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A nick for Nick, but nix to nicks for Nickie?

The American Academy of Pediatrics (AAP) has come under fire for a policy statement that has a more nuanced approach to female circumcision (FC) than its previous absolute opposition. The new policy proposes that the law be changed to allow pediatricians to perform a ritual ‘nick’ as a compromise where families request female circumcision. The AAP document strongly opposes all female circumcision that would lead to physical or psychological harm, but suggest that pricking or incising the skin of the external genitalia in females is less harmful than ear piercing. This has led to outrage from groups who oppose female circumcision in all forms.

The AAP argues in favour of the ritual nick on several grounds:

“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 [female circumcision].”

One objection to the compromise is that it would lead to worse outcomes overall for women. Opponents of the policy claim that allowing the compromise would undermine efforts to reduce far more harmful forms of female circumcision, and so lead to more mutilating forms of FC. The authors of the AAP statement argue that the compromise would prevent at least some parents from going overseas to have far more extensive, risky and harmful procedures (or having them illegally). It is hard to be sure what the overall effect of this more permissive policy would be. But the AAP statement is very clear that it does not condone any form of FC, and that damaging forms of FC should remain illegal. It appears plausible that allowing the ritual nick would prevent some harm.

However, Lakshmi Anantnarayam writing in the Guardian claims that even if the compromise were effective in reducing FC it should not be permitted

“human rights standards are absolute and not to be compromised upon in the name of possible harm reduction”

If all forms of FC, including the suggested ‘nick’, represent serious human rights violations, then perhaps it should not be allowed in any circumstances. But if the AAP authors are correct in their claim that there is no physical or psychological harm attributable to this procedure, how or why are the rights of the female infant violated by having it performed? The claim might also lead us to ask another question. Why does the ritual nick violate the rights of female infants, but far more extensive genital surgery performed routinely on males not violate their rights?

Part of the motivation for the AAP’s change of view appears to be recognition that its previous positions on male and female circumcision were inconsistent. There are two consistent positions

A. Surgery on the genitals of the newborn for religious/cultural reasons or parental preference should not be permitted in either females or males.

B. Minor surgery, of an equivalent risk and extent, for religious/cultural reasons or parental preference should be permitted in both males and females.

The new statement from the AAP, although it moves towards B does not in fact achieve consistency. For that it would need to either permit more extensive genital cutting in females than the ritual nick, or prohibit excision of the foreskin in males (but allow a nicking or piercing of the foreskin). However, given that there are some reasons(1) to be more liberal about male circumcision than female circumcision, it appears to be a reasonable compromise.

The other point to note is that the AAP takes great pains to distinguish between interventions that should be discouraged, criticised and avoided, and those that should be criminalized. Not all activities that are morally wrong should be legally prohibited. No parent should subject their child to medically unnecessary genital surgery in infancy. If such procedures are culturally significant they should be performed in later life when the individual can choose for themselves whether to undergo it. Circumcision procedures with significant risks of physical or psychological harm should be outlawed. Nevertheless, even if we disapprove, we may allow parents to choose minor low-risk forms of circumcision for their males or female infants.

(1) Male circumcision (but not FC) has some potential health benefits, offering a degree of protection against HIV. Female circumcision, unlike the male form includes a spectrum of far more pernicious forms, and often occurs within a social context of oppression, discrimination and rights violations.


Ritual Genital Cutting of Female Minors PEDIATRICS Vol. 125 No. 5 May 2010, pp. 1088-1093 (doi:10.1542/peds.2010-0187) 

Female Genital Mutilation PEDIATRICS Vol. 102 No. 1 July 1998, pp. 153-156

Why are US doctors allowing genital mutilation? Lakshmi Anantnarayam Guardian 11/5/10

Cultural Rite, Medical Wrong Elizabeth Reis Bioethics Forum

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8 Comment on this post

  1. You state that male circumcision has some potential benefits and some degree of preotection against HIV, and make no reference to Stallings 2005 findings that Circumcised Tanzanian women (When all confounding variables were controlled for) were found to have lower) rates of HIV. And I would speculate that circumcised women if medical science was interested, would probably have lower rates of vulval cancer. You need to be careful about making assumptions, that may lead to unintended consequences.

