The Diary of a Midwife

In a controversial new statement, the American Academy o f Pediatrics (AAP) published a new policy statement on female genital cutting which suggested the possibility of doctors being allowed to perform a small, pinprick “ritual nick” in place of the more severe forms of female genital cutting (FGC).  FGC is a fairly common practice among many cultures in Africa and Asia, and their hope is that by keeping it on American soil in the hands of trained physicians they can limit the severity of the practice, or at the very least avoid families sending these adolescents and young girls sent back to their home countries for the more severe types of cutting, or sending them to non-medically trained practitioners in North America.  To quote the AAP’s new policy statement:

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.

This is a really slippery slope, though.  On the one hand, you want to be able to keep a dialog open with members of these cultures, and you want to be able to offer them alternatives to the actual practice of cutting, which is often done by non-medically trained practitioners in unsterile environments, and can be dangerous and deadly, besides the actual sexual and future child-bearing limitations that these practices entail.  On the other hand, it seems a hard thing to condone, and I’m not sure how positive change could be affected through this practice, coming as it does from an outsider/ western institution like the AAP.  The New York Times ran an article on this after the AAP’s announcement, and they did a good job up summing up both sides of the story, but in particular the response to this announcement by advocacy groups like Intact America:

“There are countries in the world that allow wife beating, slavery and child abuse, but we don’t allow people to practice those customs in this country. We don’t let people have slavery a little bit because they’re going to do it anyway, or beat their wives a little bit because they’re going to do it anyway.”–Georganne Chapin, executive director of Intact America.

And she is right about that.  Is allowing American physicians to perform a “ritual prick” the same thing as condoning the practice?  And even if a ritual prick is less damaging to a little girl than male circumcision is to a little boy, what it’s standing in place of is still a debilitating and often times misogynistic practice that in many cultures  is designed to limit a woman’s sexual enjoyment (and therefore her promiscuity), enhance male sexual pleasure, and preserve her status/ virginity/ honor/ marriageability and group identity, and has with it a host of medical conditions

Female Genital Cutting is a difficult subject to broach, even at the best of times.  This something I have struggled with for years.   My first initial response to seeing it was one of shock and outrage at the brutality of it, and ended with me declaring that it is and always will be mutilation, and that I must speak out against it whenever and wherever I saw it.  Further thought on the subject has made me come to realize that as an outsider to these cultures, I can’t approach a woman by telling her that she’s been mutilated as the starting point for any future conversations–that will immediately close her off to me and only serves to project my own cultural bias over her own.  The important thing to remember is that to women brought up in cultures which practice FGC, it is no more strange to them than piercing bellybuttons or lips or eyebrows is to us, even if the implications, the actual act itself and the repercussions of it can be much more damaging to them than a bellybutton piercing.  When viewed within their culture, it’s a mark of belonging and identity, a way of fitting in, a symbol of their womanhood, a manifestation of their virtue and honor, and on its most basic level, the way that they think vaginas are supposed to look–beautiful, even, to their eyes.  When a woman who has been cut sees a picture of an uncut vagina for the first time in her life, the reaction is usually one of shock and horror at how ugly and deformed it is, lacking the symmetry and neatness of infibulation. As members of the western/ dominant/ imperial culture, we are not in a prime position to be doing the actual hard work of change.  Our position of privilege and dominance allows us to advocate for change, but the actual change itself needs to come from within, from programs like Tostan’s, which spends 30 months teaching and empowering community leaders and members of the community, giving them the tools they need to choose to stop FGC for themselves.  Compared to that kind of impetus, the AAP advocating for a western doctor to perform a “ritual nick” seems like trying to put out a fire with a squirt-gun.

But then, on the flip side, I do hear the AAP’s argument for trying to limit the prevalence and severity of FGC by offering a cleaner, safer, less invasive option, and it does seem like they have some research to back this up (but very limited research…and it seems there is also a fair amount of research arguing against adopting this practice. To quote again from their policy: “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“)  My question is: does the AAP really think that women and families from cultures which practice FGC would be approaching their pediatricians about this in the first place?  And in the AAP’s defense, they are by no means recommending this routinely, only offering the option of a ritual nick as a potential last ditch effort when other attempts at education and dissuasion have failed.   The actual recommendations at the end of the policy are as follows:

The American Academy of Pediatrics:

1. Opposes all forms of FGC that pose risks of physical or psychological harm.
2. Encourages its members to become informed about FGC and its complications and to be able to recognize physical signs of FGC.
3. Recommends that its members actively seek to dissuade families from carrying out harmful forms of FGC.
4. 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.

I don’t anticipate any actual change to legislation any time soon which would non-criminalize acts of FGC, despite what the AAP may suggest.  In fact, it seems like ths US is cracking down on FGC even more at this time, especially in the form of the new proposed legislation (The Girls Protection Act H.R. 5137) which would criminalize not only acts of FGC in the US, but also sending women and girls abroad to have the procedure done (which  is already law in most of the countries of Europe).  It will be interesting to see how this plays out in the months to come.  Any other thoughts on this?