Does Female Genital Mutilation Have Health Benefits? The Problem with Medicalizing Morality

Does Female Genital Mutilation Have Health Benefits? The Problem with Medicalizing Morality

By Brian D. Earp (@briandavidearp)

Please note: this piece was originally published in Quillette Magazine.


Four members of the Dawoodi Bohra sect of Islam living in Detroit, Michigan have recently been indicted on charges of female genital mutilation (FGM). This is the first time the US government has prosecuted an “FGM” case since a federal law was passed in 1996. The world is watching to see how the case turns out.

A lot is at stake here. Multiculturalism, religious freedom, the limits of tolerance; the scope of children’s—and minority group—rights; the credibility of scientific research; even the very concept of “harm.”

To see how these pieces fit together, I need to describe the alleged crime.

* * *

The term “FGM” is likely to bring to mind the most severe forms of female genital cutting, such as clitoridectomy or infibulation (partial sewing up of the vaginal opening). But the World Health Organization (WHO) actually recognizes four main categories of FGM, covering dozens of different procedures.

One of the more “minor” forms is called a “ritual nick.” This practice, which I have argued elsewhere should not be performed on children, involves pricking the foreskin or “hood” of the clitoris to release a drop of blood.

Healthy tissue is not typically removed by this procedure, which is often done by trained clinicians in the communities where it is common. Long-term adverse health consequences are believed to be rare.

Here is why this matters. Initial, albeit conflicting reports suggest that the Dawoodi Bohra engage in this, or a similar, more limited form of female genital cutting – not the more extreme forms that are often highlighted in the Western media. This fact alone will make things rather complicated for the prosecution.

The defense team has already signaled that it will emphasize the “low-risk” aspect of the alleged cutting, claiming that it shouldn’t really count as mutilation. It is, after all, far less invasive than Jewish ritual male circumcision, which is legally allowed on minors in the US, no questions asked.

Based on this discrepancy, if attorneys for the Bohra can show a gendered or religious double standard in existing law, the ramifications will be not be small. Either male circumcision will have to be restricted in some way, or “minor” forms of FGM permitted. The outcome either way will be explosive.

I will dig into the male-female comparison—and explore its legal implications—later on. But the law will not actually be my main focus. Instead, what I’ll suggest in this piece is that the question of health consequences, whether positive or negative, should not exhaust the ethical analysis of these procedures.

There is more to “good” and “bad” than healthy versus unhealthy.

In fact, as the Bohra case will show, there are serious, even dangerous downsides to medicalizing moral reasoning – and to moralizing medical research. On both counts, I argue, at least when it comes to childhood genital cutting, apparently biased policies from the WHO are making things a great deal worse.

* * *

“The tendency today is to roll over and ‘scientify’ everything,” says Julian Savulescu, a philosopher at the University of Oxford. He goes on: “Evidence will tell us what to do, people believe.” But people are getting it wrong. When you reduce your ethical analysis to benefit-risk ratios, you miss important questions of value.

Take the ritual nick, or male circumcision for that matter, and ask yourself what might be morally problematic about these customs, benefits and risks to one side. A few possibilities come to mind.

First, the perceived need to cut children’s genitals—whatever their sex or gender, and however severe the cutting—as a precondition for accepting them into a community should plausibly be questioned, rather than taken for granted.

Part of the reason for this is that, regardless of health consequences, many individuals whose genitals were cut when they were children grow up to feel disturbed by what they take to be an intimate violation carried out when they were too young to understand or refuse.

That prospect alone should weigh heavily in parents’ minds when contemplating these sorts of practices. The genitals are not like other parts of the body. People assign different meanings to having their “private parts” cut or altered, and they do not always appreciate, much less value or endorse, the intentions of the ones who did the cutting.

For example, realizing that they needed to be “marked” or “purified”—that they were not seen as perfect the way they were born—can be hard to swallow for many “cut” individuals, even if no tissue is removed. A person can always undergo a genital procedure later on in life, if that is what they want. But those who resent being cut cannot “undo” what has happened.

There is also the possibility of psychological harm, over and above the issue of contested “meanings.” Although it is hard to measure scientifically, such harm undoubtedly varies with the mental and emotional disposition of the child and the timing and circumstances of the cutting.

Some Bohra women, for example, report feeling emotionally traumatized by what happened to them when they were little girls—the confusion, the pain, the embarrassment of being held down with their genitals exposed—while others insist that they didn’t mind, and are proud of being cut. (Similar ambivalence can be found among religiously circumcised men.)

Both kinds of testimony should be taken seriously. Yet those who claim there is no harm in “mild” forms of childhood genital cutting often ignore such individual differences. Instead, they point to vague, impersonal averages or talk in abstract, theoretical terms.

Not uncommonly, they claim to be speaking on behalf of their entire religious community, as though it were a monolith (at least with respect to attitudes about cutting). Meanwhile, dissenters from within the community are often ridiculed, waived away, or simply silenced: those who speak out may be faced with “excommunication and social boycott.”

The power of tradition to smother resistance can be intense.

* * *

All of that said, even if “health consequences” were the only thing that mattered morally, the fact that a given act of cutting is less severe than some alternative does not eliminate the need for concern. This is because any time a sharp object is brought into contact with sensitive flesh, it poses some risk of physical harm, however small.

