Surgery or mutilation?: How autonomy can strengthen the anti-FGM movement

The World Health Organization (WHO) defines female genital mutilation as any alteration to the female external genitalia or genital organs for nonmedical reasons. This definition is both over- and under-inclusive. Western cosmetic surgeries, such as vaginal rejuvenation, are technically included in the definition, but are ignored by the anti-FGM movement and are discounted in prevalence statistics. Further, the anti-FGM movement, using the above definition, condemns all third-world genital alteration practices, often overstating the prevalence of the most extreme practices, attributing all third-world practices to patriarchy and ignoring other significant factors. This paper will argue that the anti-FGM movement should shift focus to banning all questionable genital alteration practices, those in which benefits are norm dependent, rather than all third-world genital alteration practices. I will make my case by first showing that the anti-FGM movement fails to exhaust all relevant cases of genital alterations and does not address the actual prevalence of female genital mutilation, as defined by WHO. Second, I will explain how the movement misrepresents third-world practices by overestimating the prevalence of the most severe forms of genital alterations and pointing to causes that are unrepresentative of many communities. I will also address some of the Western practices the anti-FGM movement largely ignores. Finally, I will suggest what a new definition ought to look like and discuss an approach for the anti-FGM movement that focuses on increasing autonomy and reducing coercion and social norms.

SURGERY OR MUTILATION? HOW AUTONOMY CAN STRENGTHEN THE ANTI-FGM MOVEMENT by Eliana C. Sanchez A Senior Honors Thesis Submitted to the Faculty of The University of Utah In Partial Fulfillment of the Requirement for the Honors Degree in Bachelor of Science In Philosophy Approved: _______________________________ Leslie Francis Supervisor _______________________________ Stephen Downes Chair, Department of Philosophy _______________________________ Eric Hutton Philosophy Honors Advisor _______________________________ Sylvia D. Torti Dean, Honors College May 2014   2   ABSTRACT The World Health Organization (WHO) defines female genital mutilation as any alteration to the female external genitalia or genital organs for nonmedical reasons. This definition is both over- and under-inclusive. Western cosmetic surgeries, such as vaginal rejuvenation, are technically included in the definition, but are ignored by the anti-FGM movement and are discounted in prevalence statistics. Further, the anti-FGM movement, using the above definition, condemns all third-world genital alteration practices, often overstating the prevalence of the most extreme practices, attributing all third-world practices to patriarchy and ignoring other significant factors. This paper will argue that the anti-FGM movement should shift focus to banning all questionable genital alteration practices, those in which benefits are norm dependent, rather than all third-world genital alteration practices. I will make my case by first showing that the anti-FGM movement fails to exhaust all relevant cases of genital alterations and does not address the actual prevalence of female genital mutilation, as defined by WHO. Second, I will explain how the movement misrepresents third-world practices by overestimating the prevalence of the most severe forms of genital alterations and pointing to causes that are unrepresentative of many communities. I will also address some of the Western practices the anti-FGM movement largely ignores. Finally, I will suggest what a new definition ought to look like and discuss an approach for the anti-FGM movement that focuses on increasing autonomy and reducing coercion and social norms. Keywords: female genital mutilation/cutting, autonomy, harmful cultural practices   3   Table of Contents ABSTRACT ....................................................................................................................... 2 I. INTRODUCTION ......................................................................................................... 4 II. BACKGROUND .......................................................................................................... 6 LEGAL BASIS ........................................................................................................................... 6 WORLD HEALTH ORGANIZATION DEFINITION AND PREVALENCE ................... 8 III. WESTERN SURGERIES, AFRICAN MUTILATION........................................ 