This post was inspired and informed by the collaborative research conducted by Ranit Mishori, Kevin FitzGerald, Sam Wu and Holly Hedley as part of the Georgetown Complex Moral Grant.
After a three year investigation, the UK’s Crown Prosecution Service (CPS) announced in late February of 2017 that it would not prosecute a surgeon and psychiatrist involved in a clitoris removal operation performed on an adult woman. Both physicians published a case study about the operation in 2012 and after reading it, another physician urged the CPS to investigate the case because it appeared to breach the UK’s law banning female genital mutilation/cutting (FGM/C). The case highlights some of the difficult questions that physicians and policymakers are currently considering as they struggle to reconcile a growing culture of female genital cosmetic surgery (FGCS) with the definitions included in well-established laws prohibiting FGM/C.
Since the early 2000s, many countries in the global north (e.g. Australia, Canada, UK, U.S., etc.) have seen an increase in rates of FGCS, which is defined as any surgical procedure that alters the female genitalia for aesthetic rather than medical reasons. According to the British National Health Service, the number of labiaplasty interventions performed in the UK increased five-fold in nine years, from 2001 to 2010. The number of girls and adolescents undergoing FGCS is also increasing, with an 80 percent increase between 2014 and 2015 in the number of girls under the age of 18 who had had labiaplasty in the U.S.
Difficult legal and ethical questions arise for physicians in this context because some FGCS procedures (e.g. labiaplasty, clitoridectomy, etc.) fall within the definition of FGM/C, as established by domestic laws that prohibit the practice. Countries in the global north, where FCGS is most common, began prohibiting FGM/C in the 1980s and have further strengthened those laws in recent years, particularly in the wake of increased levels of migration from counties where FGM/C is prevalent. Official guidance for health professionals on the extent to which FGM/C laws apply to FGCS is lacking in most countries, despite calls for action from both sides of the debate.
On one side of the debate are those who focus on the double standard at play and call upon governments to make it explicit that FGCS constitutes FGM/C. The Home Affairs Committee in the UK, for example, has noted how problematic it is to hold ethnic minority communities to a different standard than the wider community. “We cannot tell communities in Sierra Leone and Somalia to stop a practice which is freely permitted in Harley Street”.
On the other side of the debate are those who believe there are important differences between FCGS and FGM/C, focusing on capacity to consent to and motivation for undergoing each of the practices. According to the psychiatrist involved in the case referenced above: “FGM is an abhorrent practice conducted on girls against their consent motivated by a desire to control female sexuality, but [cosmetic genital surgery] is provided for adult women with capacity to consent and motivated by a desire to improve their appearance and sexuality. It’s no different to any other cosmetic surgery”.
The debate is complex and far from settled. As physicians and policymakers continue to grapple with how to proceed, it will be important for them to consider the perspectives of other professionals who can speak to the legal, ethical, social, cultural, etc. dimensions of this debate.