Zero tolerance

FGCP include a range of procedures: labiaplasty, clitoroplasty, and introitoplasty aim to reshape or reduce the size of the inner or outer labia, clitoris, and vaginal opening, respectively. Hymenoplasty involves the reconstruction of the hymen; vaginal rejuvenation refers to tightening the vaginal canal and/or increasing its thickness and elasticity through surgical or laser techniques; and intimate peeling refers to the chemical bleaching of skin in the genital area (Goodman 2022). Unlike gynaecological surgeries that address health issues, such as uterine prolapse, incontinence, or the removal of vaginal tumours, FGCP are typically pursued for aesthetic reasons or functional enhancement rather than medical necessity. Reliable data on the prevalence and geographical spread of FGCP are limited due to inconsistent reporting and lack of standardised surveys. However, data from the International Society of Aesthetic/Cosmetic Surgery (ISAPS) indicate a rising trend in countries such as the USA, UK, Brazil, Mexico, Germany, Argentina, Turkey, India, and Iran (ISAPS 2023). Clinics offering these procedures are also present in countries where FGM/C is prevalent, such as Egypt, Ghana, and Kenya. Feminists have linked the rise of FGCP to unrealistic beauty standards propagated by traditional and social media, pornography, and sex education materials (e.g. Maki et al. 2023). The idealised vulva is typically depicted with small, symmetrical labia minora tucked within the labia majora, with an evenly coloured, smooth appearance. Medicine reinforces these standards by medicalising genital variations, framing them as abnormalities in need of correction (Braun 2019). Cosmetic surgeons promote labiaplasty as a solution to ‘excessive’ labia, further pathologising natural diversity. This interplay between beauty norms and medicalisation has fuelled demand for FGCP, as many women come to perceive their genitalia as not only unattractive but also abnormal.

FGCP technically fall under the WHO definition of FGM/C as the total or partial removal or any injury to female genitalia for non-medical reasons (WHO 2018). Yet they are not treated or criminalised as FGM/C by governments and development agencies, nor are they generally perceived as such in public opinion. Since the 1990s, feminist scholars have criticised this selective condemnation and argued that it reflects racism and colonial legacies, rather than inherent differences (Pedwell 2007). They highlight that FGM/C shares significant similarities with Western beauty practices and genital surgeries as all involve modifying the body to conform to socio-cultural ideals around gender, identity, and sexuality (Boddy 1998, 2016; O’Neill et al. 2020). Some have drawn direct parallels between FGM/C and FGCP, noting that both seek to create a ‘neat’ and ‘feminine’ appearance by removing parts considered excessive or masculine, such as the clitoris or longer inner labia (Boddy 2020). Others, such as Gruenbaum (2005), link both practices to dominant expectations of female sexuality, arguing that they serve cultural ideals of attractiveness for male pleasure. Shahvisi and Earp (2019) further argue that FGM/C and FGCP are anatomically comparable, as FGCP – such as clitoroplasty, labiaplasty, and vaginal tightening – correspond directly to the WHO’s FGM Types 1, 2, and 3 respectively. Given these similarities, scholars have questioned why FGM/C and FGCP are treated so differently. Defenders of this distinction claim that FGM/C is patriarchal, affects children, is non-consensual, and unsafe, but Shahvisi (2023) challenges these assumptions, arguing that FGM/C serves multiple functions beyond controlling female sexuality, that similar procedures are performed on minors in Western countries, and that FGCP is just as embedded in cultural pressures. She further notes that the increasing medicalisation of FGM/C in some regions has narrowed the safety gap between the two practices. These observations have led scholars to conclude that the moral and legal distinction between FGM/C and FGCP is not based on inherent differences but reflects a double standard rooted in ethnocentric, racist, and colonial assumptions (Ahmadu 2017; Earp and Johnsdotter 2021). A key aspect of this bias is the assumption that African women are passive victims of patriarchal cultures, while Western women are portrayed as autonomous agents unaffected by culture (Mohanty 1988). Scholars have challenged this dichotomy, arguing that all women – African and Western – make bodily choices within structures that shape, constrain, or normalise certain practices. They reject the idea that Western women’s choices are entirely autonomous. Boddy (1998), for example, discusses the social and economic penalties for failing to meet beauty standards.