The knife could slip. Nerve damage could occur. Bleeding or infections could ensue. And while those factors might not be ethically decisive for more “neutral” parts of the body—even ear-piercing and cosmetic orthodontics carry risks—a person might reasonably conclude that any chance of adverse outcomes is too great when it comes to their sexual organs.

Finally, if health consequences in the form of “health benefits” are seen as legitimizing childhood genital cutting—as is often suggested in the case of male circumcision—then proponents of female genital cutting (FGC) who are loath to give up their valued custom might be motivated to find such benefits in order to appease their critics.

They might even succeed in doing so. For reasons I will get into later, it is not actually implausible that certain “mild” forms of FGC, such as neonatal labiaplasty, could reduce the risk of various diseases.

But that wouldn’t make the cutting a good idea. Instead, I will argue that children should be free to grow up with their genitals intact—no nicks, cuts, or removal of tissue—even if the risk of adverse health consequences turns out to be mild, and even if certain health benefits can be found.

* * *

What about the legal issues? I can’t say too much about the particulars of the forthcoming trial because I don’t want to prejudice the outcome, but I can make some general observations.

To be frank, the US government has probably picked the worst possible case to show it is “serious” about addressing FGM. It is setting itself up for plausible accusations of anti-Muslim bias, as well as sexist double standards (as I hinted at before).

The main reason for this is as follows. If convicted, the Muslim minority defendants face 10 years to life in prison for allegedly practicing a form of FGM that is less physically invasive than other forms of medically unnecessary genital cutting that are legally tolerated in Western countries.

I have already mentioned male circumcision. There is also intersex genital “normalization” surgery (which has been brilliantly discussed in this context by Nancy Ehrenreich); supposedly virginity-signaling hymen “repair” surgeries (which I have written about elsewhere); and at least some so-called “cosmetic” female genital operations, which are increasingly being carried out on minors.

I promised I would tackle the male-female comparison, so let’s look at male circumcision (some details are needed to spotlight the inconsistencies, but I hope you will bear with me). Unlike the “ritual nick,” which does not typically alter the form or function the external (female) genitalia, male circumcision permanently alters both.

To begin with, it—by definition—removes most or all of the foreskin, which is about 50 square centimeters of elastic tissue in the adult organ and the most sensitive part of the penis to light touch.

It creates a ring of scar tissue around the shaft that is often discolored.

It makes sexual activities that involve manipulation of the foreskin—see here for a NSFW video—impossible. And it exposes the head of the penis, naturally an internal organ, to rubbing against clothing, which can cause chafing and irritation.

Those are the guaranteed effects. Possible “side effects” include painful erections if too much skin is removed (the penis is very small at birth and the choice of where to cut is essentially a guess), partial amputation of the glans due to surgical error, infections, cysts, fistulas, adhesions, pathological narrowing of the urinary opening, severe blood loss, and rarely—except in tribal settings where it is common—death.

Yet it is perfectly legal in the United States to perform a circumcision on a male child for any reason. Religion, culture, parental preference—regardless of the motivation, the cutting is tolerated, and you don’t need a medical license to do it.

In fact, even ultra-Orthodox Jews who perform an unhygienic “oral suction” form of circumcision, in which the circumciser takes the boy’s penis into his mouth and sucks the wound to staunch the bleeding, are legally permitted to do so without state certification or oversight. This is despite confirmation of more than a dozen cases of herpes transmission, two cases of permanent brain damage, and two infant deaths likely caused by the practice between 2004 and 2012.

Those are just the figures for New York City. But still there are no legal restrictions. As the bioethicist Dena Davis has pointed out, “states currently regulate the hygienic practices of those who cut our hair and our fingernails, so why not a baby’s genitals?”

She means “baby boy’s” genitals; baby girls’ genitals are protected by law.

The Bohra defense team will likely flag these inconsistencies. If ritual male circumcision is not only legally permitted but completely unregulated in the US, they will argue, then how can a procedure that carries fewer risks and is less physically damaging be classified as a federal crime? They will also point to the religious significance of “female circumcision” among the Bohra. They will ask: aren’t religious practices granted strong legal protections in the United States and other Western countries?

The prosecution will almost certainly make two moves in response. First, they will argue that FGM is not truly a religious practice, but is “merely” a cultural tradition, because there is no mention of female circumcision in the Koran. And second, they will point out that male circumcision has been linked to certain health benefits, whereas FGM “has no health benefits” (as stated by the WHO).

* * *

But things are not so simple. It is true that female circumcision is not mentioned in the Koran; but neither is male circumcision. And yet the latter is widely regarded as a “religious” practice not only within Judaism but also Islam. As Alex Myers notes, “if we defer to religious justifications, we shall find that in many cases, the circumcision of female as well as male children could be permitted on this basis.”

How could that be so? In her landmark paper entitled, “Male and Female Genital Alteration: A Collision Course with the Law,” Dena Davis notes that “binding religious obligations” can stem from oral traditions and other “extrabiblical sources,” such as rabbinic commentaries or papal encyclicals in the case of Judaism or Christianity. Likewise, “Islam looks to other sources to interpret and supplement Koranic teachings.”

One such source is the Hadith—the sayings of the Prophet Mohammed—which is the other major basis for Islamic law apart from the Koran.

