Mutilation or Enhancement? What is Morally at Stake in Body Alterations

By Brian D. Earp (@briandavidearp)

 

Those who follow my work will know that I have published a number of papers on the ethics of medically unnecessary genital cutting practices affecting children of all sexes and genders (a partial bibliography is at the end of this post). When my writing touches on the sub-set of these practices that affect persons with characteristically female genitalia, primarily women and girls, I have on occasion received some pushback for using the term ‘FGC’ for female genital cutting rather than ‘FGM’ for female genital mutilation (though I have also received words of appreciation, so, I cannot please everyone).

A recent instance of such pushback came from a respected colleague in response to a forthcoming paper of mine in Archives of Sexual Behavior, in which I explicitly argue against the use of ‘mutilation’ in certain contexts, as there is evidence that such stigmatizing language may have adverse effects on the very people who are meant to be helped. The paper, “Protecting Children from Medically Unnecessary Genital Cutting Without Stigmatizing Women’s Bodies: Implications for Sexual Pleasure and Pain” is available as a pre-print here.

Given that this terminological issue is likely to keep coming up, I thought I would share parts of the reply I wrote to my colleague (lightly edited). I certainly don’t expect that everyone will agree with what I say below, but I hope it can shed some light on at least one plausible way of thinking about such difficult matters.

One last thing. In order to understand my reply, you need to know that my colleague argued that my use of ‘FGC’ rather than ‘FGM’ is disrespectful because it goes against the recommendation of the 2005 Bamako Declaration adopted by the Inter-African Committee (IAC) on Traditional Practices Affecting the Health of Women and Children. My answer is immediately below.

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Thank you very much for your feedback. I have been pressed on this issue before, and while I do not agree with the use of ‘mutilation’ as a catch-all term to describe all medically unnecessary (female) genital cutting as such, I hope I may make an effort to explain my reasoning. That way, perhaps, we can narrow in on where it is exactly we seem to be diverging in our approaches.

On the matter of disrespect. I have had many conversations with women who consider themselves circumcised, rather than mutilated, and even if they agree that medically unnecessary genital cutting should not be performed on persons who are incapable of consenting, primarily children, they insist that it is harmful, stigmatizing, and paternalistic for others to simply define their own modified genitals as mutilated (a term that implies disfigurement or even an intent to cause harm).

They explain that their loving parents, however misguided, did not intend to cause them net harm, just as, for example, Jewish parents who authorize that their sons be circumcised do not intend to harm them, but rather, take an action that is sincerely believed to appropriately integrate the child into an ancestral community; and they recognize that, in their own communities, both male and female genital cutting practices are widely seen as improving the genitalia, including aesthetically, which is contrary to the very notion of mutilation. I may not agree with that interpretation or appraisal myself, but it is not my position to tell these women (or their brothers) that their altered genitals are ugly or disfigured rather than, as they see it, aesthetically (or in some cases, culturally or religiously) improved.

As far as I can glean from my conversations with women who object to having their most private anatomy described as mutilated, as well as my reading of the anthropology literature, the African leadership you refer to is not representative of the views of the majority of the affected women. So I will ask: Were these leaders democratically elected to express the considered opinions of their constituents, or were these leaders self-appointed? At the very least, they cannot have been authorized to speak on behalf of countless Southeast Asian or Middle Eastern women who have been affected by ritual forms of female genital cutting.

In any event, I face a choice: I can disagree with the conclusion of these African leaders who seem to feel qualified to speak on behalf of millions of other women, including non-African women, and impose an entirely negative and stigmatizing interpretation of all of their altered genitalia regardless of how those women see their own bodies (for the record, I do not think that disagreeing with someone’s view implies any kind of disrespect); or, I can show very clear disrespect to those women who have shared their stories with me, as well as all the women in various reports and testimonies who have expressed strong objections to the term ‘mutilation’ being forced on them, and who would simply like to have the room to be able to evaluate and describe their own genitals as they see fit. One woman explained her feelings like this:

In my opinion, the word ‘mutilation’ used in reference to [what happened to me] is a degrading and disempowering term that strips women of their dignity and self-worth. Basically, it is a label that has the power to negatively influence one’s self-identity. If you understand labelling theory you will understand how damaging/influential a term or classification can be to an individual.