12 YUCK: UNFAIR APPEAL TO DISGUST ........................................................................... 12 PATRIARCHY, SAVAGERY AND SEXUAL REPRESSION .......................................... 13 ARE AFRICAN PRACTICES YUCKIER THAN WESTERN COUNTERPARTS? ...... 19 IV. A DIFFERENT APPROACH ................................................................................. 58 V. CONCLUSION .......................................................................................................... 60 WORKS CITED ............................................................................................................. 62   4   I. INTRODUCTION Clitoridectomy is obviously a deplorable practice … We should express no sympathy toward those who practice it, and support those who struggle to end it. —Yael Tamir1 The World Health Organization’s definition of female genital mutilation (FGM) is globally accepted by other large medical organizations, the United Nations, in the legal sphere and is cited in hundreds of academic articles and books. Given the definition of FGM — any alteration to the female external genitalia or genital organs for nonmedical reasons — the practice is not limited to Africa or the African diaspora. The assertion that prevalence is isolated to these demographics highlights the double standards of WHO and the anti-FGM movement. If a white, adult, British woman wants to reduce the size of her labia, she may consult a cosmetic surgeon that specializes in vaginal rejuvenation and undergo the surgery like any other aesthetic fix. If a black, adult, African woman living in the UK wants to undergo the same surgery, she is prohibited under the laws banning female genital mutilation. Implicitly, cosmetic surgery is reserved for white women, while female genital mutilation is considered a primitive, savage, ignorant practice performed forcibly on black women, even in identical situations. The terminology used by WHO, human rights literature and the anti-FGM movement is question-begging, advocating for an end to female genital mutilation because it is mutilation. Under the larger heading of genital alterations are many practices performed on both males and females in the Third World and Western countries, some                                                                                                                 1 Yael Tamir. "Hands Off Clitoridectomy." Boston Review, June 1, 2006.   5   ethically acceptable and some not. The World Health Organization does not provide sufficient explanation of exactly what is that makes a practice mutilating. Eradication campaigns ought to be more sensitive to the possibility of nonmutilating genital alterations, focusing on the practices that occur under force or coercion, understanding that they are not isolated to Africa and that certain third-world practices, likewise, may not involve force or coercion. Further, the movements ought to be cautious with campaigns that focus on infibulation, as it is rare and perpetuates the idea that all African women have been infibulated against their will by men intending to suppress their sexuality. Movements ought to involve more specific terminology, the promotion of bodily integrity and autonomy in men, women, boys and girls, and should take into consideration the problems that social norms create across cultures, including in the West. This paper is not intended to advocate for female genital alterations of any kind, but to flesh out the varieties of practices and attempt to understand what it is that makes certain sorts of genital alterations harmful. There are serious cases of forcible, severe mutilations that require attention, and this paper is not intended to level those instances with all genital alterations. However, if the other cases are completely ignored and the practices we ought to be concerned with are defensively made secretive, they may be harder to end. This paper is intended to put the bias of the literature into perspective and consider an unbiased direction for the anti-FGM movement. It is also outside the scope of this paper to argue for either cultural relativism or universalism. To criticize cultures or cultural practices is not a form of Western imperialism, though if we do criticize, there ought to be good justification to do so. In   6   discussion of harmful traditional practices, Westerners ought to be cautious in excluding their own practices from these lists.2 II. BACKGROUND LEGAL BASIS The United Nations, using the World Health Organization’s language and statistics of FGM, passed a resolution in December 2012 on “Intensifying global efforts for the elimination of female genital cutting.” The resolution called