Both male and female circumcision are mentioned in the Hadith. Based on their reading of the relevant passages, some Muslim authorities state that “circumcision” of both sexes is recommended or even obligatory, while others draw a different conclusion. There is no ultimate authority in Islam to settle such disputes, however, so debate continues to this day.

What this means is that, until a consensus is reached in the Muslim world, the status of female genital cutting as a “religious” or “cultural” practice will depend on each community’s local evaluation of secondary Islamic scriptures. Dawoodi Bohra clerics view the practice as religious.

This leads to an uncomfortable thought. In the West, we seem more or less unfazed by the religiously sanctioned cutting of boys’ genitals; but we go into a panic over less severe procedures performed on the genitals of girls by equally pious parents.

In fact, we bend over backwards to convince ourselves that the latter procedures are “not actually religious” by selectively citing scholars who agree with us—as though not being “religious” somehow made a practice less worthy of being respected, or being “religious” made it morally OK. Neither of those propositions follow.

Finally, we attribute evil motives to the parents who circumcise their daughters, when the same parents almost invariably also circumcise their sons, sometimes more invasively, and often for identical reasons. (The stereotype that female circumcision is “all about” misogyny and sexual control, while male circumcision is about neither, is one that I, and many other scholars, have deconstructed elsewhere: see here for a fairly short summary. Suffice it to say the claim is not true.)

So who are we kidding? The overwhelming majority of American parents who circumcise their sons do it for “cultural” rather than religious reasons, and few seem concerned to bat an eye. Even many Jews who circumcise are committed atheists (and for all I know, so are many Muslims). Although the law may treat “religion” as a special, separate category, the religious versus “cultural” status of male or female genital cutting is not what drives our different moral judgments.

* * *

So maybe it’s “health benefits.” Maybe we think male circumcision is acceptable because it has medical advantages, whereas female circumcision only has “social” advantages (eligibility for marriage, greater acceptance by the community, seen as more aesthetic, and so on).

I don’t think that’s the solution, either. First, the idea that “social” benefits are less important than “health” benefits would need some defending: I have already mentioned the pitfalls of capitulating to the domain of medicine in order to avoid having to think through complex moral issues. But let us just assume that all we care about is “health” for a moment and see where this exercise leads us.

Most of the decent-quality data showing health benefits for male circumcision (primarily, a modest reduction in the absolute risk of some sexually transmitted infections) come from surgeries performed on adults in Africa, not babies in the United States or Europe. The findings cannot be simply copy-pasted from one context and age range to another.

But even if you could just copy and paste, you would still have to factor in the risks and harms of circumcision, which are not trivial. In fact, most national medical associations to have issued formal policies on the question have found that the benefits of childhood male circumcision are not sufficient to outweigh the disadvantages of the surgery in developed countries.

(There is one glaring exception to this, which we’ll come back to.)

This suggests either that the scales are closely balanced, as the Canadian Pediatric Society claims, or actually tipped in the direction of net harm, as the Royal Dutch Medical Association has concluded. Further south, the Royal Australasian College of Physicians states: “the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.”

In any case, the existence of “some” health benefits (as opposed to net health benefits—and that would still not resolve the moral issues) would make for a very weak defense of the practice even on purely medical grounds.

Just think. Removing any healthy tissue from a child’s body will confer “some” health benefits: tissue that has been excised can no longer host a cancer, become infected, or pose any other problem to its erstwhile owner. But as the bioethicist Eike-Henner Kluge has noted, if this logic were accepted more generally, “all sorts of medical conditions would be implicated” and we would find ourselves “operating non-stop on just about every part of the human body.”

* * *

Alarmingly, one place we might start operating is the pediatric vulva. Compared to the penis, the external female genitalia provide if anything “an even more hospitable environment to bacteria, yeasts, viruses, and so forth, such that removing moist folds of tissue (with a sterile surgical instrument) might very well reduce the risk of associated problems.”

In countries where female circumcision is relatively common, this is exactly what is claimed for the procedure. Cited health benefits include “a lower risk of vaginal cancer … fewer infections from microbes gathering under the hood of the clitoris, and protection against herpes and genital ulcers.”

Moreover, at least two studies by Western scientists have shown a negative correlation between female circumcision and HIV. The authors of one of the studies, both seasoned statisticians who expected to find the opposite relationship, described their findings as a “significant and perplexing inverse association between reported female circumcision and HIV seropositivity.”

None of these findings is conclusive. I am not saying that female “circumcision” can ward off HIV or any other disease. But let us just imagine that some of the above-cited health benefits are eventually confirmed. Would anti-FGM campaigners suddenly be prepared to say that female genital cutting was ethically acceptable?

I would be surprised if that turned out to be the case. In other words, even if health benefits do one day become reliably associated with some medicalized form of female genital cutting, I expect that opponents of the practice—including the WHO—would say, “So what?”

First, they would argue that healthy tissue is valuable in-and-of-itself, so should be counted in the “harm” column simply by virtue of being damaged or removed. Second, they would point to non-surgical means of preventing or treating infections, and suggest that these should be favored over more invasive methods. And third, they would bring up the language of rights: a girl has a right to grow up with her genitals intact, they would say, and decide for herself at an age of understanding whether she would like to have parts of them cut into or cut off.

