Case studies

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.2 KTN 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 genital cosmetic 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 allegedly 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. (2019) 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. ibid.). 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.