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UPDATE

The United Nations International Children's Emergency Fund (UNICEF) estimates that "between 100 million and 130 million women suffered female genital mutilation or cutting as children" and that another 2 million are at risk each year (UNICEF). It calls on all nations to honor their commitments to eliminate those practices by 2010. The World Health Organization (WHO), UNICEF, and United Nations Population Fund (UPFPA) (WHO, 1997) issued a joint statement advocating a zero-tolerance view, but it has not been endorsed universally (WHO, 2000). The worldwide scrutiny of ancient practices in which some or all of women's genitals are removed, usually during infancy or childhood, stems from several movements that began in the 1980s.

Ongoing Disputes about Zero Tolerance

In the 1980s a growing number of activists in countries where these rites are popular tried to stop these practices or at least substitute less mutilating rites (nicking the labia or the foreskin around the clitoris) for the more mutilating forms, which were and in some cases still are practiced widely, especially in Africa, and some Middle Eastern countries. Those rites include Type 1 (removal of the prepuce with or without removal of all or some of the clitoris), Type 2 (removal of the entire clitoris and all or most of the labia minora), and Type 3, or pharaonic circumcision (removal of all of the clitoris and labia minora and parts of the labia majora) as well as the practice of infibulation (the wound to the vulva from the cutting is stitched closely, leaving a tiny opening so that the woman can pass urine and menstrual flow). Also included among those rites are scraping or cutting tissue at the vaginal opening or the vagina and placing corrosive substances into the vagina to induce bleeding or narrow or tighten it (WHO, 2000).

Prominent African activists, including Olayinka Koso-Thomas (author of the main entry above), Nahid Toubia, and Raquiya Abdalla, have long advocated stopping all forms of genital mutilation and cutting while retaining the cultural and religious rituals that educate and welcome girls into adulthood and the community. They favor "circumcision through words" and family-planning education that includes telling young males about the health hazards to women and asking them to make a vow not to require circumcision as a condition of marriage. Those changes might accommodate important religious, cultural, economic, community, and family considerations without harming girls.

Others argue that a more effective approach to zero tolerance would be to replace the mutilating rituals with removal of the foreskin around the clitoris or tiny nicks in the labia (Davis; El Dareer). This, they argue, might "wean" people away from the more extreme forms of genital mutilation. If there are no complications, the tiny nicks do not preclude sexual orgasm later in life. The chance of success with this tactic is more promising and realistic, they hold, than would be the case with an outright ban; people could maintain many of their traditions and rituals of welcome without causing as much harm, especially if the operations were done by doctors and nurses under sterile conditions. However, Nahid Toubia objects, stating that removal of the clitoral hood invariably causes considerable, even if unintended, harm to the clitoris because tissue from the clitoris is very likely to be taken.

Dena Davis expresses the concern that something other than zero tolerance could send the wrong message to immigrants:

Because FGA [female genital alteration] in its most common forms around the world is mutilating and life threatening, it is reasonable to adopt a "zero tolerance" policy to make it absolutely clear to immigrants that this practice is never acceptable … further, an argument could be made that, once a "nick" is allowed, it would be difficult if not impossible for the state to make sure this did not become a loophole through which the worst elements of FGA would slide. As MGA [male genital alteration] is not anywhere close to as mutilating and threatening to life and health as are many forms of FGA, this argument would serve as a constitutionally valid distinction between the two practices. (p. 561)

In the end, however, Davis tries to justify a compromise for the sake of cultural sensitivity, legal consistency, and medical safety, arguing that procedures might be permitted that allow roughly the same harm done to girls as is done to boys in male circumcision: a minor nick in a girl's labia or clitoral hood.