The same arguments apply to male circumcision. But as Kirsten Bell has pointed out, the WHO steadfastly refuses to connect the dots. In her words, they seek to “medicalize male circumcision on the one hand” by promoting it, over the objections and reservations of many outside experts, as a form of prophylaxis against HIV. But they “oppose the medicalization of female circumcision on the other, while simultaneously basing their opposition to female operations on grounds that could legitimately be used to condemn the male operations.”

The problem with appeals to “health benefits,” then, is that they are disingenuous and inconsistently applied. As Robert Darby has argued, “official bodies working against FGC have condemned medicalization of the procedure and funded massive research programs into the harm of the surgery.” The irony, as he sees it, is that the WHO “also frames male circumcision as a public health issue—but from the opposite starting point.” Thus, we see that

instead of a research program to study the possible harms of circumcision, it funds research into the benefits and advantages of the operation. In neither case, however, is the research open-ended: in relation to women the search is for damage, in relation to men it is for benefit; and since the initial assumptions influence the outcomes, these results are duly found.

Perhaps even more striking, the WHO’s asymmetrical focus on health benefits could backfire. Specifically, it could open the door for supporters of female genital cutting to mount a defense of the procedure modeled on the male parallel.

To put it simply, if the sheer existence of health benefits is so compelling to organizations like WHO, these supporters might think, then all we have to do is generate the right kind of evidence, and we can fend off critics of our cherished custom.

* * *

There are already signs of this happening. At least one female Muslim gynecologist—from Khartoum University in the Sudan—has been reported as saying: “if the benefits [of female circumcision] are not apparent now, they will become known in the future, as has happened with regard to male circumcision.”

(Perhaps she will be inspired by the websites of American plastic surgeons, who already claim all manner of physical and mental health benefits for elective labiaplasty – and other purported “cosmetic” operations).

Similarly, the anthropologist Fuambai Ahmadu has written about the women of Sierra Leone: “Why, one woman asked, would any reasonable mother want to burden her daughter with excess clitoral and labial tissue that is unhygienic, unsightly and interferes with sexual penetration … especially if the same mother would choose circumcision to ensure healthy and aesthetically appealing genitalia for her son?”

And what about the Dawoodi Bohra? As reported by Tasneem Raja, herself a member of the community and a former editor at NPR, some Bohra women believe that female circumcision, which they call khatna, “has something to do with ‘removing bad germs’ and liken it to male circumcision, which is widely … believed to have hygienic benefits.”

It is currently illegal in Western countries to conduct a properly controlled scientific study to determine whether a “mild,” sterilized form of female genital cutting carried out in infancy or early childhood confers some degree of protection against disease.

But if anti-FGM campaigners and organizations such as the WHO continue to play the “no health benefits” card as a way of deflecting comparisons to male circumcision, it will not be long before medically-trained supporters of the practice in other countries begin to do the necessary research.

* * *

The history of male circumcision shows how this could happen. Alongside female genital cutting, male genital cutting originated in African prehistory as a ritual practice, and was later adopted by various Semitic tribes. For most of its existence, the only claimed advantages of the procedure were social or metaphysical in nature—identifying the boy as a member of a particular group, for example, or sealing a divine covenant, as in Judaism.

In the physical realm, by contrast, circumcision was largely believed to have negative effects, including on sexual feeling and satisfaction. By “dulling” the sexual organ of male children, parents believed that their sons would pay more attention to important “spiritual” matters and be less tempted by the pleasures of the flesh.

It was only in recent times that religious supporters of male circumcision began to argue that it was “physically” beneficial—recasting the procedure as a secularly defensible measure of individual or even public health, as opposed to solely a cultural or religious practice.

In the United States, for example, circumcision was adopted in part as an anti-masturbation tactic in the late 1800s (masturbation, at the time, was thought to cause not only moral but medical ills; see here for a video introduction). The resulting shift from “religious” to “medical” proved strategically important in Christian-majority societies, where genital cutting of children had otherwise been seen as barbaric.

The medical historian David Gollaher has argued that Jewish physicians, whose “attitudes toward circumcision were partly shaped by their own cultural experience,” found the late 19th century evidence of health benefits “especially compelling.” Most of it was later debunked.

Nevertheless, the search for “health benefits” continues to this day. A large proportion of the current medical literature purporting to show health benefits for male circumcision has been generated by doctors who were themselves circumcised at birth—often for religious reasons—and who have cultural, financial, or other interests in seeing the practice preserved.

* * *

Science and medicine are not immune from such agendas or biases. In 2012, the American Academy of Pediatrics (AAP) controversially concluded that the health benefits of newborn male circumcision outweighed the risks (this is the “glaring exception” I said I’d come back to). Their conclusion was puzzling, since they did not have a method for assigning weights to individual benefits or risks, much less an accepted mechanism by which the two could be compared.

They were also missing the denominator to their equation. On page 772 of their report they state that, due to limitations with the existing data, “the true incidence of complications after newborn circumcision is unknown.”

So how could we know they are outweighed by the benefits?

In an unprecedented move, the AAP was rebuked by senior physicians, ethicists, and representatives from national medical societies based in the UK, Canada, and mainland Europe, who argued that the findings were likely culturally biased. The AAP Circumcision Task Force later acknowledged that the benefits were only “felt” to outweigh the risks. It came down to a subjective judgment.

