Category Archives: American FGM

Which doctors claim that legalizing some forms of FGM will help some girls?

The most recent discussion in genital integrity forums is the publication of a paper (and related news articles) by two U.S. based gynecologysts, Kavita Arora and Allan Jacobs, of an article called “female genital alteration: a compromise solution” in the Journal of Medical Ethics. In this paper, authors Kavita Arora and Allan Jacobs reframe the discussion of female genital mutilation (FGM) as a matter of “alteration“, because they consider that the term mutilation is culturally insensitive and discriminatory towards women. They argue that mild forms of “FGA” do not constitute a human rights violation, and thus promote that some of those forms could be offered and tolerated as a “compromise” to protect children from more extensive forms of “FGA“, allowing parents to uphold cultural and religious practices “without sacrificing the health and well-being of female children“.

This is obviously a scandalous proposal, and one that is not entirely new. In May of 2010 the American Academy of Pediatrics had already suggested a similar path with their maligned “policy statement on ritual genital cutting of female minors“, a paper that was criticized by the World Health Organization as an obstacle to their efforts to eradicate FGM, and was also criticized by pro-genital integrity and children’s rights organizations such as Intact America, fearful that the American medical community may slowly reinstate the practice of FGM among Americans, a practice that persisted for at least the first half of the 20th century, before slowly falling in obsolescence. The AAP’s policy statement was retired one month later.

Both papers, the AAP policy statement and now Arora and Jacobs’ article, however, acknowledge something that most FGM activists deny: that there are parallels between FGM and the circumcision of male children. The AAP declared that some forms of FGM are far less invasive than male circumcision as practiced in the “West” (sic). Arora and Jacobs refer to the difference in the treatment of male circumcision and “FGA” as “disparate“, and recognize that a possible solution would be to proscribe both practices. They acknowledge that both practices have been criticized as a violation of human rights. However, they have already argued in a previous paper that infant circumcision is not a violation of human rights.

And here is where this new paper is a logical consequence of their previous article.

Published in 2015 in the American Journal of Bioethics, the  article, entitled “Ritual Male Infant Circumcision and Human Rights“, is a very flawed rationalization meant to deny that male infant circumcision can constitute a violation of human rights. It has been one of my objectives for several months, to write a response to this paper, but many circumstances have slowed my efforts. I will, however, summarize a few points here, so that we can better understand their mental process.

Their paper on ritual male infant circumcision pretends to appear multicultural, by using language that appeals more to an European audience.  For example, referring to infant circumcision as “ritual” is common in European circles, since it is not considered a medical practice in those places – I imagine that many American doctors would feel relatively insulted by the suggestion that they are practicing a ritual, which is what Arora and Jacobs  are doing. Through the paper, they often reinforce the fact that Muslims practice circumcision, to give the appearance of diversity. However, Robert Darby pointed that by framing their paper around infant circumcision, they are in fact excluding most “ritual” circumcision practices, such as those from African tribes, Philippines, and Muslim groups, since they occur mostly after infancy. It’s worth noting that in some languages, “infancy” refers to childhood in general, but its current use in English refers only to the pre-verbal period, so mostly the first year of life. Arora and Jacobs responded, in fact reaffirming that their paper refers to infancy only -without expressing disapproval or approval to circumcision beyond infancy, which they consider subject to a separate but related discussion, and state that Islamic circumcisions in the United States are often performed during infancy. Which leads to the basic conclusion, that their paper was not written to protect circumcision as it is performed in Africa, The Philippines or in Muslim countries, only circumcision as it is performed by Jews and Americans.

The fact that Muslims in the United States tend to circumcise during infancy is not a result of Islam, but a result of the American culture which makes infant circumcision easily available and almost normative at birth. The same argument can be made for Jewish people who allow their male babies to be circumcised by doctors before leaving the hospital; orthodox Rabbis consider circumcision performed on the second or third day of life, by gentile doctors, to be inadequate and invalid. Jewish circumcision requires a proper ceremony performed on the eighth day of life, by a trained Jewish mohel, with methods that are not the most sanitary, nor place particular interest in preventing pain for the baby. American Jews who have their babies circumcised in hospitals on the second day, do so not because they are Jews, but because they are Americans, and a similar argument could be made for American Muslims.

So once removing the embellishment and appearance of diversity, the paper is a discussion concerning American and Jewish circumcision only. Arora and Jacobs repeat a number of fallacious, obsolete and even irresponsible arguments – which we will address in a future post:

* That early circumcision is safer when performed in infancy

* That circumcision has little or no effect on male sexuality

* That circumcision causes little harm to the infant

* That the more severe complications of circumcision are of little relevance because of their low incidence – in other words, that killing or severely maiming infants is acceptable as long as it is in a very low rate.

