Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed?
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Brussels Collaboration on Bodily Integrity. 2024. Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed? The American Journal of Bioethics, ISSN 1526-5161 [Article] (In Press)
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Abstract or Description
When is it ethically permissible for clinicians to surgically intervene into the genitals of a legal minor? We distinguish between voluntary and nonvoluntary procedures and focus on nonvoluntary procedures, specifically in prepubescent minors (“children”). We do not address procedures in adolescence or adulthood. With respect to children categorized as female at birth who have no apparent differences of sex development (i.e., non-intersex or “endosex” females) there is a near-universal ethical consensus in the Global North. This consensus holds that clinicians may not perform any nonvoluntary genital cutting or surgery, from “cosmetic” labiaplasty to medicalized ritual “pricking” of the vulva, insofar as the procedure is not strictly necessary to protect the child’s physical health. All other motivations, including possible psychosocial, cultural, subjective-aesthetic, or prophylactic benefits as judged by doctors or parents, are seen as categorically inappropriate grounds for a clinician to proceed with a nonvoluntary genital procedure in this population. We argue that the main ethical reasons capable of supporting this consensus turn not on empirically contestable benefit–risk calculations, but on a fundamental concern to respect the child’s privacy, bodily integrity, developing sexual boundaries, and (future) genital autonomy. We show that these ethical reasons are sound. However, as we argue, they do not only apply to endosex female children, but rather to all children regardless of sex characteristics, including those with intersex traits and endosex males. We conclude, therefore, that as a matter of justice, inclusivity, and gender equality in medical-ethical policy (we do not take a position as to criminal law), clinicians should not be permitted to perform any nonvoluntary genital cutting or surgery in prepubescent minors, irrespective of the latter’s sex traits or gender assignment, unless urgently necessary to protect their physical health. By contrast, we suggest that voluntary surgeries in older individuals might, under certain conditions, permissibly be performed for a wider range of reasons, including reasons of self-identity or psychosocial well-being, in keeping with the circumstances, values, and explicit needs and preferences of the persons so concerned. Note: Because our position is tied to clinicians’ widely accepted role-specific duties as medical practitioners within regulated healthcare systems, we do not consider genital procedures performed outside of a healthcare context (e.g., for religious reasons) or by persons other than licensed healthcare providers working in their professional capacity.
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This work grew out of informal discussions among participants in the G3 International Experts Meeting on FGM/C in Brussels, Belgium, May 20–22, 2019, along with other scholarly collaborators. A shorter statement by some members of our group was previously published in the American Journal of Bioethics (BCBI Citation2019). Our collaborative network has shifted and grown since then, including by way of additional workshops in Höör, Sweden, and Toronto, Canada, in 2023. The present article represents the views of the signing authors listed below. We are physicians, ethicists, nurse-midwives, public health professionals, legal scholars, human rights advocates, political scientists, anthropologists, psychologists, sexologists, sociologists, philosophers, and feminists from Africa, Asia, Australasia, Europe, the Middle East, and the Americas with interdisciplinary or experiential expertise in child genital cutting practices across a wide range of cultural contexts. Although we do not necessarily share a single policy perspective with respect to such practices, nor a uniform moral assessment of every feature of them, we are united in a concern about inconsistencies, double standards, and Western cultural bias in the prevailing discourses on genital cutting of children. Some of us have evolved in our thinking over the years in response to scholarship illuminating such problems. Indeed, several of the present authors have previously performed medically unnecessary genital surgeries on healthy children at the parents’ request, whether for cultural, prophylactic, or psychosocial reasons—or as a part of their medical training—without realizing the ethical implications at the time. Some of the present authors, moreover, have authorized such surgeries for their own children (a decision for which they have sought to make amends). Those among us who were, ourselves, subjected to medically unnecessary genital cutting or surgery as children have a range of complex attitudes toward our parents and physicians; although we cannot change the past, we are committed to creating a better future. Together, we argue that no child—no person—who has not requested such an intervention and given their own “morally transformative” agreement or permission for it to occur should have a surgical or other cutting instrument applied to their genital anatomy except in cases of medical necessity. We argue for a more coherent, sex- and gender-inclusive approach that recognizes (1) the special vulnerability of young people—regardless of their sex characteristics—to medically unnecessary genital cutting or surgery and (2) the moral importance of bodily integrity, respect for bodily/sexual boundaries, and consent. The contributors are listed alphabetically. Jasmine Abdulcadir; Peter W. Adler; Melanie T. Almonte; Frank W. J. Anderson; Gabriela Arguedas-Ramírez; Mark P. Aulisio; Dina Bader; David Balashinsky; Arlene B. Baratz; Maide Bariş; Greta Bauer; Maren Behrensen; Hanoch Ben-Yami; Janice Boddy; Yasmin Bootwala; Hilary Bowman-Smart; Lori Bruce; Max Buckler; Mauro Cabral Grinspan; Pieter Cannoot; Morgan Carpenter; Marie-Xavière Catto; Moisés Catalán; Clare Chambers; Georganne Chapin; James Chegwidden; Dan Christian Ghattas; Sharyn Clough; Ronán M. Conroy; Hossein Dabbagh; Katharine B. Dalke; Sophie Dallière; Limor Meoded Danon; Dena S. Davis; Georgiann Davis; Angela J. Dawson; Debra L. DeLaet; Vilius Dranseika; Max DuBoff; James G. Dwyer; Brian D. Earp; Tammary Esho; Birgitta Essén; Mohamed A. Baky Fahmy; Ellen K. Feder; Nuno Ferreira; Odile Fillod; Stéphanie Florquin; Pierre Foldès; Marie Fox; Morten Frisch; Michela Fusaschi; Fae Garland; John Geisheker; Anca Gheaus; Teresa Giménez Barbat; Tobe Levin Freifrau von Gleichen; Samantha Godwin; Ronald Goldman; E. J. Gonzalez-Polledo; Jenny Goodman; Alexandro José Gradilla; Ellen Gruenbaum; Tatenda Gwaambuka; Ghada Hatem-Gantzer; M. Hakim; Tim Hammond; Ivar R. Hannikainen; Miriam van der Have; Debby Herbenick; Yuko Higashi; B. Jessie Hill; R. Elise B. Johansen; Aarefa Johari; Crista Johnson-Agbakwu; Matthew T. Johnson; Samuel Kimani; Eva Komba; Julia Kolak; Sophia Koukoui; Cynthia Kraus; Stephen R. Latham; Bo Laurent (formerly Cheryl Chase); Hazel Learner; Antony Lempert; Patrick Lenta; Olivia Lesslar; Jonathan Lewis; Lih-Mei Liao; Erika Lorshbough; Jean-Christophe Lurenbaum; Noni E. MacDonald; Ryan McAllister; Jonathan Meddings; Claudia Merli; Mayli Mertens; Marilyn Milos; Ranit Mishori; Surya Monro; Lisa Braver Moss; Stephen R. Munzer; Hannah M. Nazri; Daniel Ncayiyana; Ivars Neiders; Londé Ngosso; Marianne Nguena; Anton A. van Niekerk; Nathan Nobis; Alphonce Odhiambo Oduor; Sarah O’Neill; Deborah Ottenheimer; Panda Paalanen; César Palacios-González; Xin Qing; Janet Radcliffe Richards; Franck Ramus; Abdul Rashid Khan; Saarrah Ray; Elizabeth Reis; Samuel Reis-Dennis; Larissa Remennick; Fabienne Richard; Katrina Roen; Eliana Rubashkyn; Eldar Sarajlic; Lauren Sardi; Udo Schuklenk; Arianne Shahvisi; David Shaw; Guy Sinden; Daniel Sidler; Linda Skitka; Margaret A. Somerville; Sigrid Sterckx; J. Steven Svoboda; Mariya Taher; Godfrey B. Tangwa; Michael Thomson; Kate Goldie Townsend; Mitchell Travis; Robert S. Van Howe; Alla Vash-Margita; Emmanuelle Verhagen; Tiina Vilponen; Michela Villani; Hida Viloria; Elly Vintiadis; Tommaso Virgili; Bilkis Vissandjée; Eliyahu Ungar-Sargon; Anna Wahlberg; Rebecca Wald; Reubs J. Walsh; Desmond Weisenberg; Hannah Wenger; Travis Wisdom; Ernesto Zelayandia; Renata Ziemińska; Kimberly Zieselman; Mai Mahgoub Ziyada. |
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| Keywords: |
Children and families; intersex; professional ethics; gender/sexuality; circumcision; ritual pricking; “FGM” |
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| Item ID: |
37509 |
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| Date Deposited: |
05 Sep 2024 11:58 |
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| Last Modified: |
05 Sep 2024 11:58 |
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Peer Reviewed: |
Yes, this version has been peer-reviewed. |
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