The simultaneous rise of medicalised FGM/C and FGCP, alongside a zero-tolerance policy toward the former and the acceptance and even promotion of the latter as modern and empowering, makes this double standard increasingly apparent. This has created a new dynamic where women can undergo elective genital surgeries that are not medically necessary but are performed by healthcare professionals, often driven by motivations and desired outcomes similar to those of FGM/C. Furthermore, FGCP are increasingly available in African urban centres, resulting in a situation where both FGM/C and FGCP are offered side by side in the same geographical areas – yet only one is criminalised. This contrast also highlights how race and class shape access: FGCP are typically accessible to white Western women and wealthier urban Africans, while medicalised FGM/C, though costlier than traditional methods, remains more widely accessible.

As medicalised FGM/C and FGCP become more common, debates over their unequal treatment have moved from academia into policy, medical, and legal arenas. Drawing on case studies from The Netherlands (Van Bavel), Kenya (Van Bavel and Kimani), and Egypt (Van Eekert), this chapter shows that what was once seen as a theoretical concern is now clearly untenable in real-world contexts.

In 2003, the WHO rejected harm-reduction approaches altogether, adopting a zero-tolerance policy that criminalised all forms of FGM/C, including medicalised FGM/C and symbolic procedures such as clitoral hood pricking. Inspired by 1980s US law enforcement logic – that minor infractions can lead to broader societal harm (Greene 2019) – this approach assumes that medicalised FGM/C legitimises the practice by giving it a medical veneer, thereby undermining efforts toward total abandonment (WHO 2020).

The zero-tolerance approach was accompanied by a shift in the framing of the practice: previously seen primarily as a health risk, it was now also defined as an inherent violation of human rights (Shell-Duncan 2008). This shift meant that even when health risks were reduced through medicalisation or less invasive procedures, FGM/C was still deemed unacceptable because it violated women’s human rights, specifically the right to bodily autonomy and the right to be free from harm. The human rights framing thus also introduced bioethical principles, with medicalised FGM/C seen as a breach of the principle primum non nocere – ‘first, do no harm.’

The merging of human rights and bioethics played a key role in depoliticising FGM/C, framing it not as a complex political and cultural issue but as a matter of defending universal, undeniable rights and ethical principles. This removed it from discussions about colonial legacies, cultural imperialism, gender politics, and racial biases, which might have otherwise complicated or challenged the zero-tolerance approach. This discursive shift also served to delegitimise the perspectives of communities that believed medicalising FGM/C could provide a way to preserve their cultural or social practices while addressing health concerns. The response to such proposals was an unequivocal no: even when performed in a clinical setting, even if minimally invasive, FGM/C remained unacceptable.

Despite the zero-tolerance approach, medicalised FGM/C persists. One of the well-documented consequences of strict zero tolerance is that rather than eliminating a practice, it pushes it underground. In Kenya, for example, medicalised FGM/C is carried out clandestinely (Kimani et al. 2020; Van Eekert et al. 2022). In other contexts, such as Indonesia, medicalised FGM/C continues to be legally performed in medical settings (UNICEF 2016), highlighting that the WHO’s zero-tolerance approach has not been universally adopted.

Remarkably, since the WHO’s adoption of zero tolerance toward FGM/C in 2003, there has also been a rise in FGCP. While the specifics of FGCP and FGM/C differ, both involve modifying the female body in ways that are deeply cultural. The starkly different social and legal reactions to these practices are not based on inherent differences but on a double standard shaped by colonial legacies. FGM/C is framed as an irrational, oppressive, and culturally backward tradition, while FGCP is seen as an individual, medical, and empowering choice. This distinction does not reflect an objective assessment of harm or agency, but rather a visceral, historically-rooted discomfort with FGM/C as something ‘Other’ and foreign, contrasted with the Western embrace of FGCP as part of medicine and science. The rejection of medicalised FGM/C or symbolic cutting (like clitoral hood pricking), then, is not solely about protecting human rights but also about reinforcing an ideological and cultural boundary – one that positions FGM/C as beyond reform, beyond negotiation, and beyond comprehension. The current regulatory landscape has evolved to prohibit practices such as medicalised FGM/C and minor procedures like clitoral hood pricking, while FGCP, including their highly invasive forms, remain legally and socially accepted.