Their paper goes into a discussion of whether genital integrity is in fact a human right, and whether the principle of open future as suggested by Darby is applicable or not. Both discussions are fallacious, and I promise I will refute them in detail later.

Finally, they propose a three step test to determine if a parental decision constitutes a violation of human rights. Predictably enough, they find that under their test, male infant circumcision is not a violation of basic human rights. The irony that they had defined the test in such a way that a favorable result would be obtained, seems to be lost on Jacobs and Arora.

But here’s the catch: under the same test, mild forms of “FGA” would also have to be considered valid parental decisions and not violations of human rights. This new paper on female genital “alteration” is just the logical consequence of such a finding.

Personally, I believe that it is sad that educated adults and physicians, whose minds should be focused on healing, spend all the time and energy they spent into rationalizing and justifying hurting babies as a valid parental decision, as long as the harm is relatively low and any catastrophic incident has a relatively low incidence. To me, the purpose this paper serves seems to be masturbatory fodder for circumcision-crazed psychopaths, and not the work of professional and empathetic physicians, thus earning them a proper space in the bookshelf, next to the works of J. H. Kellogg, Remondino, John Money, Brian Morris, the Benatar brothers and Doug Diekema.

Kavita Arora

Kavita Arora

Kavita Shah Arora is an Assistant Professor of Reproductive Biology and Bioethics at Case Western Reserve University, as well as a practicing general obstetrician/gynecologist at MetroHealth Medical Center. She received her BS with a minor in Philosophy from the Pennsylvania State University. In 2009, she graduated with both an MD from Jefferson Medical College and a Master’s Degree in Bioethics from the University of Pennsylvania. She completed her residency in Obstetrics and Gynecology at McGaw Medical Center of Northwestern University in 2013. She has served on the national ethics committees of both the American Medical Association and the American College of Obstetricians and Gynecologists.

Dr. Arora is primarily based at MetroHealth Medical Center as a practicing general ob/gyn and also serves as the Department’s Director of Quality. She is an active member of the hospital’s ethics committee. Her research interests include reproductive ethics, reproductive technology, perinatal decision making, conscience, HIV care in pregnancy, and feminist Bioethics. She is also interested in medical education, especially with the intersection of ethics education.

An existent video of Kavita Arora appears to present an idealistic, happy, young adult with passion to provide a nice birthing experience to female patients. When was this passionate healer derailed into defending the indefensible -harming babies, male and female alike? How does she get away with publishing a paper that is beyond the scope of her practice which is not in surgery, urology or pediatric care, but the care of women and their reproductive systems?

Dr. Allan Jacobs

Dr. Allan Jacobs

Allan Jacobs is Professor of Obstetrics, Gynecology, and Reproductive Medicine at Stony Brook University School of Medicine. He received his B.A. (psychology) at Cornell University, his M.D. from the University of Southern California, and his J.D. from St. John’s University. He completed his residency at Parkland memorial Hospital and his fellowship at Mount Sinai Hospital. A board certified gynecologic oncologist, he serves as Chairman of the Department of Obstetrics and Gynecology at Flushing Hospital Medical Center. He has published articles in the field of reproductive ethics in journals such as the Hastings Center Reports. He has also published in the area of health law, a current research interest. He teaches biomedical ethics and health law to medical students and residents.

As for Allan Jacobs, his religious affiliation seems to account for his bias in favor of circumcision. Note that he too, is a gynecologist, for whom the concern for the genitals of healthy male children should be zero.

To our knowledge, none of the American doctors that used to perform clitorectomies and other forms of FGM on all-American female minors, ever paid for their crimes. Not even more recent ones, those that removed the phalluses (clitorises or penises) and gonads of intersex babies, as did Dr. Dix Poppas at Cornell University or Dr. Ian Aaronson at the Medical University of South Carolina, -and then proceeded to rationalize those procedures by calling those babies “disordered” (DSD) in the 2006 “consensus“, have paid their time for performing procedures that should be proscribed by the FGM law of 1997.

 To our knowledge, a single case stands in the United States. Dr. Hatem Elhagaly, Muslim, was fired from the Mayo Clinic  for promoting a practice that is illegal in America but, in his words, “honors Islam.” Mayo Clinic however has experience with surgical treatment of ambiguous genitalia, procedures matching the definition of FGM.

 In publishing this paper arguing for mild forms of “FGA“, Jacobs and Arora have followed the logical steps established by their previous paper, but they have also put themselves at odds with the Western rejection of FGM.

