Some awkward propositions

The first is that neither male nor female circumcision is necessary for general health or increased life expectancy. In recent decades, a wave of interest in the potential medical benefits of male circumcision, particularly with respect to preventing sexually transmitted infections, has shaped the global policy landscape around genital cutting in decisively gendered ways. Genuine medical indications for male circumcision, such as phimosis and recurrent balanitis, are rare. The global prevalence of male circumcision is slightly less than 40 per cent (WHO 2007). This means that 60 per cent of males worldwide live uncircumcised, untroubled, and without adverse effects. Male circumcision is low in Europe, Latin America, China, and Japan. In none of these regions are there associated health benefits with circumcision. According to the World Bank, Japan had the world’s highest life expectancy at birth for men in 2022, at eighty-four years. Other sources indicate that Japan has a very low male circumcision prevalence of 9 per cent (World Population Review 2025).1 World Population Review, ‘Circumcision by Country 2025’, quantifies male circumcision rates by country. See bibliography at the end of this book. A closer examination shows that this minority of Japanese men voluntarily undergo circumcision as adults because of emerging notions of genital ‘beauty’ promoted by private cosmetic surgery clinics (Castro-Vázquez 2013). This new aesthetic mirrors a trend towards the popularisation of female genital cosmetic procedures (FGCP) in some countries (see Chapter 10 this volume). In contrast, the United States has the highest male circumcision rate globally, at 71 per cent.

In Kenya, traditionally non-circumcising cultures view any advocacy for male circumcision as a form of cultural or religious indoctrination. Since 2008, the WHO has promoted Voluntary Medical Male Circumcision (VMMC) for HIV prevention in Kenya and other sub-Saharan countries. This initiative required extensive educational campaigns to overcome the suspicion of cultural imposition. Ethical concerns over consent, even coercion, have been widely overlooked in the scientific literature on the efficacy of male circumcision as a HIV-prevention strategy (Fish et al. 2021; Garenne 2023; Luseno et al. 2023; Rennie et al. 2021).

The majority of males in Kenya are circumcised to fulfil cultural obligations rather than to prevent HIV infection. Yet, while the government supports male circumcision, for cultural reasons as well as a public health measure, it does not support female circumcision under any circumstance or for any reason. This is discriminatory.

The second awkward proposition is that the lived experience of many circumcised women has been, and continues to be, largely uneventful – contrary to media hype and activist-driven exaggerations of harm. The notion that circumcision inevitably condemns a girl to a life of suffering, misery, and disability is a fallacy. The Kenya Demographic and Health Survey (KDHS) of 2022 indicates that 22 to 37 per cent of circumcised girls and women experience complications, including unintended sequelae and infections, some occurring long after the procedure. However, 63 to 78 per cent do not report such complications and heal without immediate issues. While statistical data highlights risks, lived experiences vary, and this distinction should be considered in debates about female circumcision, just as it is with male circumcision.

During my medical internship (1988–90) at Kenyatta National Hospital, I observed that female circumcision scars did not routinely cause obstructed labour. Even in the few cases where women presented with a tight perineum scar,2 The perineum is the thin layer of skin between the genitals (the vaginal opening in the case of women) and anus. It is a common site for tears during childbirth. this was managed through an episiotomy, just as it would be for any uncircumcised woman experiencing similar issues. This clinical experience led me to realise that the anticipated complications of FGM/C, such as obstructed labour, may not manifest as frequently or as severely as commonly suggested in the medical literature.

In my own professional experience as a medical officer at Hagadera Refugee Hospital, in a busy maternity unit that served Somali women, many of whom had undergone Type 3 FGM/C (with a lesser proportion having Type 2), I was struck by the ease with which most women delivered their babies vaginally. This observation was in complete contrast to what I had been taught, specifically that women with Type 3 circumcision are prone to very difficult deliveries due to inelastic, scarred vaginal tissues. Complex cases, like breech presentations, were referred to a larger hospital in Garissa. I never experienced a case where a circumcision scar presented problems that were beyond our ability to manage, or where a baby was lost due to circumcision-related complications.

These experiences challenge the prevailing narrative that all women who have undergone FGM/C are doomed to experience significant, debilitating complications. In fact, it became clear to me that FGM/C does not necessarily lead to a life of suffering and disability, as is popularly believed. While data may highlight potential risks, the lived reality for many women may be far less catastrophic than commonly believed. This provoked in me a series of questions and concerns about prevalent understandings about FGM/C, not only in the medical world, but also in terms of programmes aimed at eliminating the practice.

