Why a compromise isn’t a solution: A critical review of the JME proposal

Please Note: I will be talking about male circumcision quite a lot in this review and the two following articles, and while I strongly believe that it cannot be compared to FGM, I also want to make it clear that I do not condone either practice. All forms of genital cutting are an invasion and violation of the human body and we should be working towards ending it on all fronts.

Last month, the BMJ’s Journal of Medical Ethics published a paper entitled “Female genital alteration: a compromise solution”, in which the gynaecologists Dr Kavita Arora and Dr Allan Jacobs argued for the medicalisation of some forms of FGM. The proposal was received negatively in the following days, and while I completely agree with the existing criticisms, I wanted to do my own in-depth analysis of the paper itself. I tried to go into it with an open mind hoping to find some evidence of awareness, but every paragraph of the article makes it painfully clear that the authors just don’t understand the place of FGM in the wider problem of violence against women and girls. I will include a link to the original article below, but in this post I aim to provide an overview of their proposals and explore 7 major problems with their stance.
Screen Shot 2016-03-13 at 12.28.03Screen Shot 2016-03-13 at 12.17.58Arora and Jacobs begin by declaring that 30 years of activism haven’t been successful and that a new solution is required. They propose a re-classification of the WHO’s current Type 1-4 categorisation (Figure 1) for a new system based on impact (Figure 2), with their Types 1 and 2 being the accepted compromise. There is some exploration of related issues, under the subtitles “Cultural Sensitivity”, “Gender Discrimination”, “Human Rights Violation” and “Utilitarian Considerations” but these are largely based on misunderstandings of the practice and fail to provide any justification whatsoever for their approach. Here are the main problems I found with the proposals, the article itself and the authors’ point of view:

1. The use of the word “alteration”
Throughout the article, the authors continually downplay what is essentially torture. “Alteration” implies a small change or a positive adjustment for overall improvement, like word changes in a business document or changing the lock on a door (one dictionary defines it as “Change that does not affect the basic character or structure of the thing it is applied to”). It is not an appropriate term to describe severe child abuse and gender-based violence, especially as adequate terms exist. The authors choose “alteration” because they don’t believe their Type 1 procedure counts as mutilation as there is no permanent morphological change, even though alteration implies the same thing and the word “cutting” is a suitable alternative.

2. Frequent comparison of FGM to male circumcision
My next article will be covering this in more depth and on a wider scale than this article alone, but the authors compare the two practices so much that I have to mention it here. Arora and Jacobs have argued elsewhere that male circumcision isn’t a human rights violation and they then use this to say that we should accept their proposed Type 1 and 2. First of all, the argument that FGM should be accepted because circumcision is accepted is deeply flawed as male circumcision isn’t actually accepted and even if it was, it shouldn’t be. Secondly, comparing the removal of the clitoral hood to the removal of foreskin just does not make sense. The clitoris is all the nerves on the entire penis bundled into something the size of a pea. That’s 8,000 nerves exposed, and most people with a clitoris find direct contact on it very uncomfortable and even painful. The clitoral hood is there for a reason, and if removing it causes pain, the proposed Type 2 becomes the proposed Type 3, which the authors themselves deem unacceptable. There is much more I want to say on the topic of comparing male circumcision to FGM but it will take a whole article and the criticisms above relate to this proposal, rather than the argument as a whole.

3. Overemphasised “cultural sensitivity” and lack of understanding of other factors
The authors justify their use of the word “alteration” and their new types by saying that we have to respect practices that are important to other cultures and that condemnation of harmful practices such as FGM is cultural supremacy. However, as Leyla Hussein explores in her documentary The Cruel Cut, cultural sensitivity is precisely why progress has taken this long. The authors complain that 30 years of activism hasn’t done much and then advocate the very thing that will slow it down further. The biggest problem with approaching FGM from this viewpoint is that it’s not actually about culture. FGM exemplifies misogyny and violence against women in its most brutal form, but this discrimination isn’t specific to any one group of people. It is about controlling female sexuality and viewing women as a commodity, which can be seen worldwide. If we’re going to talk about FGM as anything other than abuse, we’re going to be talking about economics, not culture. The article doesn’t mention the significance of economic value once, despite this being the driving force behind the practice. In countries such as Yemen, poverty is largely responsible for the prevalence of FGM and forced marriage. FGM is about keeping a girl a virgin so she’s more desirable for her future husband and the more desirable, the greater the “bride price” or dowry. This is about money and women being property and has very little to do with culture.

4. Unnecessary re-classification
The main reason the authors propose a re-categorisation of the types of FGM is that “it has not aided in discussion because of the wide variety of procedures included in each category, as well as due to omissions of some procedures altogether.” I would just like to start by saying that the current categorisation does not omit procedures and is both specific and inclusive, which is exactly what is required when talking about this kind of abuse. Type 4 encompasses any procedures that do not fit into the three previous categories, in contrast to the proposed “Category 5” which the authors themselves admit is empty and therefore, quite useless. By re-classifying the procedures, all the authors have really done is make space for their own forms of FGM and compress the established classification into just two vague categories, which seems ironic given their original complaint. The re-categorisation also doesn’t allow for overlap (for example, infibulation would cross both the proposed Type 3 and 4, as sexual enjoyment and reproductive abilities are both impaired) and would only end up confusing those who have suffered the procedures and those trying to help them. Understanding exactly what has happened is a big part of healing, and this re-classification would only take that away from survivors and potentially prolong their emotional and psychological suffering.