states to “take all necessary measures, including enacting and enforcing legislation, to prohibit female genital mutilations,” and to “develop policies and regulations to ensure the effective implantation of national legislative frameworks on eliminating … female genital mutilations.”3 This resolution prompted numerous countries to bolster legislation prohibiting FGM. The U.S. Congress passed 18 USC 16 in 1996, which included: Whoever knowingly circumcises, excises, or infibulates the whole or any part of the labia majora or labia minora or clitoris of another person who has not attained the age of 18 shall be fined under this title or imprisoned not more than 5 years, or both.4                                                                                                                 2 See Bronwyn Winter’s “The UN Approach to Harmful Traditional Practices.” 3 (Intensifying global efforts for the elimination of female genital mutilations 2012), 4-5. 4 Crimes and Criminal Procedure: Female Genital Mutilation, Public Law 104208, 18 USC 116 (1996), 1, http://www.law.cornell.edu/uscode/uscprint.html (accessed February 2014).   7   Legislation in 2012 added a vacation cutting provision, preventing transport from the United States with the intention of violating the existing code.5 The U.S. code allows an exception when surgery is “necessary to the health of the person on whom it is performed, and is performed by a person licensed in the place of its performance as a medical practitioner.”6 Further, 20 states explicitly address FGM, and three extend the provision to women over 18 years of age.7 The UK enacted similar legislation in 1985 and criminalized vacation cutting in 2003. The UK code, however, does not apply only to “persons who have not attained the age of 18.” It specifies, “The Act refers to ‘girls,’ though it also applies to women.”8 The UK also builds in an exception even more ambiguous than that in the United States: “No offence is committed by a registered medical practitioner who performs a surgical operation necessary for a girl’s physical or mental health.”9 Australia, Belgium, Benin, Burkina Faso, Canada, Central African Republic, Chad, Cote d’Ivoire, Denmark, Djibouti, Egypt, Ghana, Guinea, Kenya, New Zealand, Niger, Nigeria, Norway, Senegal, Spain, Sudan, Sweden, Tanzania and Togo also all have explicit bans on FGM.                                                                                                                 5 National Defense Authorization Act for Fiscal Year 2013: Transport for Female Genital Mutilation, H.R. 4310, Sec. 1088 (2013): 339 6 18 USC 116 (1996), 1. 7 Sanctuary for Families. Female Genital Mutilation in the United States. Report (New York: Sanctuary for Families, 2013), 13. 8 The Crown Prosecution Service. Female Genital Mutilation Legal Guidance. 2014. http://www.cps.gov.uk/legal/d_to_g/female_genital_mutilation/#female (accessed February 2014). 9 Ibid.   8   WORLD HEALTH ORGANIZATION DEFINITION AND PREVALENCE The World Health Organization (WHO) defines female genital mutilation (FGM) as partial or total removal of the external female genitalia or other injury to the female genitalia for non-medical reasons. WHO cites four major categories: Type 1 – Clitoridectomy: partial or total removal of the clitoris and, in very few cases, only the foreskin Type 2 – Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora Type 3 – Infibulation: narrowing the vaginal opening by cutting and repositioning the inner, or outer, labia, with or without the removal of the clitoris Type 4 – Other: All other harmful procedures to the female genitalia for nonmedical purposes, such as pricking, piercing, incising, scraping, and cauterizing the genital area10 WHO estimates that 140 million women and girls around the world are living with the consequences of mutilation in West, East and Northeastern Africa, in some countries in Asia and the Middle East, and among migrants from these areas.11,12 Anti-FGM literature almost always begins with a phrase taken from a WHO factsheet on female genital mutilation: “FGM occurs in 28 African countries, including Western Asia, minority communities in other Asian countries, and the Middle East.”13                                                                                                                 10 WHO Media Centre. Female genital mutilation fact sheet, (Geneva: World Health Organization, 2013). 11 12 Ibid. This fact sheet is regularly updated and now reads, “More than 125 million girls and women alive today have been cut in the 29 countries in Africa and Middle East where FGM is concentrated [emphasis added].”   