She continues:

Having just about survived my ordeal of forced body alteration I was very aware of the violation to my body. However, the introduction of the term ‘mutilation’ into my consciousness affected me mentally and physically. It made me view myself as an ugly, mutilated, and frowned-upon member of society. There started my journey of self-hate, which presented itself in many forms including bulimia and social anxiety to name but a few. To be called the ‘mutilated’ girl by health professionals stripped me of any dignity and covered me in shame on numerous occasions. Thankfully, I no longer see myself as a victim or survivor of ‘FGM’ – I refuse to allow that term to take away my power or to define who I am.

Faced with the choice between respectfully disagreeing with the analysis and conclusion of a group of leaders whose qualification to speak on behalf of others I do not know, versus showing respect to those women, such as the one quoted above, who have asked for the right to determine their own victim status (including whether they regard their genitals as mutilated or otherwise), I choose the latter.

You refer to “the event” and “the torture,” using singular language to refer to a plurality of quite different events carried out in different ways by different groups for different reasons. As you know, the World Health Organization (WHO) uses the term “FGM” to refer to a dozen or more practices, ranging from nicking of the clitoral hood, which does not remove tissue and, in many communities, for example in Malaysia, is often done by a doctor with sterile equipment and pain control, through to excision of the external clitoris with a rusty implement and no pain control followed by infibulation, as occurs, for example, in some rural parts of Northeast Africa.

It is entirely accurate to say that all of those quite different interventions are medically unnecessary acts of genital cutting, and I have been at pains over the years to argue that all of them are morally impermissible if carried out on a non-consenting person. But if you are willing to lump together non-sterile, un-anesthetized excision of the external clitoris followed by infibulation, done to a terrified, fully-conscious child, with pricking of the clitoral hood of an infant with a needle and pain control, under the same term – mutilation – and collapse both of them under the banner of torture, regardless of the severity of what is done and irrespective of parental motivations, then this seems to me a plain abuse of the English language.

I have sometimes written about so-called ‘cosmetic’ labiaplasty, a common procedure in Western countries. I think the norms and pressures in society that lie behind many women’s desire to ask for this procedure are certainly problematic; but since I loathe paternalism, especially as applied to the decisions women may make about their own bodies, I tend to think it is morally permissible for an adult, fully-informed woman to decide that she wants what she regards as a cosmetic alteration to her genitals. Because the WHO typology includes all medically unnecessary cutting of female genital tissue, without regard to severity, the intention behind it, or even the capacity of the individual to consent, such labiaplasty should count as mutilation on what I take to be your view. But I would not presume to tell my friends who have undergone what they see as cosmetic labiaplasty that they are victims of genital mutilation; rather, I would accept their interpretation of their own bodies as having been enhanced by their lights.

What this suggests to me is that the sheer alteration of healthy genital tissue is not inherently mutilating (as in a net harm, or net negative). Rather, a person could interpret altered genitalia in a wide range of ways, including as improved or enhanced; and this is in fact the majority way that persons with altered genitalia do regard their own bodies, as far as I can tell from reading the primary and secondary literatures on this topic. What makes medically unnecessary genital cutting morally wrong is its being done non-consensually. It does not matter if it is mutilating or not – that is up to the person who is affected to decide – what matters is that it should be that person’s own choice, when they are competent to make such a decision.

Finally, my work is dedicated to the human rights argument that all non-consenting individuals, whatever their sex or gender,* have a fundamental moral claim against any interference with their genitals that is not medically necessary. So, for example, I believe that medically unnecessary cutting of the penis is wrong, when done without the informed consent of the affected person. In the United States, some 80% of those born with characteristically male genital anatomy (including both men and trans girls/women) have had roughly 50% of the healthy, functioning, erotogenic skin system of their penis removed without their own consent for largely cultural reasons. I argue that is morally wrong. But if I were to go around telling my circumcised friends, colleagues, etc., that, totally regardless of how they felt about their own bodies, it was up to me (or even some committee of leaders) to simply declare that they had been genitally mutilated, they would be right to be offended and to regard my claim as presumptuous and disrespectful.

And yet, since I write about all medically unnecessary genital cutting practices, which includes alterations of the vulva that are less severe than penile circumcision as it is commonly performed in my country, I cannot go around calling one set of procedures ‘mutilations’ based on the sex of the person to whom they happen, while using a different term for another set of procedures. So, I choose to use the entirely accurate, non-stigmatizing language of ‘medically unnecessary genital cutting’ in all cases, leaving 100% of the leeway to each individual to determine for themselves whether they regard their own genitals as mutilated or disfigured rather than something more neutral or even enhanced.