5. The blatant disregard of psychological trauma
This is a problem related to the reclassification I just mentioned, but it is also clear throughout the whole article. The re-categorisation is based solely on physical impact and completely ignores the deep and extensive mental violation that occurs when FGM is carried out. FGM, in all its forms, has no medical benefits at all but it can be extremely detrimental in several ways. In cutting a part of a girl’s body that is perfect on its own, they are still telling her that there is something wrong that needs to be fixed, no matter how “mild” the procedure may be. It is telling her that she needs to suffer in order to appease others and that her body is not her own. If that isn’t a human rights violation, I honestly don’t know what is.

6. Their compromise wouldn’t work
This is perhaps the most major flaw and it stems from the same lack of understanding as the previous five criticisms. Aside from the fact that any form of genital mutilation is just plain wrong, their proposed “solution” probably wouldn’t be accepted by the communities that practice FGM, especially infibulation. As I’ve said earlier in this post, FGM is about controlling and obliterating female sexuality and making a girl a thing to pass from father to husband. The effect has to be lasting and visible in order for the husband’s family to know that she is, without doubt, a virgin. The proposed Type 1, according to Arora and Jacobs, would be fast-healing with no consequences (once again ignoring psychological impact and risk of infection) and this in itself means that there’s no proof that FGM has actually been carried out. Post-healing, it would do nothing to ensure that the girl is a virgin and it’s highly doubtful that this would be accepted in places were the harshest forms of FGM are practiced. The only solution in these cases is a change of mindset, which is happening but will take a decent amount of time, which brings me onto my final point…

7. They belittle the achievements of activists
Arora and Jacobs justify proposing this “solution” by saying that 30 years of activism hasn’t got us very far. However, I completely disagree and would argue that great strides have been made in the past 5-10 years alone, and we can expect to see incredible advancements in the coming years. There is so much happening, especially in the UK, to eradicate FGM within a generation. Most of the change we’re seeing now is a result of survivors having the immense courage to face their own experiences and decide to speak out, and given how hard that must be and how many people have had to do this, 30 years seems really quite impressive to me. Arora and Jacobs make it sound like the practice is being condemned by outside forces, by white women who don’t understand culture and in the same breath will turn around and ask for cosmetic surgery which just isn’t the case. When FORWARD started in 1983, it was women from within African communities standing up against the practice. In contrast, second-wave feminist icon Germaine Greer is guilty of actually advocating FGM in The Whole Woman (1999). Yes, it would be incredible if all FGM ended right this minute, but the practice has existed for so long and is so engrained that it will take a little while longer to ensure that it’s really gone. Understanding the harm of the tradition is so important both in preventing it now and making sure it never comes back. Again, FGM is part of a much greater problem of widespread discrimination and eliminating the practice itself doesn’t ensure that all forms of violence against women and girls disappear too.

While I doubt this JME article is going to be taken remotely seriously as the voices of survivors and activists have already done a great job of disregarding the ideas, I do think it’s important that we explore why compromise just shouldn’t be an option. This proposal exposes a deep lack of understanding of the causes and effects of FGM and its only positive effect is that we can use it to show what change actually needs to happen. We should be supporting survivors and helping them eradicate the practice entirely, not negotiating the health and safety of millions of girls. We should be amplifying their voices, not ending the conversation half-addressed. And as doctors, Arora and Jacobs should respect one of the oldest medical rules in the book. The Hippocratic Oath has always been interpreted as “Do no harm”, not “Try something that actually works, give up way too soon and do a slightly different kind of harm.”

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3 thoughts on “Why a compromise isn’t a solution: A critical review of the JME proposal

  1. The American Association of Pediatrics (APP) proposed and then resoundingly rejected the ‘little nick’ idea in 2010. http://www.medscape.com/viewarticle/722840 It’s deeply unethical, totally against WHO advice http://www.who.int/reproductivehealth/publications/fgm/rhr_10_9/en/ and in any case wouldn’t work because traditionalists would insist on doing the FGM again, this time ‘properly’. Whatever was the JME thinking of, when it permitted resurrection of this appalling idea?


    1. Hi Hilary,

      Thanks for commenting and for sending these links. I had read about the AAP’s attempt but hadn’t come across the WHO Global Strategy document – they really do explicitly state why it’s such a bad idea! I’m quite disappointed that they would publish such an under-researched article, especially as the BMJ has contributed to a lot of my understanding of the practice. Hopefully the idea won’t be revisited again, it clearly isn’t a good option.

      Best wishes,


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