Their only positive point is breaking again that “taboo” that makes most American doctors afraid to suggest any comparison between male infant circumcision and female genital mutilation. But the conclusion that those practices are not violation of human rights seems to detract from the humanity and dignity of the authors.

 We believe doctors should dedicate their efforts to serve their patients as healers, not as cultural or religious brokers defending the “parental right” to harm the child (the patient) as part of a ritual.

We hope to see Arora and Jacobs publicly retract their two papers, or follow the steps of Dr. Elhagaly.

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Are American doctors still performing clitoridectomies (FGM) on girls?

The website “Atlas of Pelvic Surgery” has an article on “excision of the hypertrophied clitoris“. I first thought it was a historic note about how clitoridectomies used to be performed 60 years ago, but no, what I found was that the”Atlas of Pelvic Surgery was originally developed as a practical guide to the performance of gynecologic procedures which reflected Dr. Wheeless’ broad experience in surgery and his skill as a teacher.

The “Atlas of Pelvic Surgery” started as a book published by Dr. Wheeless, with its third edition printed in 1997 (coincidentally the year that the federal law against FGM was enacted in the United States). The website itself constitutes the 4th edition of the Atlas. In fact the index of recent updates includes the article on excision of the hypertrophied clitoris, so this article must be relatively recent (but no date is given)

Graphic taken from the Atlas of Pelvic Surgery website

I was in shock. Yes I know that the treatment for intersex girls with enlarged clitoris used to be the removal of the clitoris… long time ago! Today, they use “nerve sparing surgeries” to reduce but not to remove the clitoris (clitoroplasty), and yet this procedure when performed on a minor constitutes a violation of a child’s physical integrity (according to the PACE), may damage orgasmic function, and is rejected by the intersex community as a violation of human rights.

But… clitoridectomy (excision of the clitoris)… TODAY?

Excised hypertrophied clitoris… from a 1925 book

The website is the work of Clifford R. Wheeless, Jr., MD, and Marcella L. Roenneburg, MD. both of them servicing Baltimore, Maryland, Dr. Wheeless here, and Dr. Roenneburg here.

I verified the ownership of the website. The domain is registered to Dr. Roenneburg.

According to Jewish Woman International, Dr. Roenneburg is a Jewish woman providing service to African women.

These are the indications and purpose of the excision of the hypertrophied clitoris described in the Atlas of Pelvic Surgery (I underlined key words):

Clitoral hypertrophy, regardless of etiology, is a source of psychological stress, especially in young females. Most pediatric gynecologists stress the importance of normal external genitalia in young children. It is important to weigh the role of the clitoris in sexual climax against the psychological stress incurred when the genitalia of a young child are different from her peers.

The purpose of the operation is to excise the hypertrophied clitoris and create normal-appearing external genitalia.

Female patient before and after clitoroplasty (not full excision – but nevertheless removal of a large portion of the clitoris). While the authors of this 2006 article considered the “cosmetic results” good, some loss of sensation and sexual damage is inevitable when altering the clitoris.

I decided to review the U.S. federal law against FGM:

(a) Except as provided in subsection (b), whoever knowingly circumcises, excises, or infibulates the whole or any part of the labia majora or labia minora or clitoris of another person who has not attained the age of 18 years shall be fined under this title or imprisoned not more than 5 years, or both. 

(b) A surgical operation is not a violation of this section if the operation is— 

(1) necessary to the health of the person on whom it is performed, and is performed by a person licensed in the place of its performance as a medical practitioner; or 

(2) performed on a person in labor or who has just given birth and is performed for medical purposes connected with that labor or birth by a person licensed in the place it is performed as a medical practitioner, midwife, or person in training to become such a practitioner or midwife.

Notice that the FGM law provides an exception when it is “necessary to the health of the person“. However the excision of hypertrophic clitoris is not medically necessary. It is only done to “normalize” the aspect of the genitalia, adducing “psychological stress” of the child – but in reality this refers to the “psychological stress” of parents who perceive their daughter as abnormal.

I also checked if Maryland has a law against FGM, and found that the punishment for FGM includes “imprisonment for up to five years and/or a fine of up to $5,000“.

According to the World Health Organization, there are four types of female genital mutilation, the first one being:

  • Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).
 The recent resolution of the Parliamentary Assembly of the Council of Europe names several procedures that violate the physical integrity of children, among them Female Genital Mutilation and early childhood interventions of intersex children. The procedure described by the Atlas of Pelvic surgery is both, a childhood intervention of intersex children and female genital mutilation.
Given that the Atlas of Pelvic Surgery “reflect[s] Dr. Wheeless’ broad experience in surgery“, we have to ask: has Dr. Wheeles performed the excision of hypertrophied clitoris? Has he performed this surgery after 1997?
Since the site also reflects “his skill as a teacher“, does he teach how to perform this procedure? (the existence of this article on the website would be evidence for this).
Given that Dr. Roenneburg provides service to African women, has she performed this procedure on daughters of African women? On those from countries and cultures where FGM is prevalent?