It is not my place to speak on behalf of others about their bodies; nor do I think it is the place of these African leaders you refer to, to speak on behalf of millions of women who may not agree with them (in fact, it is likely that most do not). Moreover, as I argue at length in the paper I sent around, there is very good reason to think that the language of mutilation is stigmatizing and harmful. Since it is not necessary to stigmatize women’s bodies in order to ground the ethical claim that cutting children’s genitals is morally wrong if not medically necessary (see post script for why), I choose to use non-stigmatizing language.

Warmly,
Brian

*Note: terminology surrounding sex categorization is also controversial. Language used by members of marginalized populations is often contested but people who are born with differences of sex development – or who have a range of what are sometimes called variations of sex characteristics (VSC) or intersex variations – are identifiable precisely because their bodies raise questions about their membership in either the male or female sex class, according to conventional/biological criteria for sex category membership. The ways that individuals with such traits are categorized depend on who is doing the categorization and toward what end, with different views about what makes someone with a VSC (all things considered) female, male, or – perhaps – a member of a third category. Decisions about such matters are often made by others according to their interests and not necessarily those of the individual so consigned. People with VSCs, medical professionals, parents, human rights advocates, and other stakeholders vie for terms and concepts that are consistent with their aims. Thus, some individuals may say, “I am neither entirely nor exclusively male nor female; I am intersex – and proud of it!” Others might identify themselves as female or male and intersex. Others will prefer medicalized terms, whether for purposes of gaining access to needed medical treatments, distancing their sense of self from the status of their reproductive anatomy, or for other reasons.

P.S. Here is an excerpt from my forthcoming paper, which explains my view further (internal references omitted apart from quotes):

            One possibility is that those who wish to prohibit medically unnecessary genital cutting of children may believe it is necessary to appeal to the extremes of sexual or other harms that can result from such cutting in order to explain why the practice is morally wrong. But relying on a harm-based approach to justify opposition to non-Western FGC as such—rather than, for example, only its more radical forms—can lead to empirically questionable, exaggerated, and over-generalized claims of harm that may then be assumed to apply to all women who have experienced such FGC. These claims and assumptions, in turn, may themselves cause harm insofar as they promote homogenizing, often race-based stereotypes about the affected women or their communities, or elicit body-shaming and sexual stigma.

            So how should opposition to FGC be grounded? Recognizing the pitfalls of a harm-based approach, a number of activists, ethicists, physicians, legal scholars, feminists, and other stakeholders have sought to distinguish the moral concept of wrongfulness from that of harmfulness. As I noted in a recent exchange, one way a person can be wronged is if they are harmed without adequate excuse or justification. But a person can also be harmed without being wronged: for example, if someone accidently and non-negligently bumps into them on a busy sidewalk, causing them to fall and scrape their knee. Finally, a person can be wronged without being harmed: for example, if someone “softly” sexually penetrates them while they are asleep (assuming no prior consent) in such a way that they could never find out, nor suffer any physical or emotional injury.

            One implication of this distinction is that medically unnecessary genital cutting could morally wrong a person regardless of the level of harm caused, insofar as it is non-voluntary (that is, done without the informed consent of the affected individual). On this view, individuals have a fundamental moral and, in many settings, also a legal right against any interference with their sexual anatomy to which they do not consent, whether or not unambiguous harm (or ill intent) can be proven, unless (1) they are incapable of consenting and (2) there is an urgent medical need, such that the interference cannot reasonably be delayed without undermining the individual’s future bodily autonomy (for example, by putting them at serious risk of death or disability).

            A similar principle has been claimed to underlie, and explain, the intrinsic wrongfulness of sexual assault or rape. As David Archard argues, the fundamental wrong of non-consensual sexual contact is not that it is always harmful (though it is often very harmful indeed); rather, such contact is wrongful because it illegitimately infringes upon the sexual integrity of the person who has not consented. In this, it denies that they are worthy of a certain kind of respect that is central to their embodied personhood, by eluding their right to decide who may engage with their most intimate anatomy under what conditions. Such behavior is therefore inherently wrong “independent of any distress [the person] could experience.”

