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Are 'ritual nicks' a humane alternative to FGM? Doctors debate.

Two American gynecologists have created controversy with an idea to limit the most dangerous female genital mutilation, instead of ending it outright. They say the strategy switch could save lives. 

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    Somali students wait for class at a school in Mogadishu in this June 2014 file photo. About 98 percent of Somalian women ages 15 to 49 have undergone FGM, according to the World Health Organization.
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An estimated 200 million women around the world have experienced female genital mutilation (FGM), the United Nations announced this month, increasing previous estimates by more than 50 percent. 

But two gynecologists are now raising eyebrows with a new strategy to prevent the pain and health complications that often accompany such procedures: a "compromise" plan that calls for legalizing less extreme forms of FGM, in the hopes of combining cultural sensitivity with safety. 

"Even if one girl can be saved from a more extreme FGA procedure and have a de minimis procedure as we outline, that our strategy would be worthwhile," Dr. Kavita Shah Arora tells the Monitor in an email interview. 

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Families who want their daughters to have just a "ritual nick" should be allowed to, she and co-author Dr. Allan J. Jacobs argued Monday in the Journal of Medical Ethics. They reason that a single cut for tradition's sake is similar to male circumcision, and that by outlawing FGA wholescale, well-meaning activists actually push families towards more extreme versions of FGM: often, a young girl's clitoris or labia are partially or wholly removed, and sometimes sewn shut before marriage, in the name of "purity." The procedures, which are often performed by locals without medical training, can cause long-term health issues. 

Throughout many parts of northern Africa and the Middle East, FGM is practically universal: 87 percent of women ages 15 to 49 in Egypt have undergone a procedure, for example, despite being banned in 2008. In Somalia, it's 98 percent, according to the United Nations.

Criminalizing FGM drives it into the shadows, the two gynecologists argue, making families more reluctant to seek medical help. It can make it that much harder for women's advocates to figure out who seeks FGM for their daughters, when, and why — key questions in the fight to one day end more dangerous versions completely.

"We are not arguing that any procedure on the female genitalia is desirable," the team writes. "We only argue that certain procedures ought to be tolerated by liberal societies": minimal, non-lasting "ritual nicks" that they compare to infant ear piercings, or male infant circumcision, and say we object to out of "cultural supremacy."

Even opponents of the "compromise" plan agree that culture is at the heart of FGM's ongoing prevalence, and equally at the heart of change. There's no religious basis, but FGM dictates women's lives in some regions, since "uncircumcised" women are often feared, or shunned as brides; young men are taught that the more traumatic versions, in particular, will dull sexual desire and keep their wives faithful. Until an entire community comes on board, the decision to forego FGM can seem like it's subjecting a woman to an even more difficult future, without the support of a husband or family. 

"People are participating in this practice out of love for the most part," Gannon Gillespie, the Director of Strategic Development at West Africa-based NGO Tostan, told the Monitor in 2013. "There aren’t evil intentions here – and once you understand that you see the pathway to how it might change."

A new wave of culturally sensitive campaigns to help local leaders end the practice is starting to pay off, bringing alternate ceremonies and better health education along with them.

As NPR reports on the rise of a new rite of passage in some Maasai and Samburu communities in Kenya and Tanzania:

After two or three days of preparatory sessions for the girls, the celebration culminates with communal singing and dancing and blessings by the village elders, who pour a mixture of milk and honey and water over the heads of the girls. Goats and cows are slaughtered for specially prepared stews or roasts. Traditional beer is brewed for the men to drink. The young women don multi­colored clothing and decorative beads that dangle from their heads and hang around their necks.

Such ceremonies have included from 200 to more than 1,000 girls, says, Peter N. Nguura, project manager, of Unite for Body Rights Project, AMREF Kenya Country Office, with several communities often coming together for the celebration. Usually, the elders also make a public declaration abandoning FGM, and the young men will similarly make public assurances that they will marry women who did not undergo FGM. That's important because any girl who refused to be cut was shamed and shunned, subjected to a life of isolation, without marriage or children.

But such alternative ceremonies can't keep up with population growth, say UN officials, and are one reason the study's authors say a new plan is needed. 

Still, other doctors and advocates have fervently spoken up against legalizing even minimal procedures. They say there's no such thing as a "safe" FGM, no matter how well-intended. 

"FGA has its origin and purpose in controlling women," Dr. Ruth Macklin, an advisor to the UN and World Health Organization, writes in a rebuttal. By limiting women's health and sexuality, FGM is "a means of making women and girls physically, aesthetically or socially acceptable to men."

While "nick" practices limit the medical harm, they still have zero physical benefits. The United Nations General Assembly condemns FGM, in general, as "irreparable, irreversible abuse," and UNICEF, which has led the charge to end it completely, calls it a violent example of gender discrimination. Many activists fear that approving even a mild version, like FGA, could still legitimize harsher forms.

Whether advocates push for a gradual approach, or insist that all forms be outlawed, however, their goal is the same: changing minds, more than laws.

And winning trust is key. In their Journal of Medical Ethics paper, Arora and Jacobs cite the example of a Seattle hospital that briefly permitted minimal FGAs in the late 1990s, attempting to keep Somalian immigrant families from sending their daughters abroad for more dangerous procedures. The genital "nickings" soon stopped amid controversy, but earned approval from the American Academy of Pediatrics, and mutual respect between doctors and their newest patients.

Gradually, both in the U.S. and abroad, some see attitudes shifting. 

"There is definitely a shift on the ground in terms of the openness of people," Mona Amin, an anti-FGM campaign worker at Egypt's National Population Council, told the Guardian. "Young girls don’t feel embarrassed to talk about the problems of the practice in front of their parents. Previously even women who didn’t circumcise their daughters didn’t want to say. It’s a very important shift in attitude."

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