    If you are arguing that somehow male circumcision is ok because of some potential medical benefits, then does this also apply to female circumcision, if evidence accumulated that it also had some potential medical benefits. Or is all non-therapeutic genital surgery on those who cannot consent wrong?

  2. Your point about the lack of future medical benefits to female circumcision does require challenge…. exactly how many studies do you think there have been to establish female circ ‘benefits’? Practically none.

    Stallings found the above result apparently by accident and her results didn’t get published – odd that isn’t it!?

    The reality is that it’s just too controversial in the West to sugggest any medical benefits to routine female cutting, even type Ia or IIa. Yet if it’s true that genital folds or flaps are dirty why wouldn’t women be cleaner and have less bacteria/viruses if they were excised?? Here’s an example of the different tack we take with women – in Chennai India researchers found a higher rate of genital HPV among women with poor hygiene. Did anyone argue that bits of skin be cut off to make this water poor/soap poor community safer? No.

    Increasingly though women are speaking up to claim health benefits from FGC – check out not Fuambai Ahmadu’s writing about ‘Bondo’ culture in Sierra Leone’s Patriotic Vanguard as one exammple.

    Ahmadu points out that HIV is significantly lower in African communities which cut both boys and girls, and that (I think) syphilis is lower in cut women. She also points out that the WHO study so often quoted as showing serious long term harm from FGC actually found type I and II had NO statistically significant long term effects. The latest interagency statement says that 90% of FGC is type I, II or type IV nicking – so that would mean only 10% of FGC is harmful according to these criteria…and most is not.

    Check out also cleansexy on you tube who highlights this :

    “Kanki et al. reported that, in Senegalese prostitutes, women who had undergone Female Circumcision had a significantly decreased risk of HIV-2 infection when compared to those who had not.

    Kanki P, M’Boup S, Marlink R, et al. “Prevalence and risk determinants of human immunodeficiency virus type 2 (HIV-2) and human immunodeficiency virus type 1 (HIV-1) in west African female prostitutes
    Am. J. Epidemiol. 136 (7): 895-907. PMID ”

    I’m not trying to justify FGC, but merely point out we Westerners do practise horrific double standards as regards genital cutting.

    Whether a tiny baby will grow up to be dirty, reckless and promiscuous is unknowable. What is clear is that he or she is a human being with rights. And the primary of those rights is to own the skin they’re in.

  3. Dominic Wilkinson

    Interesting points.
    You may both be right that there could be putative health benefits for FC to compare with those ascribed to male circumcision. If so, perhaps we should adopt one of the consistent positions above, either prohibiting or allowing both FC and MC.
    However, the evidence for such benefits for FC is much weaker than the evidence for health benefits of MC. One conference abstract ( is widely cited. No randomised controlled trials (as far as I know) have ever been performed.
    The absence of (good) evidence of benefit doesn’t mean that FC couldn’t confer such benefits, either on the incidence of STDs, or on genital carcinoma. But it does mean that health benefits provide a much weaker justification for FC compared to MC.

    The second question is what difference it would make if it *were* proven that FC confers health benefits. Deciding whether or not FC should be permitted depends not only on the benefits, but also on the harms that it causes.
    Imagine a community that decides to institute prophylactic mastectomy in infancy. Routine excision of breast tissue from female infants might well prevent cases of breast cancer in later life. However, the harms to a much larger group of women from scarring, sexuality and lack of ability to breast feed would vastly outweigh the potential benefits.
    Analogously procedures that involve excision of large amounts of genital tissue appear likely to cause significantly more harms than benefits.

    Additionally if either female or male circumcision does confer some health benefit, there is a further question whether it should be performed in infancy, rather than later when individuals are able to choose for themselves whether or not to undergo the procedure. And, the footnoted point above about the spectrum of much more invidious forms of FC, and the blatant misogyny that often accompanies it might justify a far more restrictive policy relating to FC than MC.