Reflecting on the debacle in a recent editorial, Task Force member Andrew Freedman tried to explain how he and his colleagues had reached a different conclusion to that of their peers in other countries despite looking at the same medical evidence. In doing so, he made a revealing comment:

Most circumcisions are done due to religious and cultural tradition. In the West, although parents may use the conflicting medical literature to buttress their own beliefs and desires, for the most part parents choose what they want for a wide variety of nonmedical reasons. There can be no doubt that religion, culture, aesthetic preference, familial identity, and personal experience all factor into their decision.

In a separate interview, Freedman stated that he had circumcised his own son on his parents’ kitchen table. “But I did it for religious, not medical reasons,” he wrote. “I did it because I had 3,000 years of ancestors looking over my shoulder.”

Arguing that it is “not illegitimate” for parents to consider such social and spiritual “realms [in] making this nontherapeutic, only partially medical decision,” Freedman went on to say that “protecting” the parental option to circumcise “was not an idle concern” in the minds of the AAP Task Force members “at a time when there are serious efforts in both the United States and Europe to ban the procedure outright.”

* * *

The women in societies that practice what they call female circumcision are just as devoted to their cultural traditions as are the men who practice genital cutting of boys. They don’t want their customs banned either. If “medical benefits” are sufficient to ward off condemnation, a strong incentive will exist to seek them out.

I suggest, therefore, that by repeating the mantra—in nearly every article focused on female genital cutting—that “FGM has no health benefits,” those who oppose such cutting are sending the wrong signal. The mantra implies that if FGM did have health benefits, it wouldn’t be so bad after all.

But that isn’t what opponents really think. Regardless of health consequences, they see nontherapeutic genital cutting of female minors as contrary to their best interests, propped up by questionable social norms that should themselves be challenged and changed.

I would go one step further. All children—female, male, and intersex—have a compelling interest in intact genitalia. All else being equal, they should get to decide whether they want their “private parts” nicked, pricked, labiaplastied, “normalized,” circumcised, or sewn, at an age when they can appreciate what is really at stake.

This doesn’t mean a “ban” on such procedures before an age of consent is necessarily the best way to go. As I have explained elsewhere, legal prohibition can be a clumsy way of bringing about social change, often causing more harm than good. I worry, for example, that taking young girls out of their homes, invasively examining their genitals in search of “evidence,” and throwing their parents—who no doubt love them—in jail, could be more traumatic than the initial act of cutting.

As for the Dawoodi Bohra case, we will just have to see how the judge interprets—and applies—the existing laws.

My own preference is for debate and dialogue, not bans and vilification. But whatever approach one takes, it is time to move beyond the tired (and false) dichotomies of male versus female, religion versus culture, and health benefits versus no health benefits. The focus for critics of genital cutting going forward, I contend, should be on children versus adults—that is, on bodily autonomy and informed consent.


Key references

Abdulcadir, J., Ahmadu, F. S., Catania, L., & Public Policy Advisory Network on Female Genital Surgeries in Africa (2012). Seven things to know about female genital surgeries in AfricaThe Hastings Center Report42(6), 19-27.

Bell, K. (2015). HIV prevention: making male circumcision the ‘right’ tool for the jobGlobal Public Health10(5-6), 552-572.

Bell, K. (2005). Genital cutting and Western discourses on sexualityMedical Anthropology Quarterly19(2), 125-148.

Darby, R. (2015). Risks, benefits, complications and harms: neglected factors in the current debate on non-therapeutic circumcisionKennedy Institute of Ethics Journal25(1), 1-34.

Darby, R. (2016). Targeting patients who cannot object? Re-examining the case for non-therapeutic infant circumcisionSAGE Open6(2), 1-16.

Darby, R., & Svoboda, J. S. (2007). A rose by any other name? Rethinking the similarities and differences between male and female genital cuttingMedical Anthropology Quarterly21(3), 301-323.

Davis, D. S. (2001). Male and female genital alteration: a collision course with the law? Health Matrix11(1), 487-570

Dustin, M. (2010). Female genital mutilation/cutting in the UK: challenging the inconsistenciesEuropean Journal of Women’s Studies17(1), 7-23.

Ehrenreich, N. (2005). Intersex surgery, female genital cutting, and the selective condemnation of cultural practicesHarvard Civil Rights-Civil Liberties Law Review, 40(1), 71-539.

Fox, M., & Thomson, M. (2009). Foreskin is a feminist issueAustralian Feminist Studies24(60), 195-210.

Frisch, M., Aigrain, Y., Barauskas, V., Bjarnason, R., Boddy, S. A., Czauderna, P., … & Gahr, M. (2013). Cultural bias in the AAP’s 2012 Technical Report and Policy Statement on male circumcisionPediatrics131(4), 796-800.

Giami, A., Perrey, C., de Oliveira Mendonça, A. L., & de Camargo, K. R. (2015). Hybrid forum or network? The social and political construction of an international ‘technical consultation’ on male circumcision and HIV preventionGlobal Public Health10(5-6), 589-606.

Gollaher, D. L. (1994). From ritual to science: the medical transformation of circumcision in AmericaJournal of Social History28(1), 5-36.

