Historical background: From harm reduction to zero tolerance, except for FGCP
Over the past century, various actors have proposed and experimented with medicalised FGM/C and minimal cutting as harm-reduction strategies (Van Bavel, Carver and Takyiakwaa 2024). In colonial Kenya and Sudan, British authorities and local elites sought to replace more invasive forms of female circumcision with what they considered less harmful alternatives – ‘minor’ circumcision in Kenya and sunnah circumcision in Sudan (Boddy 2007; Thomas 2003). More recently, in 1992, Dutch researchers proposed symbolic pricking of the clitoral hood as a harm-reduction strategy to replace infibulation among the Somali diaspora (Bartels and Haaijer 1992). In Egypt, in 1994, the government issued a decree permitting FGM/C to be performed in hospitals if deemed ‘medically necessary’ by a doctor (28 Too Many 2017). However, both the Dutch proposal and the Egyptian policy proved controversial. The Dutch researchers’ suggestion was never implemented (Kool 1994), while Egypt’s policy was reversed following outrage from women’s rights activists (El Dawla 1999).
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.