Culture Clashes and the AAP

Last week the American Academy of Pediatrics (AAP) released an updated version of its position statement on ritual genital cutting of minor females. It is telling that the original statement from 1998 addressed female genital mutilation; this change is language is not accidental. And the change in tone of the position statement produced much controversy in its wake.

Female Genital Cutting/Mutilation (FGCM)

Some describe FGCM as female circumcision, although the procedures are not analogous. Removing the foreskin does not render the penis inoperable. The World Health Organization classifies FGCM into 3 levels, most of which involve removing the clitoris.

Male circumcision produces no benefit for most, but also yields no harm. Some evidence of medical benefit exists in regards to urinary tract infections and HIV transmission. FGCM may leave women with significant health problems, especially in regards to future fertility and urinary function.

FGCM is practiced in some regions of Africa and Asia, as documented at the WHO site.

What has changed

The title of the new AAP statement provides the first clue to changes in the document apparently driven by physicians working with immigrant communities. The abstract would lead one to believe that little had changed in the recommendations:

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 healthrisks for children and women. The American Academy of Pediatricsopposes 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 activelyseek 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.

Later in the discussion, issues of cultural sensitivity arise:

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.

The 1998 statement was easy: FGCM is medically wrong and illegal; don’t do it! The current document provides final recommendations that read almost the same:

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.

Only in the discussion do they discuss offering a “ritual nick” as an alternative to a riskier procedure, recognizing that even this alternative remains illegal. My question: will the “ritual nick” eventually lead to more significant procedures to appease parents?

FGCM is illegal for a reason. I recognize that other cultures are as valid as my own, but we have outlawed these procedures for very good reasons. Other cultures permit “honor killings;” would we tolerate these in this country just to be culturally sensitive? I know we do not! When you choose to immigrate, you choose to make changes in your life. Eliminating FGCM is one change that must be made.