Through the help of a kind commenter on my Blog, I have been able to get a copy of the entire AAP Policy Statement on Ritual Genital Cutting of Female Minors. I have highlighted several sections of the Statement (in red) that I think are highly pertinent, and to my mind, suggest that the AAP might be setting the stage to creating a climate of acceptance of circumcision- both female and , of course, male. But you be the judge. I would also invite you to really look at the yellow highlighted areas that pertain to FGM.... sounds a lot like Male Genital Mutilation, doesn't it? Which begs the question that I asked in an article a while ago:
"What about our sons?"
Published online May 1, 2010
FROM THE AMERICAN ACADEMY OF PEDIATRICS
Policy Statement
Ritual Genital Cutting of Female Minors
Committee on Bioethics
The traditional custom of ritual cutting and alteration of the
genitalia of female infants, children, and adolescents, referred
to as female genital mutilation or female genital cutting (FGC),
persists primarily in Africa and among certain communities in
the Middle East and Asia. Immigrants in the United States from
areas in which FGC is common may have daughters who have undergone
a ritual genital procedure or may request that such a procedure
be performed by a physician. The American Academy of Pediatrics
believes that pediatricians and pediatric surgical specialists
should be aware that this practice has life-threatening health
risks for children and women.
The American Academy of Pediatrics opposes all types of female genital cutting that pose risks of physical or psychological harm, counsels its members not
to perform such procedures, recommends that its members actively
seek to dissuade families from carrying out harmful forms of
FGC, and urges its members to provide patients and their parents
with compassionate education about the harms of FGC while remaining
sensitive to the cultural and religious reasons that motivate
parents to seek this procedure for their daughters.
Key Words: female genital mutilation • FGM • female genital cutting • FGC
Abbreviations: FGC = female genital cutting
 | INTRODUCTION |
|---|
Ritual cutting and alteration of the genitalia of female infants,
children, adolescents, and adults has been a tradition since
antiquity. Female genital cutting (FGC) is most often performed
between the ages of 4 and 10 years, although in some communities
it may be practiced on infants or postponed until just before
marriage.
1 Typically, a local village practitioner, lay person,
or midwife is engaged for a fee to perform the procedure, which
is done without anesthesia and by using a variety of instruments
such as knives, razor blades, broken glass, or scissors. In
developed countries, physicians may be sought to perform FGC
under sterile conditions with the use of anesthesia.
The ritual and practice of FGC persists today primarily in Africa,
the Middle East, and small communities in Asia.
2 Immigrants
from these countries have brought the practice with them to
Europe and North America, but no data are available for the
prevalence of this practice in the West.
3
The language to describe this spectrum of procedures is controversial. Some commentators prefer "female circumcision," but others object that this term trivializes the procedure, falsely confers on it the respectability afforded to male circumcision in the West, or implies a medical context.
4 The commonly used "female genital
mutilation" is also problematic.
Some forms of FGC are less extensive than the newborn male circumcision commonly performed in the West. In addition, "mutilation" is an inflammatory term
that tends to foreclose communication and that fails to respect
the experience of the many women who have had their genitals
altered and who do not perceive themselves as "mutilated."
5 It is paradoxical to recommend "culturally sensitive counseling"
while using culturally insensitive language. "Female genital
cutting" is a neutral, descriptive term.
4
It is estimated that at least 100 million women have undergone
FGC and that between 4 and 5 million procedures are performed
annually on female infants and children, with the most severe
types performed in Somalian and Sudanese populations.
6,7 Pediatricians,
therefore, may encounter patients who have undergone these procedures,
and pediatric surgeons and pediatric urologists may be asked
by patients or their parents to perform a ritual genital operation.
During the past 2 decades, several international and national
humanitarian and medical organizations have drawn worldwide
attention to the physical harms associated with FGC. The World
Health Organization and the International Federation of Gynecology
and Obstetrics have opposed FGC as a medically unnecessary practice
with serious, potentially life-threatening complications.
8,9 The American College of Obstetricians and Gynecologists and
the College of Physicians and Surgeons of Ontario, Canada, also
opposed FGC and advised their members not to perform these procedures.
10,11 In 2006, the Council on Scientific Affairs of the American
Medical Association reaffirmed its recommendation that all physicians
in the United States strongly denounce all medically unnecessary
procedures to alter female genitalia and promote culturally
sensitive education about the physical consequences of FGC.
12
FGC is illegal and subject to criminal prosecution in several
countries, including Sweden, Norway, Australia, and the United
Kingdom.
13,14 In the United States, federal legislation in 1996
criminalized the performance of FGC by practitioners on female
infants and children or adolescents younger than 18 years and
mandated development of educational programs at the community
level and for physicians about the harmful consequences of the
practice.
15 Various state laws exist as well.
4
| CULTURAL AND ETHICAL ISSUES |
|---|
FGC has been documented in individuals from many religions,
including Christians, Muslims, and Jews.
5 The relationship of
FGC and Islam is complex and controversial. Some of the most
conservative Islamic societies, such as Saudi Arabia, do not
practice FGC, whereas in some African settings, the primary
motivation seems tribal and nationalistic rather than religious.