Up until the onset of anti-FGM/C campaigns in Kenya, communities that practised female circumcision viewed it as a woman’s right, rather than a form of violence against women. Because the circumcision of girls occurred alongside male circumcision, it helped to unify both genders in the creation of resilient and trustworthy community members, who would perpetuate and safeguard their traditions and morality. Each gender had vital roles to play within the community, and circumcision was seen as preparation for these roles. If female circumcision were to be removed, how would young women be prepared physically and mentally for the next phases of their lives? How would girls prove they were ready to become wives and mothers if the vetting process was eliminated?

In Kenyan circumcising communities, it has long been acknowledged that complications occasionally arise during male and female circumcision. However, these incidents have not been viewed as grounds for discontinuing the practice, but are believed to result from a circumciser’s ‘bad hand’ or witchcraft. Even today, ‘botched’ male circumcisions occur every year during the circumcision season and receive considerable media attention. Indeed, there are also incidents of violence during this period, but these are largely tolerated (see Lamont, Chapter 3 in this volume). Despite this, there are no widespread calls to ban the practice. Instead, the focus is on improving safety through more stringent regulations, training and vetting circumcisers, and, particularly, advocating medicalisation to minimise risks.

This contrasts sharply with the societal response to botched female circumcisions, which typically leads to demands for tough legal action. Parents, circumcisers, and anyone deemed responsible for the procedure often face calls for arrest and imprisonment. This sharp divide stems from a perception that female circumcision is an inherently dangerous practice – one which can never be made safe.

Such views are perpetuated in public discourse and legal frameworks, including the anti-FGM Act of 2011 which distinguishes female circumcision as mutilation, while not applying this label to sex reassignment surgery. Ironically, gender normalising surgery completely alters the female genitalia, replacing it with grafted imitation male genitalia, yet in light of legal amendments (Kenya Law 2022) to the Children Act 2001, this is not considered ‘mutilation’ (Baird 2024). Such a contradiction demonstrates tensions between cultural norms and the law in Kenya.

This discrepancy in the treatment of male and female circumcision, alongside gender normalising surgery for intersex individuals, highlights significant inconsistencies in both medical and legal frameworks. This double standard is echoed in the WHO’s diametrically opposed positions on female and male circumcision (Earp 2015, 2021). The distinction between these practices raises critical questions about cultural bias, the representation of risk, and the ways in which society responds to bodily integrity and medical safety. While the complications in both practices cannot be ignored, it is important to critically examine how societal perceptions and legal frameworks may perpetuate double standards, particularly when it comes to culturally significant practices.

The third awkward proposition is that there is a perceived double standard in government and NGO approaches to male and female circumcision. While male circumcision is supported, resourced, and medicalised, female circumcision is criminalised outright, though communities wish similar safety measures were in place. One of the key inconsistencies in circumcision policies in Kenya is that while female circumcising communities also have sons, these sons receive preferential treatment from the government to access high-quality circumcision services.

The state, alongside global health organisations, NGOs, and private medical practitioners, actively promotes and funds medicalised male circumcision, portraying it as the safest and most responsible approach. The emphasis on medicalisation has led to the perception that it is the solution to all risks associated with circumcision. It is therefore unsurprising that some female circumcising communities have sought similar medicalisation strategies for girls (Kimani et al. 2020; Van Eekert et al. 2022). If the government believes medicalisation ensures safety for boys, why does it reject the same approach for girls?

Members of these communities are not passive recipients of state policies; they are deeply embedded in the country’s health sector as nurses, midwives, clinical officers, obstetricians, gynaecologists, and surgeons. They are trained in surgical ‘best practices’, infection control, and pain management. These professionals understand that the same medical standards used in male circumcision – such as anaesthesia, sterilisation, and wound care – can also be applied to female circumcision. Indeed, cosmetic genital surgery performed in private clinics uses similar surgical techniques, yet these are legally permissible. The outright criminalisation of female circumcision, even in its medicalised form, appears contradictory to communities that have adopted modern surgical practices.

Moreover, anti-FGM/C campaigns often rely on images of blood-stained dirty knives, aged, calloused hands, and distressed children to highlight the dangers of the practice. While this caricature does capture some historical concerns about hygiene and other issues, it does not align with the experiences of communities where female circumcision has moved underground and been incorporated into clinical settings. For these groups, the more accurate depiction would be that of a candidate voluntarily being attended to by a gloved clinician wearing a face mask, using modern surgical instruments and a local anaesthetic. Communities have tested and embraced new medical technologies and practitioners for female circumcision. Consequently, many people within these communities find mainstream anti-FGM/C messaging disconnected from their lived realities.

The international legal framework regards female circumcision as a violation of bodily integrity and gender equality, which informs Kenya’s legal stance. The challenge, then, is whether medicalisation alone is a sufficient basis for the continued practice of female circumcision or whether deeper ethical concerns override the possibility of regulation.