Following the article’s publication, the Dutch healthcare inspectorate launched an investigation to determine whether plastic surgeons were indeed performing FGM/C. While The Netherlands does not have a specific law criminalising FGM/C, it is prohibited as a form of child abuse under the Dutch Penal Code (Articles 300–4, 307, 308). Medicalised FGM/C is not explicitly banned but is considered illegal under Article 436(2) of the Criminal Code, which prohibits licensed professionals from performing non-medically necessary procedures. The investigation, based on interviews and questionnaires, concluded there was no evidence of FGM/C being performed in the clinics (Inspectie voor de Gezondheidszorg 2007). However, it noted that the blurred line between FGM/C and FGCP could lead to misunderstandings where FGCP were wrongly equated with FGM/C. The inspectorate also highlighted the lack of established protocols for FGCP, describing it as ‘an undesirable situation for plastic surgeons to independently determine the limits of their actions in this field based on their own norms and values’ (ibid.:5). It recommended that relevant professional bodies establish clear guidelines for FGCP and delineate their boundaries from FGM/C (ibid.). In response, the Dutch Society for Plastic Surgery (NVPC), the Dutch Society for Aesthetic Plastic Surgery (NVEPC), and the Dutch Society of Obstetrics and Gynaecology (NVOG) co-published three documents in April 2008: a ‘Position Paper on Female Genital Mutilation’ (NVPC and NVEPC 2008), a ‘Position Paper on the Limits of Aesthetic Genital Surgery in Women’ (Hage, Karim, van der Lei et al. 2008), and a ‘Model Protocol for Labia Reduction’ (Hage, Karim, Paarlberg et al. 2008).

While these documents sought to delineate FGM/C from FGCP, none explicitly defined the distinction. The ‘Position Paper on Female Genital Mutilation’ merely reiterated the WHO’s definition, treating it as self-explanatory. It did not address the fact that FGCP fall under the WHO definition of FGM/C as any injury to female genitalia for non-medical reasons. The paper advised doctors to refuse circumcision requests but provided no guidance on how to distinguish them from FGCP. A close reading of the position papers, however, reveals the authors’ implicit assumptions about what distinguishes FGM/C from FGCP. First, FGM/C is framed as a ‘ritual based on cultural and traditional practices’ (NVPC and NVEPC 2008:1), in contrast to FGCP, which are implicitly positioned as medical rather than cultural practices. The papers thus overlook the fact that FGCP are also driven by socio-cultural ideals of beauty and femininity rather than medical necessity. Second, the authors claim that FGCP and FGM/C differ ‘fundamentally and significantly’ in intent and outcome (Hage, Karim, van der Lei et al. 2008:2) but do not clarify these differences. As many scholars have noted (e.g. Boddy 2020; Shahvisi 2023), there is significant overlap in both intent and desired outcomes across these practices. Third, while acknowledging that FGCP carry health risks, the ‘Position Paper on the Limits of Aesthetic Genital Surgery in Women’ does not consider these risks a reason to reject the procedures unless they pose ‘health risks beyond the normal surgical risks’ (Hage, Karim, van der Lei et al. 2008:3). It does not specify what these additional risks are. Complications from FGCP – including infection, scarring, loss of sensation, and painful intercourse – are similar to those associated with FGM/C (Cain et al. 2013). Yet, while the health risks of FGM/C are one of the primary justifications for its criminalisation, FGCP are framed as an informed choice. This reflects broader assumptions discussed earlier in the chapter: white women are seen as autonomous agents capable of consent, while women of colour, particularly African women, are perceived as lacking agency and in need of protection. Finally, there is an implicit assumption that genital cutting amounts to ‘mutilation’ when it involves the clitoris. The inspectorate’s initial report raised concerns about clitoral hood reduction, suggesting it could be classified as WHO FGM/C Type 1 (Inspectie voor de Gezondheidszorg 2007:5). However, labiaplasty – potentially falling under WHO FGM/C Types 1 or 2 – was neither categorised as FGM/C nor scrutinised. This raises questions about whether FGM/C is defined anatomically and, in particular, in relation to the symbolism of the clitoris in Western discourse. During the second feminist wave, the clitoris became a symbol of women’s sexual and broader liberation, leading to the interpretation that equates cutting the clitoris with women’s subordination (e.g. Dellenborg 2004).