16 For many Muslim religious scholars, male circumcision is
considered obligatory, whereas some form of female "circumcision"
is considered optional but virtuous.
17 Across nations and cultures
that practice FGC, the perception that it is religiously obligated
or at least encouraged is ubiquitous.
5 Kopelman
18 summarized 4 additional reasons proposed to explain
the custom of FGC: (1) to preserve group identity; (2) to help
maintain cleanliness and health; (3) to preserve virginity and
family honor and prevent immorality; and (4) to further marriage
goals, including enhancement of sexual pleasure for men. Preservation
of cultural identity was noted by Toubia
19 to be of particular
importance for groups that have previously faced colonialism
and for immigrants threatened by a dominant culture. FGC is
endemic in many poor societies in which marriage is essential
to women's social and economic security. FGC becomes a physical
sign of a woman's marriageability, with social control over
her sexual pleasure by clitorectomy and over reproduction by
infibulation (sewing together the labia so that the vaginal
opening is about the width of a pencil).
When parents request a ritual genital procedure for their daughter,
they believe that it will promote their daughter's integration
into their culture, protect her virginity, and, thereby, guarantee
her desirability as a marriage partner. In some societies, failure
to ensure a daughter's marriageable status can realistically
be seen as failure to ensure her survival.
20 It is tragic that
the same procedure that made the daughter marriageable may ultimately
contribute to her infertility.
21 Parents are often unaware of
the harmful physical consequences of the custom, because the
complications of FGC are attributed to other causes and are
rarely discussed outside of the family.
22 Women from developing
countries who are advocates for children's health have differing
perspectives on how to respond to FGC. Some activists put the
campaign against FGC at the center of their work, but others
complain that the West's obsession with FGC masks an indifference
to children's suffering caused by famine, war, and infectious
disease.
23
The physical burdens and potential psychological harms associated with FGC violate the principle of nonmaleficence (a commitment
to avoid doing harm) and disrupt the accepted norms inherent
in the patient-physician relationship, such as trust and the
promotion of good health.
More recently, FGC has been characterized as a practice that violates the right of infants and children to good health and well-being, part of a universal standard of basic human rights.24
Protection of the physical and mental health of girls should be the overriding concern of the health care community. Although
physicians should understand that most parents who request FGC
do so out of good motives, physicians must decline to perform
procedures that cause unnecessary pain or that pose dangers
to their patients' well-being.
| TYPES OF FGC |
|---|
Figure 1 shows the normal genital anatomy of a prepubertal female.
The various ritual genital practices are classified into 4 types
on the basis of severity of structural alteration.
2
Type 1 FGC, often termed clitorectomy, involves excision of
the skin surrounding the clitoris with or without excision of
part or all of the clitoris (
Fig 2). When this procedure is
performed on infants and young girls, a portion of or all of
the clitoris and surrounding tissues may be removed. If only
the clitoral prepuce is removed, the physical manifestation
of type 1 FGC may be subtle, necessitating a careful examination
of the clitoris and adjacent structures for recognition.
Type 2 FGC, referred to as excision, is the removal of the entire
clitoris and part or all of the labia minora (
Fig 3). Crude
stitches of catgut or thorns may be used to control bleeding
from the clitoral artery and raw tissue surfaces, or mud poultices
may be applied directly to the perineum. Because of the absence
of the labia minora and clitoris, females with type 2 FGC
do not have the typical contour of the anterior perineal structures.
The vaginal opening is not covered in the type 2 procedure.
Type 3 FGC, known as infibulation, is the most severe form,
in which the entire clitoris and some or all of the labia minora
are excised, and incisions are made in the labia majora to create
raw surfaces (
Fig 4). The labial raw surfaces are stitched together
to cover the urethra and vaginal introitus, leaving a small
posterior opening for urinary and menstrual flow. In type 3
FGC, the patient will have a firm band of tissue replacing the
labia and obscuring the urethral and vaginal openings.
Type 4 FGC includes different practices of variable severity,
including pricking, piercing, or incising the clitoris and/or
labia; stretching the clitoris and/or labia; cauterizing the
clitoris; and scraping or introducing corrosive substances into
the vagina.
The physical complications associated with FGC may be acute
or chronic. Early, life-threatening risks include hemorrhage,
shock secondary to blood loss or pain, local infection and failure
to heal, septicemia, tetanus, trauma to adjacent structures,
and urinary retention.
25,26 Infibulation (type 3 FGC) is often
associated with long-term gynecologic or urinary tract difficulties.
Common gynecologic problems involve the development of painful
subcutaneous dermoid cysts and keloid formation along excised
tissue edges. More serious complications include pelvic infection,
dysmenorrhea, hematocolpos, painful intercourse, infertility,
recurrent urinary tract infection, and urinary calculus formation.
