Defending heritage and adult rights

While the growth of the FGCS industry has been a surprise for many of us, it is difficult to criticise consenting adult decisions about legal body alterations. But what about the growth of the market for underage teenage girls seeking female genital cosmetic surgery (e.g. labiaplasty), estimated to be about 20 per cent of FGCS clients in the US (Kalampalikis and Michala 2023)? Even with parental consent or by acceptance of a younger age, like sixteen, for consent, sceptics see this unnecessary trend as influenced not by medical needs but by social pressure, pornographic images, and advertising that influence the view that ‘outies’ are in need of changing to ‘innies’. This is surely just as ‘cultural’ as other FGC, but because it is relatively new, found in middle-class families, and not based on heritage practices nor clustered in a particular race or religion, it is given a pass. What does this tell us about the inconsistency of the arguments?

Second, where there are efforts to change heritage-based genital modification practices – whether for ethical reasons, improvements to health outcomes, religious rethinking, or acculturative or other social change processes as people’s contexts change (from war, migration, education, urbanisation, national communication, new generations, or for whatever reasons) – we should investigate whether making a change to one aspect of genital cutting leads to other changes in gender and sexuality. Does changing to Type 1 invariably get ‘stuck’ there? Do healthcare providers trying to reduce harm in one period of time have a positive role to play in influencing future abandonment? I think of a 2004 conversation I heard among young mothers in the Sudanese community where Besaina served as midwife. After the community had made the shift from Type 3 to Type 1 for most families, one young mother was heard, in conversation with her friends, to ask, ‘If we can do without pharaonic, do we really need to do any cutting?’ I believe such conversations can be significant in allowing people to contemplate change. Within ten years, Besaina the midwife had taken the oath never to perform any type, an outside circumciser who had come to do secret cutting was threatened by the medical assistant and chased away, and the community had settled on abandonment. The last girls to have been cut, then teenagers, did not blame their mothers for having them cut, but they resolved never to do it to their future daughters.

Third, how do contexts impact the outcome of projects? It often seems like anti-FGM programmes are looking for a ‘key’ to change, something that will always work – persuasive educational campaigns about health risks or group pledges to generate social pressure, or new laws to deter practitioners or parents. But even good ideas can get stale when repeated. As one Kenyan feminist once told me during the long years when international organisations were stressing human rights as the key argument to replace the ‘health risks’ message: ‘We are tired of hearing about human rights. Why don’t they vary the message?’

Fourth, communication is such an important aspect of social life that the role of social marketing, social media, imagery, language, and artistic productions should all be studied for their roles in reinforcing or challenging thinking. The old posters and slogans of anti-FGM/C campaigns of recent decades can look very ‘colonial’ today, and the need for African artistic leadership in assessing public health education on this topic is compelling. I applaud Samira Amin Ahmed of UNICEF Sudan for her idea, in 2006, to convene a group of artists, poets, religious leaders, health providers, and educators to critique the existing messaging of anti-FGM/C work, suggest new ideas for messaging, and develop a new positive term for uncircumcised girls, Saleema (meaning whole, healthy, in Arabic), around which Sudanese feminists developed a social marketing communication strategy for ending FGM/C (see Alassad, Chapter 7, this volume).

Fifth, we must not neglect dignity, respect, and privacy as values for research foci. Developing clarity about the ethical work and health contexts that could maximize individual and family well-being, informed consent rights, harm reduction, legal rights, and other humanitarian considerations is beneficial. In Global North situations of migration, where laws and standards focus on practices of a racialised or religious minority, the zeal of suppression has led to mandatory reporting requirements for teachers and medical staff, sometimes even unconsented medical examinations, and oppressive surveillance of travelling families (Johnsdotter 2020; Mogilnicka et al., Chapter 8, this volume). This stigmatisation is harmful in itself and merits research attention.

The chapters of this book offer optimism that multiple challenges to the previous set of policy responses to genital modification practices are arising and ideas for workable futures are emerging. The contributors challenge the existing anti-FGM/C discourse by reigniting long-standing wisdom about the need for listening and discussing, for shifting perspectives, and recognising underlying dynamics of change – drivers, readiness for change, social norms challenges, or suppressants – that statistics alone cannot show. Scholarship is finding new footing by questioning simplistic slogans like ‘zero tolerance’ in favour of deeper understanding of lived realities.

The WHO position in the genital modification discourse continues to merit critical scrutiny, because it is inconsistent and questionable to promote infant and adolescent male circumcision based on not completely convincing research on possible benefits, even though it challenges the ‘right to bodily integrity’ that forms the basis of condemning all forms of cutting of females. Similarly, allowing medicalised contexts for genital cutting by cosmetic surgeons and for unnecessary male circumcisions, while denying such care to girls and women who have decided to undergo cultural or religious genital cutting, could be understood as discriminatory, but for the prediction that medicalised contexts prolong the process of change – but do they? Are we able to show evidence? The prevention of harm reduction that medicalisation might afford for those unready to end all forms troubles me. It is my hope that all unnecessary cutting, whether considered damaging or cosmetic, can eventually be dropped voluntarily, that compassion be exercised toward those who have experienced or desired cutting, and that we acknowledge the ultimate motivation to protect children and promote physical, social, and spiritual well-being as much as is possible within the limits of human belief systems. Scholars of all points of view on the ultimate goals should recognise the dignity and rights of individuals and communities to move toward their own social change goals in varying ways along many paths.