Rather than explicitly defining how FGCP differs from FGM/C, the papers justify FGCP by focusing on their alignment with bioethical principles – particularly non-maleficence (‘do no harm’) and autonomy (Hage, Karim, van der Lei et al. 2008:2). They argue that FGCP are acceptable if they preserve or do not harm function, yet they fail to define what constitutes ‘harm’. There is no guarantee that FGCP do not impact sensation, and little data exist on their long-term effects on sexual function (Crouch 2019). By contrast, FGM/C is widely assumed to impair sexual function due to scarring (WHO 2018). On autonomy, the guidelines state that FGCP must be voluntary, free from coercion, and patients must be informed about vulvar diversity and procedural risks. Physicians are encouraged to assess whether patients have realistic expectations and a healthy self-image. The guidelines state that FGCP should ‘in principle’ not be performed on minors (Hage, Karim, van der Lei et al. 2008:3), implying discouragement rather than strict prohibition. Interviews with Dutch healthcare professionals confirm this, revealing that FGCP are sometimes performed on minors when mental or physical suffering is considered significant (Van Bavel and Hermans forthcoming).

The Dutch standpoint papers do not consider whether FGM/C could meet the same ethical standards of ‘no harm to function’ and ‘autonomy’ applied to FGCP, and, if so, whether it might then be deemed acceptable. This omission reflects deeply ingrained assumptions that FGM/C is inherently unsafe and performed by untrained practitioners in non-medical settings, and therefore incompatible with such principles by default. In interviews with Dutch and Belgian gynaecologists and plastic surgeons, these assumptions were explicit: many described FGM/C as something done by an ‘untrained old woman’ on infants (Van Bavel and Hermans forthcoming). They were unaware that in some countries, FGM/C is increasingly performed by healthcare professionals. This reflects not just a lack of knowledge but also the influence of dominant narratives framing FGM/C as inherently harmful and fundamentally different from FGCP. In Kenya, where medicalised FGM/C is common, this assumption becomes harder to sustain. This tension surfaced in a legal case, where a medical doctor argued that criminalising medicalised FGM/C for consenting adults, while permitting FGCP and male circumcision, amounts to discrimination.

Kenya has a long history of legal and cultural contestation over FGM/C, dating back to colonial attempts to regulate or ban the practice. Local communities resisted these efforts, viewing female circumcision as an important cultural tradition and attempts to end it as cultural imperialism (Njambi 2007; Pedersen 1991; Thomas 2003). A recent example of this contestation occurred in July 2017, when Kenyan medical doctor Tatu Kamau (see Chapter 12) filed a petition to overturn the anti-FGM Act, arguing that it violated women’s constitutional rights to culture, religion, gender equality, and health (Kenya Law 2017). She claimed that criminalising medicalised FGM/C denies ‘willing adult women’ access to safe, hygienic procedures, infringing on their right to the highest attainable standard of health. Kamau also argued that the Act discriminates against women, as male circumcision is legal and actively promoted by the government for HIV prevention (Gilbertson et al. 2019). Furthermore, she contended that the law imposes foreign cultural values and infringes on women’s right to participate in cultural practices of their choice (Kenya Law 2017). (For a more detailed analysis, see Van Bavel 2023.)

As in the discourse by the Dutch associations of gynaecologists and plastic surgeons, the topics of harm and autonomy were central to the hearings. With regards to harm, Kamau argued that banning medicalised FGM/C forces women to rely on traditional circumcisers, increasing the physical and psychological risks, and that legalising it would ensure safer conditions. She also claimed that the Act discriminates against women by criminalising female but not male circumcision. The judges rejected this (Kenya Law 2021), stating that evidence showed medicalisation does not mitigate harm, and citing testimonies from women who suffered complications after medicalised FGM/C (ibid.:50). They also noted that no medical professionals are trained to perform FGM/C, and doing so violates the Hippocratic Oath. While acknowledging the legal distinction between male and female circumcision, the judges ruled it was not discriminatory, citing the health benefits of male circumcision versus the harm of FGM/C – an argument that remains contested (Lamont 2018).