Pelvic examination is difficult or impossible for women who
have been infibulated, and vaginal childbirth can present significant
challenges. Scarring may prevent accurate monitoring of labor
and fetal descent. Although deinfibulation may facilitate delivery,
women who have undergone deinfibulation are at increased risk
of complications, including perineal tears, wound infections,
separation of repaired episiotomies, postpartum hemorrhage,
and sepsis.
27
Less well-understood are the psychological, sexual, and social
consequences of FGC, because little research has been conducted
in countries where the practice is endemic.
28 However, personal
accounts by women who have had a ritual genital procedure recount
anxiety before the event, terror at being seized and forcibly
held during the event, great difficulty during childbirth, and
lack of sexual pleasure during intercourse.
29 Some women have
no recollection of the event, particularly if it was performed
in their infancy. Other women have described the event in joyful
terms, as a communal ritual that inducted them into adult female
society.
30
| EDUCATION OF PATIENTS AND PARENTS |
|---|
An educational program about FGC requires, above all, sensitivity
to the cultural background of the patient and her parents and
an appreciation of the significance of this custom in their
tradition.
5 Objective information should include a detailed explanation of female genital anatomy and function, as well as a thorough review of the lifelong physical harms and psychological suffering associated with most forms of FGC. It should be emphasized
that many countries in Africa have supported efforts to educate
the public about the serious negative health effects of FGC
and that prominent physicians from Africa are advocates for
the elimination of these practices because of their adverse
consequences. Pediatricians and pediatric surgical specialists
who care for patients from populations known to practice FGC
commonly, such as Somalian, Ethiopian, Eritrean, and Sudanese
communities, should be aware of local counseling centers. Successful
educational programs typically require the active involvement
and leadership of immigrant women, whose experience and knowledge
can address the health, social status, and legal aspects of
FGC. Health educators must also be prepared to explain to parents
from outside North America why male genital alteration is routinely
practiced here but female genital alteration is routinely condemned.
31 Some physicians, including pediatricians who work closely with immigrant populations in which FGC is the norm, have voiced concern about the adverse effects of criminalization of the practice on educational efforts.32 These physicians emphasize
the significance of a ceremonial ritual in the initiation of the girl or adolescent as a community member and advocate only pricking or incising the clitoral skin as sufficient to satisfy cultural requirements. This is no more of an alteration than ear piercing. A legitimate concern is that parents who are denied
the cooperation of a physician will send their girls back to
their home country for a much more severe and dangerous procedure
or use the services of a non–medically trained person
in North America.
33,34 In some countries in which FGC is common, some progress toward eradication or amelioration has been made by substituting ritual "nicks" for more severe forms.2 In contrast, there is also evidence that medicalizing FGC can prolong the custom among middle-class families (eg, in Egypt).35 Many anti-FGC
activists in the West, including women from African countries,
strongly oppose any compromise that would legitimize even the
most minimal procedure.
4 There is also some evidence (eg, in
Scandinavia) that a criminalization of the practice, with the
attendant risk of losing custody of one's children, is one of
the factors that led to abandonment of this tradition among
Somali immigrants.
36 The World Health Organization and other international health organizations are silent on the pros and cons of pricking or minor incisions. The option of offering a "ritual nick" is currently precluded by US federal law, which makes criminal any nonmedical procedure performed on the genitals of a female minor.
The American Academy of Pediatrics policy statement on newborn male circumcision expresses respect for parental decision-making and acknowledges the legitimacy of including cultural, religious, and ethnic traditions when making the choice of whether to surgically alter a male infant's genitals. Of course, parental decision-making is not without limits, and pediatricians must always resist decisions that are likely to cause harm to children. Most forms
of FGC are decidedly harmful, and pediatricians should decline
to perform them, even in the absence of any legal constraints.
However, the ritual nick suggested by some pediatricians is not physically harmful and is much less extensive than routine newborn male genital cutting. There is reason to believe that offering such a compromise may build trust between hospitals and immigrant communities, save some girls from undergoing disfiguring
and life-threatening procedures in their native countries, and
play a role in the eventual eradication of FGC.
It might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick as a possible compromise to avoid greater harm.
Efforts should be made to use all available educational and
counseling resources to dissuade parents from seeking a ritual
genital procedure for their daughter. For circumstances in which
an infant, child, or adolescent seems to be at risk of FGC,
the American Academy of Pediatrics recommends that its members educate and counsel the family about the detrimental health effects of FGC. Parents should be reminded that performing FGC is illegal and constitutes child abuse in the United States.
| RECOMMENDATIONS |
|---|
The American Academy of Pediatrics:
- Opposes all forms of FGC that pose risks of physical or psychological harm.
- Encourages its members to become informed about FGC and its complications and to be able to recognize physical signs of FGC.
- Recommends that its members actively seek to dissuade families from carrying out harmful forms of FGC.
- Recommends that its members provide patients and their parents with compassionate education about the physical harms and psychological risks of FGC while remaining sensitive to the cultural and religious reasons that motivate parents to seek this procedure for their daughters.
HERE to read the entire statement on the AAP website
50% at all ages throughout infancy. We recommend including the advice to breastfeed through 6 months of age in sudden infant death syndrome risk-reduction messages.