Raquiya Abdalla, however, objects to equating female circumcision with male circumcision because their purposes differ and the degree of harm frequently is drastically different. For some people the best reason for drawing parallels between male and female genital cutting is to help abolish both practices. Even if the timetables do not coincide exactly, they hold, comparisons should not be used to allow some female circumcision in countries that permit male circumcision. Still others maintain that there are health benefits to male circumcision that justify distinguishing the two. Most agree, however, that it is unfortunate that the same word, circumcision, is used for the full range of practices, from trivial to mutilating. Removal of the clitoris is comparable to amputation of the penis rather than removal of the foreskin in men.

Findings about Morbidity and Mortality

In the 1980s some African clinician-activists from countries that practice those rites documented and brought to the world's attention the accompanying morbidity and mortality. Those pioneering medical studies include the ones conducted in the Sudan by Asma El Dareer (1982), in Sierra Leone by Olayinka Koso-Thomas (1987), and in Somalia by Raquiya Haji Dualeh Abdalla (1982). The death, infection, and disabilities associated with the rites are well established, challenging local beliefs that the rites promote health and well-being. For example, as Koso-Thomas (p. 10) pointed out, stable medical evidence discredits the belief that "death could result if, during delivery, the baby's head touches the clitoris, " and Abdalla (p.16) pointed to the disutility of regional practices of putting "salt into the vagina after childbirth … [because this] induces the narrowing of the vagina—to restore the vagina to its former shape and size and make intercourse more pleasurable for the husbands." Some of those studies suggest that many women would prefer not to perform the rites if they were not necessary for the marriage of their daughters and that more younger women are having second thoughts about this cultural practice for their own daughters (Moschovis).

Other epidemiological studies have confirmed the morbidity and mortality associated with those rites and have demonstrated that they are still widespread in some regions. For example, Daphne Williams Ntiri (1993) found that in some African countries most young girls between infancy and ten years of age have received Type 3 circumcision from traditional practitioners who often used sharpened or hot stones, razors, or knives, frequently without anesthesia or antibiotics. The WHO estimates that worldwide about 80 percent of the rites involve excision of the clitoris and labia minora and that infibulation is done in about 15 percent of all cases (WHO, 2000). In some regions, such as Egypt, Guinea, Somalia, Eritrea, and Mali, national surveys indicate that 94 to 99 percent of women are circumcised (WHO, 2000, 2001).

Oppression of Women

Beginning in the 1980s, despite insistence by people within the culture about their good intentions, voices worldwide condemned the rites as brutal forms of oppression of women comparable to making men eunuchs (removal of the testes or external genitals). International organizations denounced the practices, including UNICEF, the International Federation of Gynecologists and Obstetricians, and WHO, along with the American Medical Association and many women's groups. They deny that this is just a cultural issue, arguing that the rites should be opposed with the same vigor as other violations of human rights (Schroder; Toubia). Pressure from human rights groups, for example, forced some governments to ban all registered health professionals from performing female cutting or infibulation and helped women find political asylum in other countries to avoid genital cutting.

Some countries are more willing to pass laws prohibiting the rites than to enforce those laws. UNICEF (2003) is troubled by governments' lack of will to confront those practices, educate their communities about the risks, and enforce existing laws that prohibit them. UNICEF promotes challenges to the beliefs, attitudes, and customs that support these rites and discrimination against uncircumcised women. Even in the United States, the United Kingdom, France, Canada, and other countries where female circumcision is viewed as child abuse, it is practiced in "back rooms" (Davis). UNICEF praised the European Parliament's launching of an initiative called "Stop FGM" in December 2002. Whether or not the intent of the rites is to honor women, UNICEF and others regard them as "culturally sanctioned forms of women's oppression, male domination, and control of women's sexuality" (UNICEF, 2003).

Immigration

After 1980 waves of immigrants from North Africa and southern Arabia made the rites better known and widely condemned. Those immigrants came from regions where most women receive Type 2 and Type 3 forms of circumcision and moved to areas of the world where those rites are viewed as horrific and oppressive practices that put young girls at terrible risk of death and chronic disability. Consequently, families that seek female genital cutting in their adopted countries generally avoid the healthcare system, and the risks of nonmedical circumcision are assumed to be very high (Davis).