According to Jewish Women International, Dr. Roenneburg has operated “on scores of women with these devastating childbearing-related wounds, called vesicovaginal fistulas—holes between the bladder and the vagina” in Niger. It should be safe to assume that she is aware that these vesicovaginal fistulas are sometimes consequence of female genital mutilation, and that FGM is prevalent in Niger (one of the forms of FGM prevalent in Niger is clitoridectomy). So why does a website registered under her name and which includes her bio, and which is meant to be used as a learning resource, explains how to perform clitoridectomies? 

Is FGM at the hands of American surgeons any less of a crime?

Are there American girls and women of any ethnia living their lives without their clitoris, having had it removed at the hands of Dr. Wheeles, Dr. Roenneburg, or the students of Dr. Wheeles or readers of his book or their website?

Related: How parents ‘consenting’ to intersex genital mutilations (IGM) do so because of biased information given by doctors

Related: Clitoris Amputations & Intersex Genital Mutilation (see PDF files)

Testimonials of American women subjected to clitoridectomy as a way to prevent masturbation, by American doctors, at parents request, during the 20th century.

Please listen to their testimonies. They were traumatized by doctors. Is it fair to perform this procedure on any girl? Even if she has a “hypertrophic” (which simply means “large”) clitoris?

To put it in perspective, would you treat a boy with a “large penis” by having the penis removed?

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Related: Hida Viloria, intersex activist, on Montel Williams. Hida Viloria was born with what these doctors would consider a “hypertrophied clitoris”, but her dad, a Colombian doctor, had the awareness to decline surgery.

Circleaks is willing to listen to Dr. Wheeless and Dr. Roenneburg. We wish they can provide a sworn statement that they have not performed this procedure, and can justify a reason why this procedure should be even included on a teaching website -or proceed to advise AGAINST this procedure on their website, and if they do so, we will make their voice public.  Otherwise, it is our duty to expose to the American public our suspicion that these doctors may have performed this procedure or taught others (either in person, through Dr. Wheeless book or through the website) how to perform it, thus possibly prolonging  the history of forced clitoridectomy (female genital mutilation) in the United States into the 21st century.

And yes we are aware that the article is about excision of the “hypertrophied” clitoris – in other words, a large clitoris that resembles a small penis. It remains true that the clitoris is an integral part of female sexuality, and whether it is small or large, its removal has devastating lifetime consequences for the individual. No parent – and no doctor- should ever make this decision for any girl.

Related: Upcoming book about female circumcision and clitoridectomy in the United States

Resources on the Victorian Era clitoridectomy in UK and US

Isaac Baker Brown and his “harmless operative procedure”

Isaac Baker Brown and the clitoridectomy operation

According to this article on FGM Network, a 1894 doctor was one of the last doctors to perform clitoridectomies. We know this is not the case, with the two video testimonials having had their operation during the middle of the 20th century, and with intersex clitoridectomies occurring up to the 70s… or until now?

 The sexual politics of female circumcision – mostly about FGM in Africa, it includes a first person account of a victim of African clitoridectomy and also some information about the origin and motivation of clitoridectomies in the US and UK.

An obsolete residual of the Victorian era, much like routine infant circumcision:

In females, the author has found the application of pure carbolic acid (phenol) to the clitoris an excellent means of allaying the abnormal excitement. John Harvey Kellogg, Plain Facts for Old and Young, 1888 

Cool sitz baths; the cool enema; a spare diet; the application of blisters and other irritants to the sensitive parts of the sexual organs, the removal of the clitoris and nymphae… John Harvey Kellogg, Ladies’ guide in health and disease, 1893

More on Dr. Wheeless and Dr. Roenneburg’s background:

Dr. Wheeless is certified by the American Board of Obstetrics and Gynecology, is a fellow of the American College of Obstetrics and Gynecology, the American College of Surgeons and the Southern Surgical Association. He received his degree from the University of North Carolina and has been a member of The Johns Hopkins Medical Institution. He was a Professor of Gynecology and Obstetrics at Emory University and at Sinai Hospital, and later at the Hopkins School of Medicine.

