition of criminal assault under the legal codes of most of these societies."
He also raises concerns about regulating the procedures; he worries that it might "open the door" for more invasive procedures. Earp's commentary goes on to discuss medical, sexual, cultural and political issues that would go hand in hand with weakening laws surrounding FGM.
Cutting slack and cutting corners
Arianne Shahvisi, of the Department of Ethics, Brighton & Sussex Medical School, UK, also submitted a commentary regarding a legislative easing around FGM. Her paper is entitled "Cutting slack and cutting corners: an ethical and pragmatic response to Dr. Arora and Jacobs' "Female genital alteration: a compromise solution."
She also argues that Category 1 FGM would not be adequate to bring about the desired effect.
Shahvisi explains that "in Somalia, FGA ensures religious adherence; in Nigeria, the clitoris is believed to pose a threat in childbirth. Satisfying these reasons often requires complete clitoral excision or infibulation. Since obtaining these changes is the very reason for performing the practice, Dr. Arora and Jacobs' suggested replacement procedure would miss the mark."
For the majority of people in the West, there is no level of FGM that should be deemed acceptable. However, opening debates on this issue, whether accepted or rejected can still be a useful undertaking. Hiding from, avoiding or ignoring these topics would be the greatest mistake.
In 2014, Medical News Today wrote an article asking how society should address the issue of FGM.