Cultural Sensitivity

The cultural clashes that have resulted from criticisms of female circumcision have centered on whether there is any justification for interfering with the deeply held practices of other cultures. Extreme ethical relativists state that there is no moral or epistemological basis for interfering with popular customs in other countries and that meddling constitutes cultural imperialism (Scheper-Hughes; Ginsberg; Shweder). This view, which once was popular among anthropologists and others, has been challenged on many sides (Kopelman, 1994, 1997).

First, shared goals and methods sometimes can be used to assess other cultures in a way that has moral and epistemological authority. For example, most people share the goal of seeking health for woman and infants and endorse similar methods of logic, science, and medical investigation. Medical research is respected in those communities and their own studies show that the rites cause pain, emotional trauma, infection, chronic disease, disability, and death. These shared goals and methods can be used to help reason with people about destructive cultural practices that involve not just female genital cutting but wars, pollution, and epidemics.

Second, criticism of these practices within those communities is growing (Moschovis), and as a result the depth of the commitment to the rites is changing. As the investigators who originally touched off the contemporary debate over female circumcision illustrate, cultures are not monolithic but contain passionate disagreements and may change rapidly. Moreover, most people do not live in only one culture but cross easily from one culture to another in their professions, religions, and ethnic groups. People who brought the practice of female genital cutting with them when they moved, for example, live in more than one culture. It no longer is possible to count or separate cultures sharply when world travel and communication are so easily available. Cultural, religious, professional, ethnic, and other groups overlap and have many variations within nation-states. To say that people belong to overlapping cultures or that people cannot distinguish precisely between or count cultures, however, undercuts extreme ethical relativism and its tenet that the only way to determine whether something is right is to see if it has cultural approval (Kopelman, 1994, 1997).

Third, cross-cultural criticism seems to be important and even obligatory when one considers cultures that engage in terrorism, war, torture, mass rape, infanticide, and slavery, and so people should be able to criticize female genital cutting on the same basis. Otherwise, people would be led to the very problematic view that any act is right if it has cultural approval even if it is a culturally endorsed act of war, oppression, enslavement, aggression, rape exploitation, racism, or torture. In this view the disapproval of other cultures is irrelevant in determining whether acts are right or wrong. Even if this version of ethical relativism is defended consistently, its plausibility is eroded by its conclusion that the disapproval of people in other cultures, even victims of war, oppression, enslavement, aggression, exploitation, rape, racism, or torture, is irrelevant in deciding what is wrong in the aggressor culture (Kopelman, 1994, 1997).

Consistency

Finally, scrutiny has revealed apparent contradictions in the beliefs and attitudes associated with the rites. For example, on the one hand people from those regions say that nothing is given up because women cannot enjoy sex, but on the other hand they say that the rites are needed to control women who mighty be sexually out of control without the surgeries (Kopelman, 1994, 1997). (This fear that girls will be sexually promiscuous is a frequently given reason for doing the surgery in the West, where girls and young women have considerable freedom compared with the situation in their original homelands.) Another apparent inconsistency concerns insistence that respect for cultural mores requires that deeply embedded cultural views about female genital cutting must be respected in the adopted countries even if this means violating the deeply embedded views of the dominant culture of the new land. It is inconsistent to insist that their deeply embedded views must be respected—but not those of other cultures. Finally, some say that there is no way to determine what is right when cultures disagree but also insist on transcultural universal normative principles such as "every culture counts for one, " "preserve ancient cultures, " and "when in Rome do as the Romans do."