9   FGM is “on the rise” in Western countries, and the increase is attributed to diaspora communities. 14,15 The belief in London, for example, is that “The majority of the cases [of female genital mutilation] … were from African countries, including Somalia, Eritrea, Gambia, Nigeria and Sierra Leone.”16 Likewise, in the United States, the idea persists that FGM is “performed by new immigrants” — new as of 1995 — “veiled in deference to a cultural tradition of the developing world.” 17 Sanctuary for Families, a U.S. anti-FGM nonprofit says, “Typically, girls in the U.S. are most affected by FGM if they are part of a community originally from a country where FGM is prevalent.”18 There are questionable forms of genital alterations and practicing communities left wholly out of the conversation. This is not because the data do not exist, but because the anti-FGM movement does not consider some sorts of non-medical genital alterations mutilating. By WHO’s definition of FGM — any nonmedical alteration to the female genitalia — the practice is significantly more widespread than stated, even outside                                                                                                                                                                                                                                                                                                                                           13 See, for example, Rosemarie Skaine. Female Genital Mutilation: Legal, Cultural and Medical Issues. (Jefferson, North Carolina: McFarland & Company, Inc., Publishers, 2005), 35. 14 Clare Lopez, "Female Genital Mutilation on Rise in U.S." The Clarion Project, 18 March 2013. 15 BBC News. "'Rise in female genital mutilation' in London." BBC News, 22 August 2010. 16 Ibid. 17 Linda Burstyn, "Female Circumcision Comes to America," The Atlantic Online, October 1995: 28-35. 18 Sanctuary for Families, Female Genital Mutilation in the United States, 7.   10   diaspora communities. FGM occurs in North and South America, Europe, Asia, Australia, and Africa, not only by Africans in African diasporas. In the United States, removal of the clitoral hood was used to cure masturbation, and cauterizing or burning the clitoris and amputation were recommended for lesbianism, epilepsy, hypersexuality and “other nervous affects of women” well into the 20th century.19 In the United States, there were approximately 45,000 external female genital surgeries performed from 1968 to 1977. However, Linda Burstyn, in an article in the Atlantic Monthly, argued that the “American medical profession stopped performing clitoridectomies decades ago.”20 In fact, by WHO’s definition, female genital mutilation is still occurring in the United States. There are limited data on vaginal rejuvenation or vaginoplasty surgeries before 2011, but according to the American Society for Aesthetic Plastic Surgery, there was a 64.4% increase in these surgeries in the United States from 2011 to 2012.21 Likewise, surgeries involving partial or total removal of the labia increased five-fold in the UK from 2000 to 2010.22 These surgeries include labioplasty, vaginal tightening, hymenoplasty, clitoroplasty, perineoplasty, and pubic enhancement. Current data suggest                                                                                                                 19 Edward Wallerstein, Circumcision: An American Health Fallacy, Vol. 1 (New York: Springer Publishing Company, 1980): 173-177. 20 Linda Burstyn. "Female Circumcision Comes to America." The Atlantic Online, October 1995: 28-35. 21 American Society for Aesthetic Plastic Surgery, Cosmetic Surgery National Data Bank Statistics,. Data, (Columbus: The American Society for Aesthetic Plastic Surgery, 2012). 22 RCOG Ethics Committee, Ethical considerations in relation to female genital cosmetic surgery (FGCS), Ethical opinion paper, Royal College of Obstetricians & Gynaecologists, (RCOG, 2013): 3.   11   that about 37% of women seek labia reduction surgery for strictly aesthetic, non-medical reasons and 31% for both functional and aesthetic reasons. Circumcision, or removal of the clitoral hood, is still practiced in the United States to improve likelihood of clitoral orgasm. 