Regarding autonomy, Dr Kamau contended that adult women should have the right to choose, much like they can choose to smoke or engage in other risky behaviours.2KTN News Kenya (2018). ‘Case filed by Dr. Tatu Kamau seeking to legalize FGM adjourned’. Nairobi, Kenya, 17 January. https://www.youtube.com/watch?v=NEOavMlmUWg [Accessed 11 July 2025]. The defence witnesses, whether intentionally or not, misunderstood or misrepresented her argument, framing it as if it applied to minors. Their testimonies focused on the harm experienced by underage girls following FGM/C (Kenya Law 2018). Kamau clarified that her petition concerned adults only, stressing that minors were still protected under the Children Act of 2001. The defence countered that adult women in practising communities are pressured into FGM/C and face stigma if they refuse. The judges agreed, ruling that social pressure undermines true consent. ‘Women,’ they argued, ‘are thus as vulnerable as children due to social pressure and may still be subjected to the practice without their valid consent’ (Kenya Law 2021:48–9). This explicitly addressed what remained implicit in the Dutch position papers: the assumption that adult women from FGM/C-practising communities cannot meaningfully consent to being cut. While postcolonial scholars like Mohanty (1988) critique the infantilisation of African women in Western discourse, this case highlights a similar dynamic within African societies, where ethnicity and class shape assumptions about which women are seen as capable of autonomous decision-making.

Kamau argued that the anti-FGM Act imposes foreign cultural values and violates women’s constitutional right to participate in their cultural practices by forcing women from circumcising communities to adopt norms from non-circumcising ones (Kenya Law 2018). She also criticised the Act for criminalising female circumcision while allowing sex reassignment and cosmetic genital surgeries, arguing that these procedures equally constitute mutilation under the FGM/C definition and should not be privileged. Defence witnesses responded that outlawing FGM/C aligns Kenya with international human rights standards, but failed to address Kamau’s argument about the unequal treatment of FGM/C compared to FGCP and gender-affirming surgeries. Kamau pointed out that the deponents did not explain why ‘female genital surgeries conducted by gynaecologists and plastic surgeons for cosmetic purposes in developed countries are legitimate, yet female genital surgeries in Africa are criminalised’ (Kenya Law 2018).

While the judges dismissed the petition, they acknowledged the inconsistency in allowing certain female genital surgeries while banning others. They noted that the Act ‘favoured a minuscule of the population who practiced aspects of Type IV FGM including women who could afford labiaplasty or the cutting favoured by some religious sects’ (Kenya Law 2021). The Attorney General was instructed to propose amendments to the Act to prohibit all forms of FGM/C, but as of June 2025, no changes have been made. Anti-FGM/C activists have raised concerns that this legal gap may allow FGM/C to be carried out under the guise of FGCP (Esho 2022), a phenomenon already observed in Egypt.

Despite subsequent bans, the ‘medically necessary’ clause introduced in 1996 continues to influence current practices. Studies show that healthcare professionals still perform FGM/C after assessing whether it is ‘medically necessary’ (El-Gibaly, Aziz, and Abou Hussein 2019; Van Eekert et al. 2025). Mothers often seek medical advice to determine if their daughters ‘need’ circumcision, typically based on whether the clitoris or labia appear ‘too large’. These assessments are not grounded in objective medical criteria but reflect beauty standards that view protruding genitalia as unattractive, unfeminine, or even ‘abnormal’. El-Gibaly et al. (ibid.) found that ‘normal’ female genitalia were defined as the ‘non-protrusion of the clitoris beyond the labia minora’. Physicians examined girls and classified them as either ‘indicated’ or ‘non-indicated’ for cosmetic correction based on whether their genitalia matched this standard. Remarkably, Egyptian healthcare professionals denied performing FGM/C, instead referring to these procedures as ‘cosmetic operations’ intended to ‘refine’ and ‘beautify’ girls (El-Gibaly et al.). Van Eekert et al. (2025) similarly found that mothers base their decision to circumcise on the presence of an ‘observable need’, defined by whether the genitalia are considered ‘too large’. In addition to medical professionals, mothers may consult dayas (traditional midwives), nurses, family members (particularly grandmothers), or assess their daughters themselves.

In Egypt, genital cutting is thus framed as enhancing or normalising a girl’s appearance, seen as crucial for her well-being and marriage prospects. The decision to circumcise a girl is based on ‘correcting’ genitalia that deviate from the norm. This medical framing helps legitimise the practice, as it is framed not as a cultural tradition but as a medically necessary procedure validated by the authority of a physician (Van Eekert et al. 2025). Health professionals may label the practice as a cosmetic operation to market or legitimise it to clients and/or to circumvent legal restrictions against FGM/C (El-Gibaly et al. 2019; Van Eekert et al. 2025).