Worldwide attention to female genital mutilation and cutting rituals since the 1980s has made those rites the center of controversy about practical and theoretical issues concerning human rights, ethical relativism, and the limits of tolerance of cultural diversity. Medical studies document the resultant morbidity, mortality, and disabilities and the resulting lack of sexual sensitivity and satisfaction for millions of women. Proposals by activists in those regions include stopping clinicians from participating in the rites and adopting and enforcing meaningful legislation, but many people believe that education about the harms of genital cutting and infibulation may be the most important way to stop the practices (El Dareer; Abdalla; Dirie and Lindmark; Toubia).

loretta m. kopelman

SEE ALSO: Anthropology and Bioethics; Body: Cultural andReligious Perspectives; Children: Rights of; Circumcision, Male; Circumcision, Religious Aspects of; Coercion; Feminism; Harm; Islam, Bioethics in; Judaism, Bioethics in; Medicine, Anthropology of; Sexual Behavior, Social Control of; Women, Historical and Cross-Cultural Perspectives

BIBLIOGRAPHY

Abdalla, Raquiya H. D. 1982. Sisters in Affliction: Circumcision and Infibulation of Women in Africa. London: Zed.

Davis, Dena. 2001. "Male and Female Genital Alteration." Health Matrix 11: 487–569.

Dirie, M. A., and Lindmark, G. 1992. "The Risk of Medical Complications after Female Circumcision." East African Medical Journal 69(9): 479–482.

El Dareer, Asma. 1982. Woman, Why Do You Weep? Circumcision and Its Consequences. London: Zed.

Ginsberg, Faye. 1991. "What Do Women Want? Feminist Anthropology Confronts Clitoridectomy." Medical Anthropology Quarterly 5(1): 17–19.

Kopelman, Loretta M. 1994. "Female Circumcision/Genital Mutilation and Ethical Relativism." Second Opinion 20(2): 55–71.

Kopelman, Loretta M. 1997. "Medicine's Challenge to Relativism: The Case of Female Genital Mutilation." In Philosophy of Medicine and Bioethics in Retrospect and Prospect: A Twenty-Year Retrospective and Critical Appraisal, ed. Ronald A. Carson and Chester R. Burns. Vol. 50 in the Philosophy of Medicine Series. Dordrecht, Netherlands, and Boston: Kluwer.

Koso-Thomas, Olayinka. 1987. The Circumcision of Women. London: Zed.

Moschovis, Peter P. 2002. "When Cultures Are Wrong." Journal of the American Medical Association 288(9): 1131–1132.

Ntiri, Daphne Williams. 1993. "Circumcision and Health among Rural Women of Southern Somalia as Part of a Family Life Survey." Health Care for Women International 14(3): 215–216.

Scheper-Hughes, Nancy. 1991. "Virgin Territory: The Male Discovery of the Clitoris." Medical Anthropology Quarterly 5(1): 25–28.

Schroeder, P. 1994. "Female Genital Mutilation—A Form of Child Abuse." New England Journal of Medicine 331: 739–740.

Shweder, Richard. 1990. "Ethical Relativism: Is There a Defensible Version?" Ethos 18: 205–218.

Toubia, Nahid. 1994. "Female Circumcision as a Public Health Issue." New England Journal of Medicine 331: 712–716.

INTERNET RESOURCES

United Nations International Children's Emergency Fund. 2003. "UNICEF Calls on Governments to Fulfill Pledge to End Female Genital Mutilation: International Day of Zero Tolerance of FGM Is Springboard for Action." UNICEF press release, February 18, regarding meeting in Addis Ababa and Nairobi, February 6, 2003. Available from <www.unicef.org/newsline/2003/03pr08fgm.htm>.

World Health Organization. 1997. "Genital Mutilation: A Joint WHO/UNICEF/UNFPA Statement." Geneva: World Health Organization. Available from <www.who.int/frh-whd/publications/p-fgm1.htm>.

World Health Organization. 2000. "Female Genital Mutilation." Fact Sheet No. 241. Available from <www.who.int./inffs/en/fact241.html>.

World Health Organization Estimated Prevalence Rates for FGM. 2001. Available from <www.who.int/frh-whd/FGM/FGM%20prev%20update.html>.

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