Goodman, J. (1999). Jewish circumcision: an alternative perspectiveBJU international83(S1), 22-27.

Gruenbaum, E. (1996). The cultural debate over female circumcision: the Sudanese are arguing this one out for themselvesMedical Anthropology Quarterly10(4), 455-475.

Hammond, T., & Carmack, A. (2017). Long-term adverse outcomes from neonatal circumcision reported in a survey of 1,008 men: an overview of health and human rights implicationsThe International Journal of Human Rights21(2), 189-218.

Hodges, F. (1997). A short history of the institutionalization of involuntary sexual mutilation in the United States. In Sexual Mutilations (pp. 17-40). New York: Springer US.

Hodžić, S. (2013). Ascertaining deadly harms: aesthetics and politics of global evidenceCultural Anthropology28(1), 86-109.

Johnsdotter, S., & Essén, B. (2010). Genitals and ethnicity: the politics of genital modificationsReproductive Health Matters18(35), 29-37.

Johnson, M. (2010). Male genital mutilation: Beyond the tolerable? Ethnicities10(2), 181-207.

Lightfoot-Klein, H., Chase, C., Hammond, T., & Goldman, R. (2000). Genital surgery on children below the age of consent. In Psychological Perspectives on Human Sexuality (pp. 440–79). New York: John Wiley & Sons.

Mason, C. (2001). Exorcising excision: medico-legal issues arising from male and female genital surgery in AustraliaJournal of Law and Medicine9(1), 58-67.

Obiora, L. A. (1996). Bridges and barricades: rethinking polemics and intransigence in the campaign against female circumcisionCase Western Reserve Law Review47, 275.

Reis-Dennis, S., & Reis, E. (2017). Are physicians blameworthy for iatrogenic harm resulting from unnecessary genital surgeriesAMA Journal of Ethics19(8), 825-833.

Shahvisi, A. (2017). Why UK doctors should be troubled by female genital mutilation legislationClinical Ethics12(2), 102-108.

Shell‐Duncan, B. (2008). From health to human rights: female genital cutting and the politics of interventionAmerican Anthropologist110(2), 225-236.

Shweder, R. A. (2013). The goose and the gander: the genital warsGlobal Discourse3(2), 348-366.

Shweder, R. A. (2000). What about “female genital mutilation”? And why understanding culture matters in the first placeDaedalus129(4), 209-232

Solomon, L. M., & Noll, R. C. (2007). Male versus female genital alteration: differences in legal, medical, and socioethical responsesGender medicine4(2), 89-96.

Steinfeld, R., & Earp, B. D. (2017). How different are male, female, and intersex genital cutting? The Conversation. May 15.

Svoboda, J. S. (2013). Promoting genital autonomy by exploring commonalities between male, female, intersex, and cosmetic female genital cuttingGlobal Discourse3(2), 237-255.

Van den Brink, M., & Tigchelaar, J. (2012). Shaping genitals, shaping perceptions: a frame analysis of male and female circumcisionNetherlands Quarterly of Human Rights30(4), 417-445.

Van Howe, R. S. (2011). The American Academy of Pediatrics and female genital cutting: when national organizations are guided by personal agendasEthics and Medicine27(3), 165-173.


Further related reading by the author (by year)

Earp, B. D., Hendry, J., & Thomson, M. (2017). Reason and paradox in medical and family law: shaping children’s bodiesMedical Law Review, in press.

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

Earp, B. D., & Frisch, M. (2017). Circumcision of male infants and children as a public health measure in developed countries: a critical assessment of recent evidence. Global Public Health, in press.

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

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.

Earp, B. D. (2016). Between moral relativism and moral hypocrisy: reframing the debate on “FGM.” Kennedy Institute of Ethics Journal26(2), 105-144.

Earp, B. D. (2016). In defence of genital autonomy for childrenJournal of Medical Ethics42(3), 158-163.

Earp, B. D. (2016). Boys and girls alike: The ethics of male and female circumcision. In E. C. H. Gathman (Ed.), Women, Health, & Healthcare: Readings on Social, Structural, & Systemic Issues (pp. 113-116). Dubuque, IA: Kendall Hunt Publishing Company.

Earp, B. D. (2016). Infant circumcision and adult penile sensitivity: implications for sexual experience. Trends in Urology & Men’s Health, 7(4), 17-21.

Earp, B. D. (2015). Female genital mutilation and male circumcision: toward an autonomy-based ethical frameworkMedicolegal and Bioethics5(1), 89-104.

Earp, B. D. (2015). Sex and circumcisionThe American Journal of Bioethics15(2), 43-45.

Earp, B. D. (2015). Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Frontiers in Pediatrics, 3(18), 1-6.

Earp, B. D., & Darby, R. (2015). Does science support infant circumcision? The Skeptic, 25(3), 23-30.

Earp, B. D. (2014). Female genital mutilation (FGM) and male circumcision: Should there be a separate ethical discourse? Practical Ethics. University of Oxford.

Earp, B. D. (2013). The ethics of infant male circumcisionJournal of Medical Ethics39(7), 418-420.

Earp, B. D. (2013). Criticizing religious practices. The Philosophers’ Magazine, 63(1), 15-17.