The parallels between medicalised FGM/C in Egypt and FGCP in Western countries are striking. Both aim to produce ‘normal femininity’, characterised by symmetrical genitalia with the labia minora and clitoris hidden within the labia majora (Sharp, Tiggemann, and Mattiske 2016). These aesthetic ideals are socially driven: Western media, particularly pornography, promotes the ‘hairless clean slit’ (Boddy 2020), while in Egypt, FGM/C is associated with cleanliness, beauty, and sexual control – qualities linked to marriageability and social acceptance (El-Gibaly et al. 2019; Van Eekert et al. 2025). In both settings, women undergo these procedures to meet social norms and improve life opportunities. Both are also increasingly framed as medically necessary ‘corrections’ of ‘abnormal’ genitalia, even though no objective standard exists for what constitutes ‘too large’. Medical assessments rely on subjective judgments of normality (Reitsma et al. 2011). Terminology also overlaps, with Egyptian providers denying involvement in FGM/C and instead calling the procedures ‘cosmetic operations’. If the terminology is identical, how can we distinguish whether Egyptian girls undergoing genital cutting in hospitals are receiving medicalised FGM/C or FGCP?

A key difference, however, is that in Egypt mothers often initiate the procedure. In other contexts where FGCP have been studied, minors may also seek FGCP, and in some cases, mothers exacerbate their daughters’ insecurities by confirming that their genitalia look abnormal (Simonis et al. 2016). However, in most FGCP cases, the decision is patient-driven (though influenced by socio-cultural pressures), unlike in Egypt, where the mother typically drives the decision.

In The Netherlands, the distinction between FGM/C and FGCP is portrayed as relatively easy to maintain. Professional associations of plastic surgeons and gynaecologists rely on widely accepted assumptions that frame FGM/C as inherently oppressive, performed on non-consenting children by untrained practitioners, and fundamentally different from FGCP. However, this narrative simplifies FGM/C as a practice that does not represent FGM/C as it is practised today. There is limited public awareness of medicalised FGM/C. As a result of this limited awareness, the double standard – where FGM/C is criminalised and FGCP are permitted – remains largely uncontested in public discourse.

In contrast, in Kenya, maintaining this binary distinction requires greater effort. The dominant narrative of FGM/C as universally oppressive is challenged by the presence of medicalised FGM/C and by adult women who advocate for their right to undergo circumcision. These realities complicate the assumption that FGM/C is always non-consensual and harmful. As a result, the double standard becomes more visible and harder to justify. Unlike in The Netherlands, where FGM/C can be positioned as ‘Other’ and fundamentally distinct from FGCP, in Kenya the lived realities expose the inconsistencies in how these practices are treated. This tension was acknowledged by the judges in the Kamau lawsuit, who recognised the discrepancy and called for the criminalisation of all forms of female genital surgery. In their ruling, the judges explicitly noted that the current legal framework ‘favoured women who could afford labiaplasty’, thereby acknowledging the class-based discrimination inherent in the legislation. This recognition suggests that both Kamau and, to some extent, the judges were among the first to explicitly address the racial, cultural, and class-based biases embedded in the differential treatment of genital surgeries. Their call for consistency marked an important legal consideration of these intersecting forms of discrimination.

In Egypt, the double standard is challenged in practice, as (what anti-FGM/C activists call) medicalised FGM/C is increasingly described as ‘cosmetic surgery’ within practising communities. Healthcare providers examine girls’ genitalia and classify cases as either ‘indicated’ or ‘non-indicated’ for cosmetic correction to achieve a ‘normal’ shape. There is thus a clear overlap between medicalised FGM/C and FGCP in terms of their intent, desired outcomes, and the fact that both are carried out by medical professionals. This trend clearly challenges the argument that FGM/C and FGCP differ in intent and outcomes.

Across all three contexts, the concepts of harm and consent played key roles in justifying or challenging the differential treatment of genital surgeries. However, various actors put forward differing interpretations of what constitutes harm. In The Netherlands, there is a prevailing assumption that FGM/C is inherently harmful, even in its least invasive forms, such as pricking the clitoral hood. Conversely, FGCP are framed as acceptable and generally harmless, unless they involve ‘health risks beyond the normal surgical risks’. This framing conveniently excludes the usual harms associated with surgery – such as bleeding, infection, scarring, and keloids – which are considered routine in the context of FGCP but are framed as unacceptable and defining features of harm in the context of FGM/C.