            In a forthcoming paper, legal theorist Kai Möller extends such reasoning to genital cutting. It is of course much worse, he writes, from a moral perspective, “to impose extremely grave physical harm on a girl, to irreparably damage or even destroy any possibility for enjoyable sex, to create various significant, further health risks, and to do all this as part of a structure that oppresses female sexuality,” than it is to impose, for example, a “ritual nick with (arguably) no long-term damage, no further health risks, and no negative effects on sexual pleasure.” But although these two cases differ significantly in terms of the likely degree of harm imposed on the child, they still share a common moral core: “namely the intrinsic wrong that lies in the fact that someone acts on a claimed entitlement to apply a sharp object to a child’s genitals.” In other words, the wrong of medically unnecessary, non-consensual genital cutting “flows not (in the first instance) from contingent empirical factors relating, for example, to harm or social structures, but from the child’s right to have his or her [sexual] integrity respected and protected.”

              I agree with this view and have offered supporting arguments in a recent body of work, emphasizing that non-consenting persons of all sexes and genders have a moral right against any medically unnecessary interference with their sexual anatomy. By adopting such a rights-based approach, I suggest that campaigners against genital cutting could achieve two important ends. They could (1) promote and justify laws and policies aimed at protecting vulnerable children from such cutting, without having to resolve contestable empirical disputes about specific levels of harm, much less abstract philosophical disputes about what constitutes harm in a given context; while (2) avoiding further stigmatization of those who have already experienced such cutting and may be looking for ways to heal. This could create room in the discourse for relatively more adaptive interpretations of medically unnecessary genital cutting and its potential effects on sexual pain or pleasure, without sacrificing a clear moral basis for opposing all such non-consensual genital cutting in future generations.

Quoted references in excerpt

Archard, D. (2007). The wrong of rape. The Philosophical Quarterly, 57(228), 374-393.

Earp, B. D., and Yuter, J. (2019, September 3). On circumcision and morality: an exchange. Letter. Available at https://letter.wiki/conversation/127#letter_458

Möller, K. (in press). Male and female genital cutting: between the best interests of the child and genital mutilation. Oxford Journal of Legal Studies, in press.

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A short addendum. In response to my claim that “FGM” is stigmatizing, the same colleague referred me to some language in the above-mentioned Bamako Declaration: “The term FGM is not judgmental. It is instead a medical term that reflects what is done to the genitalia of girls and women. It is a cultural reality. Mutilation is the removal of healthy tissue. The fact that the term makes some people uneasy is no justification for its abandonment.”

My response to this was as follows:

There are a number of issues here. One of them is that the WHO typology for FGM includes practices such as ritual nicking that do not in fact remove healthy tissue. Nevertheless, I believe it is false to say that calling someone’s genitals mutilated is non-judgmental. Most competent speakers of the English language would say that the term mutilation implies a (negative) evaluative judgment of a body-alteration. When a body-alteration is undertaken to improve the body, it is rarely if ever called a mutilation by native (or other competent) speakers.

Thus, cosmetic orthodontia are not called ‘dental mutilations’ and cosmetic breast augmentations (or reductions) are not called ‘breast mutilations’ and ear piercings for teenagers are not called ‘ear mutilations’ and sixth-digit removal is not called ‘hand mutilation’ and so on. So the term mutilation is judgmental, as it connotes a negative change to the body. But as I’ve said, those who undertake, e.g., labiaplasty do not see it as a negative change, but rather, a positive change; hence, labiaplasty in the West is not generally considered a mutilation. Now, labiaplasty would be morally wrong if it were done to a non-consenting person. But not because it would ‘mutilate’ the person; because it would be medically unnecessary and non-consensual.

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What does it mean for an intervention to be medically necessary? For anyone wondering about my use of the term ‘medically unnecessary’ throughout this post, I am relying on the definition recently published by the Brussels Collaboration on Bodily Integrity (BCBI), adapted from my chapter, “The Child’s Right to Bodily Integrity” in the book Ethics and the Contemporary World. The BCBI definition (plus discussion) is as follows (internal references omitted):

A common understanding is that an intervention to alter a bodily state is medically necessary when (1) the bodily state poses a serious, time-sensitive threat to the person’s well-being, typically due to a functional impairment in an associated somatic process, and (2) the intervention, as performed without delay, is the least harmful feasible means of changing the bodily state to one that alleviates the threat. ‘Medically necessary’ is therefore different from ‘medically beneficial,’ a weaker standard, which requires only that the expected health-related benefits outweigh the expected health-related harms. The latter ratio is often contested as it depends on the specific weights assigned to the potential outcomes of the intervention, given, among other things, (a) the subjective value to the individual of the body parts that may be affected, (b) the individual’s tolerance for different kinds or degrees of risk to which those body parts may be exposed, and (c) any preferences the individual may have for alternative (e.g., less invasive or risky) means of pursuing the intended health-related benefits. We argue that although the weaker, ‘medically beneficial’ standard may well be appropriate for certain interventions into the body, it is not appropriate for cutting or removing healthy tissue from the genitals of a nonconsenting person. If someone is capable of consenting to genital cutting but declines to do so, no type or degree of expected benefit, health-related or otherwise, can ethically justify the imposition of such cutting. If, by contrast, a person is not even capable of consenting due to a temporary lack of sufficient autonomy (e.g., an intoxicated adult or a young child), there are strong moral reasons in the absence of a relevant medical emergency to wait until the person acquires the capacity to make their own decision.