Earp, B. D. (2012). The AAP report on circumcision: bad science + bad ethics = bad medicine. Practical Ethics. University of Oxford.


About the author

Brian D. Earp is a philosopher, psychologist, and ethicist. A proponent of accessible, public communication of science and philosophy, he has written for such venues as Aeon, The Atlantic, The Chronicle of Higher Education, Quillette, Newsweek and Slate. His collected publications, both academic and popular, are freely available at Brian holds degrees from Yale, Oxford, and Cambridge Universities.

Can we trust research in science and medicine?

By Brian D. Earp  (@briandavidearp)

Readers of the Practical Ethics Blog might be interested in this series of short videos in which I discuss some of the major ongoing problems with research ethics and publication integrity in science and medicine. How much of the published literature is trustworthy? Why is peer review such a poor quality control mechanism? How can we judge whether someone is really an expert in a scientific area? What happens when empirical research gets polarized? Most of these are short – just a few minutes. Links below:

Why most published research probably is false

The politicization of science and the problem of expertise

Science’s publication bias problem – why negative results are important

Getting beyond accusations of being either “pro-science” or “anti-science”

Are we all scientific experts now? When to be skeptical about scientific claims, and when to defer to experts

Predatory open access publishers and why peer review is broken

The future of scientific peer review

Sloppy science going on at the CDC and WHO

Dogmas in science – how do they form?

Please note: this post will be cross-published with the Journal of Medical Ethics Blog.

Hard lessons: learning from the Charlie Gard case

by Dominic Wilkinson and Julian Savulescu


On the 24th July 2017, the long-running, deeply tragic and emotionally fraught case of Charlie Gard reached its sad conclusion (Box 1). Following further medical assessment of the infant, Charlie’s parents and doctors finally reached agreement that continuing medical treatment was not in Charlie’s best interests. It is expected that life support will be withdrawn in the days ahead.

Over the course of multiple hearings at different levels of the court in both London and Strasbourg, the Charlie Gard case has raised a number of vexed ethical questions (Box 2). The important role of practical ethics in cases like this is to help clarify the key concepts, identify central ethical questions, separate them from questions of scientific fact and subject arguments to critical scrutiny. We have disagreed about the right course of action for Charlie Gard,1 2 but we agree on the key ethical principles as well as the role of ethical analysis and the importance of robust and informed debate. Ethics is not about personal opinion – but about argument, reasons, and rational reflection. While the lasting ramifications of the case for medical treatment decisions in children are yet to become apparent, we here outline some of the potential lessons. Continue reading

Press Release – “The Worst Outcome” Prof Dominic Wilkinson

This afternoon the long-running, deeply tragic and emotionally fraught legal dispute over treatment of Charlie Gard reached its sad and sadly inevitable conclusion. Following further medical assessment of Charlie by several international experts, Charlie’s parents and doctors finally reached agreement that continuing life support and experimental treatment could not help him.

This is the worst possible outcome for Charlie’s family. They have had to accept the devastating news that their beloved son cannot recover and that their hopes for an experimental treatment cannot be realised.

There are important lessons to learn from this case. Cases of deep disagreement between parents and doctors about treatment for a child are rare. Where they occur, it is often possible with time, patience, and support to find common ground. Where agreement cannot be reached, there is an important role for the courts in helping to reach a decision. However, court review of cases like this is not ideal. It is adversarial, costly, and lengthy. In this case, Charlie has received months of treatment that doctors and nurses caring for him felt was doing him more harm than good.

We need to find better ways to avoid cases of disagreement from coming to court. There is an important role for mediation to help parents and doctors where they have reached an impasse.

We also need a fair, expedient way of resolving disputes. This would mean that patients can access early experimental treatment if there is a reasonable chance that it would not cause significant harm. It would also mean that futile and harmful treatment is not prolonged by a protracted legal process.

Medical tourism for controversial treatment options

By Dominic Wilkinson


Baby C’s parents had done their research. They had read widely about different options for C and had clear views about what they felt would be best for their child. They had asked a number of doctors in this country, but none were willing to provide the treatment. After contacting some specialists overseas, they had found one expert who agreed. If the family were able to pay for treatment, he was willing to provide that treatment option.

However, when C’s local doctors discovered that the parents planned to leave the country for treatment the doctors embarked on court proceedings and contacted the police.

One of the questions highlighted in the Charlie Gard case has been whether his parents should be free to travel overseas for desired experimental treatment. It has been claimed that the NHS and Great Ormond St are “keeping him captive”. Why shouldn’t C’s parents be free to travel to access a medical treatment option? When, if ever, should a state intervene to prevent medical tourism? Continue reading

The ethics of treatment for Charlie Gard: resources for students/media

by Dominic Wilkinson and Julian Savulescu


The case of Charlie Gard has reached its sad conclusion. However, it continues to attract intense public attention. It raises a number of challenging and important ethical questions.

The role of Practical Ethics in cases like this is to help clarify the key concepts, identify central ethical questions, separate them from questions of scientific fact and subject arguments to critical scrutiny. We have disagreed about the right course of action for Charlie Gard, but agree on the role of ethical analysis and the importance of robust and informed debate. Ethics is not about personal opinion – but about argument, reasons, and rational reflection.

