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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