In Kenya, the debate focused on which option causes the least harm: FGM/C itself, its criminalisation, or its medicalisation? Dr Kamau argued that criminalisation drives the practice underground, increasing health risks and deterring women from seeking medical care due to fear of prosecution. She further contended that medicalised FGM/C could reduce harm by ensuring safer conditions – a justification also common in Egypt (El-Gibaly et al. 2019). To date, no research has systematically compared the health risks associated with FGM/C, medicalised FGM/C, and FGCP. A systematic comparison of these procedures, along with a deeper reflection on what constitutes harm, is crucial. The same health risks that render FGM/C unacceptable are often dismissed in the case of FGCP, while the same clinical procedures used to justify the safety and acceptability of FGCP are not extended to (medicalised) FGM/C.

With regard to consent, the prevailing assumption among the Dutch healthcare associations reflects a colonial mindset: that African women are incapable of giving genuine consent, while Dutch women – including minors – are presumed to have full bodily autonomy. In the Kenyan court case, however, this colonial configuration is reconfigured along socio-economic and cultural lines. The distinction is no longer drawn between African and Western women but between women from cutting communities – typically rural, lower socio-economic groups – and those from non-cutting communities, often urban, educated, and from higher socio-economic classes. In this context, the ability to consent is tied to class, education, and cultural affiliation rather than race. This mirrors Mahmood Mamdani’s (1996) argument that colonial power structures persist in postcolonial contexts, with paternalistic authority merely shifting from white rulers to Black elites.

In both the Dutch and Kenyan cases, there is broad acknowledgment that autonomy, choice, and consent are heavily influenced by socio-cultural factors when it comes to women from cutting communities. It is also recognised that these influences do not simply disappear when a woman reaches the age of eighteen. However, this level of scrutiny is less frequently applied when it comes to FGCP. The Egyptian case, however, offers insight into where the distinction might lie: who drives the decision? In the Dutch context, women seeking FGCP are typically the primary agents in making the decision, even though they are undoubtedly influenced by prevailing socio-cultural beauty standards. For minors, while family members or peers may reinforce these insecurities, the expectation is that the girl herself must express a clear and persistent desire for the procedure. In contrast, the Egyptian case suggests that the decision-making process is more externally driven. It appears that mothers often initiate the procedure, and healthcare professionals reinforce the necessity, positioning the girl as a passive recipient rather than an active decision-maker.

In conclusion, our research shows how the double standard applied to FGM/C and FGCP is challenged in real-world practice. Moreover, it pinpoints the ongoing inconsistencies in how harm and consent are defined and applied to female genital surgeries across different contexts. We argue that to move beyond these double standards, we must adopt a more consistent definition of harm that applies equally across cultural and geographical contexts, alongside a nuanced understanding of consent that accounts for socio-cultural pressures, decision-making dynamics, and access to alternatives. Further research is needed to systematically compare the health risks associated with FGM/C, medicalised FGM/C, and FGCP, as well as to examine the growing acceptance of FGCP in contexts where FGM/C is practised and how its boundaries with medicalised FGM/C are negotiated.

A strengthened human-rights approach, and moves towards eradication, led to the United Nations launching an annual International Day of Zero Tolerance for Female Genital Mutilation on 6 February 2012. The aim was to raise awareness of FGM/C and galvanise efforts to eradicate it by 2030. Zero tolerance sends an unequivocal message – that all types of FGM/C are unacceptable, and strategies which ban only the most harmful forms, but tolerate lesser forms, should not be supported.

This approach is not universally favoured. Some scholars and practitioners question its effectiveness and credibility, pointing to inconsistencies between FGM/C and elective cosmetic genital modification. Widespread condemnation of FGM/C is not mirrored by condemnation of cosmetic genital surgery. This inconsistency can be seen as Eurocentric, if not neocolonial.

Zero tolerance can be perceived as prescriptive, and is often directly linked to fundraising by NGOs and development agencies. A zero-tolerance approach only recognises the elimination of all types of FGM/C as success, and does not regard harm reduction as a valid interim goal. Change often involves incremental steps, and takes time. But, with zero tolerance, communities are expected to move from practising FGM/C to total abandonment in one step. If a community abandons infibulation but continues with a lesser cut, this is not seen as a positive outcome under a zero-tolerance policy.