 

The paper that inspired the discussion that inspired this post

Earp, B. D. (in press). Protecting children from medically unnecessary genital cutting without stigmatizing women’s bodies: implications for sexual pleasure and pain. Archives of Sexual Behavior, in press.

Some papers on the politicized and stigmatizing nature of ‘FGM’

Ahmadu, F. (2016). Why the term female genital mutilation (FGM) is ethnocentric, racist and sexist – let’s get rid of it! Hysteria.

Davis, D. S. (2001). Male and female genital alteration: A collision course with the law. Health Matrix, 11(1), 487–570.

Duivenbode, R. (2018). Reflecting on the language we use. Islamic Horizons, January/February, 54–55.

Obiora, L. A. (1996). Bridges and barricades: rethinking polemics and intransigence in the campaign against female circumcision. Case Western Reserve Law Review, 47, 275–378.

Onsongo, N. (2017). Female genital cutting (FGC): Who defines whose culture as unethical? International Journal of Feminist Approaches to Bioethics, 10(2), 105–123.

Rashid, A., & Iguchi, Y. (2019). Female genital cutting in Malaysia: a mixed-methods study. BMJ Open, 9(4), e025078.

Other papers by myself and colleagues linked to in this post

Earp, B. D., & The Brussels Collaboration on Bodily Integrity. (2019). Medically unnecessary genital cutting and the rights of the child: moving toward consensus. American Journal of Bioethics, 19(10), 17-28.

Earp, B. D., & Darby, R. (2017). Circumcision, sexual experience, and harm. University of Pennsylvania Journal of International Law, 37(2 – online), 1-56.

Earp, B. D. (2019). Religious freedom, equal protection, and the child’s (gender neutral) right to bodily integrity. Invited lecture, National Secular Society. May 18. London, England, UK.

Earp, B. D. (2019). The child’s right to bodily integrity. In D. Edmonds (Ed.). Ethics and the Contemporary World (pp. 217-235) Abingdon and New York: Routledge.

Earp, B. D. (2019, January 15). ‘Unconstitutional’ US anti-FGM law exposes hypocrisy in child protection. The Conversation. Available at

Earp, B. D. (2017, August 15). Does female genital mutilation have health benefits? The problem with medicalizing morality. Practical Ethics (University of Oxford).

Earp, B. D. (2016). Between moral relativism and moral hypocrisy: reframing the debate on “FGM.” Kennedy Institute of Ethics Journal, 26(2), 105-144 and E1-E28.

Earp, B. D. (2016). In defence of genital autonomy for children. Journal of Medical Ethics, 41(3), 158-163.

Earp, B. D., Hendry, J., & Thomson, M. (2017). Reason and paradox in medical and family law: shaping children’s bodies. Medical Law Review, 25(4), 604-627.

Earp, B. D. & Shaw, D. M. (2017). Cultural bias in American medicine: the case of infant male circumcision. Journal of Pediatric Ethics, 1(1), 8-26.

Earp, B. D., & Steinfeld, R. (2017). Gender and genital cutting: a new paradigm. In T. G. Barbat (Ed.), Gifted Women, Fragile Men. Euromind Monographs – 2, Brussels: ALDE Group-EU Parliament.

Mohamed, F. S., Wild, V., Earp, B. D., Johnson-Agbakwu, C. & Abdulcadir, J. (in press). Clitoral reconstruction after FGM/C. A review of surgical techniques and ethical debate. Journal of Sexual Medicine, in press.

Myers, A., & Earp, B. D. (in press). What is the best age to circumcise? A medical and ethical analysis. Bioethics, in press.

Shahvisi, A., & Earp, B. D. (2019). The law and ethics of female genital cutting. In S. Creighton & L.-M. Liao (Eds.) Female Genital Cosmetic Surgery: Solution to What Problem? (pp. 58-71). Cambridge: Cambridge University Press.