Dr. Roennesburg received her medical degree from the Medical College of Wisconsin and completed her internship and residency at Union Memorial Hospital in Baltimore, under the direction of Dr. Wheeless. She received a Distinguished Alumni Award for Community Service by the University of Winsconsin.

Additional Exhibits

Types of Female Genital Mutilation per the World Health Organization. Notice that type I is shown removing not only the external portion of the clitoris, but also the clitoral hood (the prepuce, the equivalent of the male foreskin)

Lawson, Wilkins et al, removal of hypertrophic clitoris. Published in 1958 and again in 1971, pretty much the same procedure explained by Dr. Wheeless and Dr. Roenneburg.
Source: stop.genitalmutilation.org
“Nerve sparing” clitoroplasty, still a mutilating surgery which intends to spare the nerve bundle. Adult patients who had this procedure during childhood still report pain and sexual dysfunction. 
Image source: Article by John M. Hutson at Pediatric Urology Book. Text added by an activist opposing these kinds of surgeries.

Related topic: Dr. Dix Poppas caused strong commotion in 2010 when people learned that he was following up on “nerve sparing clitoroplasties” by testing sensitivity with a q-tip and a vibrating device… on minor patients. This scandal allowed many people to learn about clitoromegaly (“hypertrophied” clitoris) and congenital adrenal hyperplasia. However, as far as we know, nobody has apologized for reducing the clitoris of these girls.

From Hasting Reports, Bad Vibrations

From Secular Parent, The not so good touches of Dr. Dix Poppas

Dr. Dix Poppas, Description of technique

OII Intersex network: A conspiracy of deceit

In “Aesthetic surgery of the Female Genitalia” (2011), Dobbeleir et al indicate that four ethical principles mark the difference with genital cutting practices. The first principle is “Autonomy of the patient” (Patients should be over 18 years old, psychologically stable, and fully informed on the risks and expected results, so that the decision in full knowledge of the issue is theirs only. An informed consent should always be obtained). The text indicates that if any of the preconditions are not fulfilled, aesthetic genital surgery should not take place.

Clitoral surgery on “young girls” does not fulfill this requirement, thus making it Female Genital Mutilation.

The World Health Organization

While far from condemning intersex genital surgeries, the World Health Organization casts such surgeries in negative light (underlined by us):

Many intersex children have undergone medical intervention for health reasons as well as for sociological and ideological reasons. An important consideration with respect to sex assignment is the ethics of surgically altering the genitalia of intersex children to “normalize” them.

Clitoral surgery for intersex conditions was promoted by Hugh Hampton Young in the United States in the late 1930s. Subsequently, a standardized intersex management strategy was developed by psychologists at Johns Hopkins University (USA) based on the idea that infants are gender neutral at birth. (38) Minto et al. note that “the theory of psychosexual neutrality at birth has now been replaced by a model of complex interaction between prenatal and postnatal factors that lead to the development of gender and, later, sexual identity”. (39) However, currently in the United States and many Western European countries, the most likely clinical recommendation to the parents of intersex infants is to raise them as females, often involving surgery to feminize the appearance of the genitalia. (40)

Minto et al. conducted a study aiming to assess the effects of feminizing intersex surgery on adult sexual function in individuals with ambiguous genitalia. As part of this study, they noted a number of ethical issues in relation to this surgery, including that:

  • there is no evidence that feminizing genital surgery leads to improved psychosocial outcomes;
  • feminizing genital surgery cannot guarantee that adult gender identity will develop as female; and that
  • adult sexual function might be altered by removal of clitoral or phallic tissue. (41)

World Health Organization – Gender and Genetics 

The mentioned idea that infants are gender neutral at birth comes from John Money and Johns Hopkins University, who first tested this on David Reimer, when, as a baby (born Bruce, 1965), lost his penis as the result of a botched circumcision. John Money oversaw his raising as a female (Brenda) including follow ups. David’s later testimony tells of John Money forcing him and his twin brother Brian to “play sex” with the hope that “Brenda” would accept the passive role. According to David, Money photographed these sessions; David was however unable to obtain copy of the records, which were donated to the Kinsey Institute to remain sealed in perpetuity. During adolescence, the test was deemed a failure, and “Brenda” took a new male identity, David, undergoing breast removal and penile reconstruction. For many years, Money continued presenting the “John/Joan” case (fictitious names) as a success until David went public in 1997. David committed suicide in 2004, at the age of 38.

Many medical institutions still cite the work of John Money when dealing with intersex patients and genital surgeries.

I find it ironic that when dealing with medical excision of clitoral tissue, the WHO says that “adult sexual function might be altered“, but when described in the context of female genital mutilation, it “interferes with the natural functions of girls’ and women’s bodies“.