    There is a strong argument that non-therapeutic or prophylactic genital surgery in infancy should not be performed in males or in females. However, in a large number of different contexts we permit parents to make choices that potentially lead to minor harms for their children. Accordingly we should not prohibit procedures that have minimal or no risks of significant physical or psychological harm.

  4. This policy seems to have been decided by a few “cultural relativist” ethicists who have listened to the handful of educated circumcised women who defend the practice (not only for themselves, as is their right, but also for their daughters), but haven’t consulted any of the many women’s agencies that work to end it. Those agencies will have no truck with any “ritual nick”. Cultural relativism is appropriate when studying anthropology, but not necessarily in dealing with customs that are objectively harmful.

    The AAP offers no evidence that girls are being subjected to FGC by amateurs in the US (or that any parents are asking paediatricians first), nor that any are being taken overseas for it. The same day their policy came out, a Bill was introduced in the Senate (H. R. 5137) to outlaw the latter practice.

    The AAP offers no evidence that “ritually nicking” a girl’s genitals does her no harm, especially psychological harm, and it’s hard to see how the experiment could be ethically done to find out. The author of the policy has added that the girl’s “assent” to the procedure should be obtained if she is old enough to give it. What is that age, and why not insist on waiting till that age?

    “Consent” must of course be informed consent, but of what can she be informed? That if she does not consent to a “ritual nick” she might be subjected to clitoridectomy by an amateur? How is that different from a threat? And if she refuses to give her consent, what then? Send the family home, for her perhaps to be punished more violently? Does the AAP advocate asking a boy’s permission for a non-therapeutic male circumcision too? If so, the same questions apply. If not, why the double standard?

    This all suggests that you are correct in thinking the AAP’s main purpose here is to close the glaring gap between its policies on female and male genital cutting. It’s just moving the wrong policy in the wrong direction.

    Non-therapeutic genital cutting is done primarily to benefit, not the child, but the parents. (The disease-prevention claims are all far too weak to justify prophylactic surgery.) This raises critical ethical issues that the AAP’s Committee on Bioethics (and its Committee on Circumcision even more, so far) has failed to address. The child, not the parents, is the patient. She or he is healthy and requires no procedures. It is the parents’ issues that should be dealt with, compassionately, skilfully and ethically.

    The claim that circumcision has a role in preventing HIV is quite dubious, but it seems to hypnotise people. (The underlying motivation for circumcision has always been fear – of disease, ritual pollution, or non-conformity.) Babies don’t have sex, and there is plenty of time for them to decide for themselves if they want part of their genitals removed for that purpose. The fact that doing it in infancy second-guesses their decision should ring alarm bells, not spur anyone on.

  5. Dominic Wilkinson

    Thanks Hugh,

    you make a number of good points

    Certain assumptions in the AAP policy, if incorrect, would invalidate their conclusions.
    So, for example, if a ritual nick or piercing did cause significant physical or psychological harm, then it would undermine their compromise argument.
    Equally, if you are right that there are no or few parents who would (illegally) inflict worse forms of FC on their female infants (were the compromise not legally available), there would be no good reason to allow the ritual nick.

    Those assumptions should be challenged, and may not be correct. However, it is plausible that minor forms of type IV FC would be no more harmful than piercing an ear. Baby ear piercing is not that uncommon. It is more common (even the norm) within some ethnic or cultural groups. Perhaps parents shouldn’t choose to pierce the ears of their infant. But if there is some minor physical harm associated with such a procedure, that is within the bounds of what (within a liberal society) we would permit parents to choose for their child.

    I also agree with your third point, that the potential health benefits would be realisable by later surgery, and that it would be better if circumcision – either male or female, were offered at an age at which individual consent were possible.

    However, I don’t think that cultural relativism plays any significant role in the AAP’s policy. Cultural relativists claim that there is nothing intrinsically right or wrong, it is all a matter of perspective. The AAP policy (and my comment above) clearly indicates that physically or psychologically harmful forms of FC are intrinsically wrong and should not be permitted. They do exhibit ‘cultural sensitivity’, which is the much more plausible idea that, even if we disagree with them we should pay attention to, and take into account the sincerely held views of those in other cultures.