23, 24 An estimated 12-14% of college students in the United States also have nipple and/or genital piercings, which fall under WHO’s broad description of FGM.25 Latin America is also rarely considered in the anti-FGM discussion, though women in Guatemala undergo a practice called “intimate surgery,” a form of hymen reconstruction.26 There is also evidence of introcision, a severe form of cutting involving splitting of the perineum, that falls under WHO’s type IV category, in Colombia, Peru, Eastern Mexico and Brazil.27,28 There is also evidence of ritual genital alterations among aboriginal tribes in Australia, though the current prevalence is unknown.29,30                                                                                                                 23 J.R. Miklos and R.D. Moore, "Labiaplasty of the labia minora: patients' indications for pursuing surgery," J. Sex Med. (PubMed), (March 2008): 1492-1495. 24 Sarah B. Rodriguez "Female Circumcision as Sexual Therapy: The Past and Future of Plastic Surgery?" Pacific Standard Magazine: The Science of Society, (February 28, 2014). 25 Carol Caliendo, Myrna L. Armstrong, and Alden E. Roberts, "Self-reported characteristics of women and men with intimate body piercings," Journal of Advanced Nursing 49, no. 5 (March 2005): 474-484. 5. Hannah Roberts, "Reconstructing virginity in Guatemala." Lancet 367, no. 9518 (April 2006), 1227-1228. 6. Anastasia Moloney, "Colombia steps up campaign to stop FGM among Embera Indians." Thomas Reuters Foundation: News, Information and Connections for Action, 29 November 2013. 7. Office of the High Commissioner for Human Rights, “Harmful Traditional Practices Affecting the Health of Women and Children." Fact Sheet, Convention on the Elimination of All Forms of Discrimination Against Women, 1979. 29 Ibid.   12   III. WESTERN SURGERIES, AFRICAN MUTILATION YUCK: UNFAIR APPEAL TO DISGUST Early societies in Africa established strong controls over the sexual behavior of their women and devised the brutal means of circumcision to curb female sexual desire and response. —Olayinka Koso-Thomas31 Anesthetics and antiseptic treatment are not generally used and the practice is usually carried out using basic tools such as knives, scissors, pieces of glass and razor blades. —The Foundation for Women’s Health, Research and Development32 The removal of or damage to healthy, normal genital tissue interferes with the natural functioning of the body. —World Health Organization33                                                                                                                                                                                                                                                                                                                                           30 Helen Pringle, "The Fabrication of Female Genital Mutilation: The UN, Walter Roth and Ethno-Pornography." Paper (School of Politics and International Relations, University of New South Wales, (2004). 31 Olayinka Koso-Thomas, The Circumcision of Women: A Strategy for Eradication (London: Zed Books, Ltd., 1987): 37. 32 The Foundation for Women's Health, Research and Development. Female Genital Mutilation (FGM). http://www.forwarduk.org.uk/key-issues/fgm (accessed February 2014). 33 World Health Organization (WHO). Eliminating female genital mutilation: An interagency statement. Statement, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCHR, UNHCR, UNICEF, UNIFEM, WHO, Geneva: World Health Organization, (2008): 1.   13   The anti-FGM movement emphasizes the worst third-world genital alteration practices and suggests that they are performed to suppress women’s and girls’ sexuality. However, female genital alterations in third-world countries cannot be solely attributed to patriarchy, ethnicity or religion. As in Western countries, there are many factors that play into a woman’s decision to alter her or her daughter’s genitals. The media portrayals of Western and third-world genital alterations differ greatly and regularly draw unfair distinctions. When a white, Western woman tightens her vagina, trims her inner labia, or shortens the clitoris of her newborn baby, it is considered surgery. When a third-world woman chooses to alter her or her daughters’ genitals, it is considered mutilation, and it is assumed that it happened against her will. We are given statistics of genital cosmetic surgeries and prevalence of mutilation. Western women choose surgery while African women undergo mutilation. Echoing Uma Narayan’s comparison between Indian dowry murders and Western domestic violence: Traveling across borders decontextualizes information and has a negative effect on the understanding of specific issues.34 PATRIARCHY, SAVAGERY AND SEXUAL REPRESSION Female Genital Mutilation is without a doubt powered by the poison of patriarchy. —Siobhan Courtney, Al Jazeera35                                                                                                                 34 Uma Narayan. Dislocating Cultures: Identities, Traditions and Third World Feminism. (New York and London: Routledge, 1997): 86. 