We have collected together below some of the materials on the Charlie Gard case that we and others have written as well as some relevant resources from our earlier work. We will update this page as more material becomes available. (*Updated 4/8/17) Continue reading

The non-identity problem of professional philosophers

By Charles Foster

Philosophers have a non-identity problem. It is that they are not identified as relevant by the courts. This, in an age where funding and preferment are often linked to engagement with the non-academic world, is a worry.

This irrelevance was brutally demonstrated in an English Court of Appeal case,  (‘the CICA case’) the facts of which were a tragic illustration of the non-identity problem. Continue reading

Are Incentives Corrupting? The Case of Paying People to be Healthy.

Written by Dr Rebecca Brown

Financial incentives are commonplace in everyday life. As tools of states, corporations and individuals, they enable the ‘tweaking’ of motivations in ways more desirable to the incentiviser. A parent may pay her child £1 to practice the piano for an hour; a café offers a free coffee for every nine the customer buys; governments offer tax breaks for homeowners who make their houses more energy efficient. Most people, most of the time, would probably find the use of financial incentives unobjectionable.

More recently, incentives have been proposed as a means of promoting health. The thinking goes: many diseases people currently suffer from, and are likely to suffer from in the future, are largely the result of behavioural factors (i.e. ‘lifestyles’). Certain behaviours, such as eating energy dense diets, taking little exercise, smoking and drinking large amounts of alcohol, increase the risk that someone will suffer from diseases like cancer, heart disease, lung disease and type II diabetes. These diseases are very unpleasant – sometimes fatal – for those who suffer from them, their friends and family. They also create economic harms, requiring healthcare resources to be directed towards caring for those who are sick and result in reduced productivity through lost working hours. For instance,the annual cost to the economy of obesity-related disease is variously estimated as £2.47 billion£5.1 billion and a whopping $73 billion (around £56.5 billion), depending on what factors are taken into account and how these are calculated. Since incentives are generally seen as useful tools for influencing people’s behaviour, why not use them to change health-related behaviours? Why not simply pay people to be healthy? Continue reading

Damages and communitarianism

By Charles Foster

The Lord Chancellor recently announced that the discount rate under the Damages Act 1996 would be decreased from 2.5% to minus 0.75%. This sounds dull. In fact it is financially tectonic, and raises some important ethical questions.

In the law of tort, damages are intended to put a claimant in the position that she would have been in had the tort not occurred. A claimant who, as result of negligence on the part of a defendant, suffers personal injury, will be entitled to, inter alia, damages representing future loss of earnings, the future cost of care and, often, private medical and other treatment.

Where damages are awarded as a lump sum, there is a risk of over-compensating a claimant. Suppose that the claimant is 10 years old at the time of the award, and will live for 70 years, and the future care costs are £1000 a year for life. Should the sum awarded be £1000 x 70 years = £70,000? (70, here, is what lawyers call the ‘multiplier’). It depends on the assumption one makes about what the claimant will do with the lump sum. If she invests it in equities that give her (say) an annual 5% return, £70,000 would over-compensate her.

In the case of Wells v Wells1, the House of Lords decided that, to avoid the risk of under-compensation, claimants should be treated as risk-averse investors. It should be assumed, said the House, that the discount rate should be fixed by reference to the return on index-linked gilts – Government securities. The rate was 2.5% from 2001 until February of this year. The reasons for the change to minus 0.75% are hereContinue reading

Guest Post: Mind the accountability gap: On the ethics of shared autonomy between humans and intelligent medical devices

Guest Post by Philipp Kellmeyer

Imagine you had epilepsy and, despite taking a daily cocktail of several anti-epileptic drugs, still suffered several seizures per week, some minor, some resulting in bruises and other injuries. The source of your epileptic seizures lies in a brain region that is important for language. Therefore, your neurologist told you, epilepsy surgery – removing brain tissue that has been identified as the source of seizures in continuous monitoring with intracranial electroencephalography (iEEG) – is not viable in your case because it would lead to permanent damage to your language ability.

There is however, says your neurologist, an innovative clinical trial under way that might reduce the frequency and severity of your seizures. In this trial, a new device is implanted in your head that contains an electrode array for recording your brain activity directly from the brain surface and for applying small electric shocks to interrupt an impending seizure.

The electrode array connects wirelessly to a small computer that analyses the information from the electrodes to assess your seizure risk at any given moment in order to decide when to administer an electric shock. The neurologist informs you that trials with similar devices have achieved a reduction in the frequency of severe seizures in 50% of patients so that there would be a good chance that you benefit from taking part in the trial.

Now, imagine you decided to participate in the trial and it turns out that the device comes with two options: In one setting, you get no feedback on your current seizure risk by the device and the decision when to administer an electric shock to prevent an impending seizure is taken solely by the device.

This keeps you completely out of the loop in terms of being able to modify your behaviour according to your seizure risk and – in a sense – relegates some autonomy of decision-making to the intelligent medical device inside your head.

In the other setting, the system comes with a “traffic light” that signals your current risk level for a seizure, with green indicating a low, yellow a medium, and red a high probability of a seizure. In case of an evolving seizure, the device may additionally warn you with an alarm tone. In this scenario, you are kept in the loop and you retain your capacity to modify your behavior accordingly, for example to step from a ladder or stop riding a bike when you are “in the red.”

Continue reading


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