  6. Should we “take into account the sincerely held views” that Nazi culture had and has of the value of Jews, homosexuals, Gypsies and other “defectives”?

    All human beings have the human right to the physical integrity of our bodies. Those who want to violate our rights and our bodies need compassionate but firm education – and control, and appropriate penalties for their violations – not leeway to violate our bodies to some nebulous depth just because they want to, especially in our most private parts.

    Who are the nick police? Who defines the depth and location of permissible violations of babies’ and other children’s sex organs and their human right to the integrity of those and all other healthy, living tissues of their bodies? And what about the children who contract deadly MRSA and other “super-bug” infections and die from these sick sexual nick violations? Is it permissible to kill some children so that ignorant and perverted parents can keep doing “minor” violations of other children’s sex organs? How many children is it OK for looney adults to kill so that responsible (?) adults won’t have to confront other badly mistaken adults and prevent them from inflicting risky, evil cultural practices on their own or other children’s sex organs?

    I say it is permissible to kill zero children for this purpose, no more.

    Do you have a different number to suggest, Dominic?

    What sex the child put at unnecessary risk of injury and death happens to have been born is 100% irrelevant. Boys have no advantage over girls in their circumcision graves. Do we really have to know what sex the dead child is, do we really have to dig them up and verify their sex, before we know whether the deadly circumcision nick violated their human right to bodily integrity, to life itself?


    LOST BOYS: AN ESTIMATE OF U.S. CIRCUMCISION-RELATED INFANT DEATHS – A study published Monday, 26 April 2010, in Thymos: Journal of Boyhood Studies estimates that more than 100 baby boys die from circumcision complications in the USA each year, including from anesthesia reaction, stroke, hemorrhage, and infection. Because infant circumcision is elective, all of these deaths are avoidable.

  7. “However, it is plausible that minor forms of type IV FC would be no more harmful than piercing an ear. Baby ear piercing is not that uncommon. It is more common (even the norm) within some ethnic or cultural groups. Perhaps parents shouldn’t choose to pierce the ears of their infant. But if there is some minor physical harm associated with such a procedure, that is within the bounds of what (within a liberal society) we would permit parents to choose for their child.”

    Many rough things happen out in the real world, but we are talking about what it is ethical to do in a doctor’s office. It would not be lawful or ethical for a doctor to pierce a baby’s ear (though it wouldn’t surprise me if some do). Don’t forget that they undertake to “First do NO harm”, not “just a little harm”. I like the remark attributed to a professional piercer/tattooist: “Bring her back when she can talk and ask for it herself, without parental pressure, and I can tell her it will hurt.”

    The Chair of the AAP’s Bioethics Committee, Dr Douglas Diekema made it clear in an affidavit: “A surgical procedure should not be performed solely because a parent requests it.” (See ) He seems to have forgotten that now.

    “Equally, if you are right that there are no or few parents who would (illegally) inflict worse forms of FC on their female infants (were the compromise not legally available), there would be no good reason to allow the ritual nick.” Or if there are no or few parents who would NOT inflict worse forms of FC on their female infants, were the compromise legally available. See what this Djibouti woman, “K”, has to say: Do you think she would be satisfied or fooled by a “ritual nick”?

  8. Dominic Wilkinson

    Thanks Hugh, Van Lewis,

    you are both right to put pressure on the claim that MC or minimal forms of FC would be devoid of physical or psychological harm. We shouldn’t simply accept claims that these procedures are risk free and harm free. The figure from the Thymos paper is interesting, but I am unable to assess the validity of its claims since it is not available to read in full.
    I agree with you that we should not circumcise infants, as I wrote above “No parent should subject their child to medically unnecessary genital surgery in infancy. If such procedures are culturally significant they should be performed in later life when the individual can choose for themselves whether to undergo it. ”
    The question is about whether such procedures should be outlawed. The AAP policy, and my view, is that they should not.

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