35 Siobhan Courtney. "The horror of female genital mutilation." Al Jazeera, (May 30, 2012).   14   Figure 136 A commonly used photo in media articles involving FGM. The picture portrayed over and over again in anti-FGM campaigns is only one of hundreds of diverse third-world genital alteration practices. In the picture above, adult African men are forcibly restraining and cutting a very young girl in an obviously unsanitary environment with an equally filthy razorblade. The disturbing image suggests that genital alteration is a practice forced upon young girls and women by men and that the Africans that practice it are primitive and torturous. Female genital mutilation has become viewed as the epitome of patriarchy. AntiFGM literature insists that third-world genital alteration practices are intended to suppress a women’s sexuality. That is, with the removal of the clitoris and thus pleasure, women and girls are forced to remain chaste. The origin story of ritual genital alterations may involve patriarchy. Certainly, the fact that women in many communities feel required to undergo a ritual practice points to women’s dependency on marriage their                                                                                                                 36 Original source unknown.   15   socioeconomic subordination.37 But patriarchy alone is vastly insufficient in explaining third-world genital alterations. As Gerry Mackie explains, “most, if not all, communities that do not practice FGM/C are also patriarchal.”38 Both men and women endorse and perpetuate their communities’ various practices, in many cases believing a ritual cut is a requirement of marriage. In third-world rituals, it is more often “mothers or grandmothers who organize and support the cutting of their daughters, and in many places the practice is considered ‘women’s business.’”39 There are also matricentric communities with genital alteration rituals, and many practicing communities perform cuts on both boys and girls. Figure 2: Before-and-after depiction of infibulation40                                                                                                                 37 Gerry Mackie and John LeJeune. Social Dynamics of Abandonment of Harmful Practices: A New Look at the Theory. Working Paper, Innocenti Research Centre, UNICEF, Florence: United Nations Children's Fund, (2009): 6. 38 Ibid. (emphasis added). 39 Ibid., 5. 40 “Infibulation.” Excision, Parlons-en! Accessed March, 2014, http://www.excisionparlonsen.org.   16   The anti-FGM movement bases its campaigns on infibulation, the most severe, but not most prevalent form of third-world practices. For example, Ayaan Hirsi Ali’s critically acclaimed and widely read book Infidel opens with her horrendous infibulation experience, which was remarkably painful both in the moment and for weeks after.41 The health effects cited by WHO and anti-FGM campaigns — trouble urinating and menstruating, painful intercourse, need for later surgeries, increased risk during childbirth — are side effects of infibulation. Though these side effects are not fabricated, carelessly citing them as the effects of FGM in general implies that all forms of FGM as defined by WHO are this dangerous. Anti-FGM literature rarely specifies which genital alterations cause this sort of harm. In this way, the anti-FGM movement also exaggerates the prevalence of infibulation. An article posted on UN.org explains, “The majority [of patients seeking reconstructive surgery for FGM] have undergone the most severe kind of cutting, called infibulation.”42 Cosmopolitan Magazine, a publication read by 78 million, recently published a piece on female genital mutilation in the United States.43 Like many, it opened with a detailed depiction one girl’s infibulation experience, tied down, screaming for help, cut by the same razorblade used on 20 other girls.44 Then, without explaining the various forms of genital alterations or widely differing circumstances under which it                                                                                                                 41 Ayaan Hirsi Ali, Infidel, (New York: Atria Paperback, 2007): 32-33. 42 Jocelyne Sambira, "Reconstructive surgery brings hope to survivors of genital cutting," Africa Renewal, January 2013, (accessed February 2014). 43 Bauer Media Group, Cosmopolitan. 2013, http://www.bauermedia.com.au/cosmopolitan.htm, (accessed March 2014). 44 Heather Wood Rudolph, "Why Aren't More People Talking about Female Genital Mutilation in the U.S.?" Cosmopolitan, March 4, 2014.   17   happens, the article continues, “Female genital mutilation … has affected 125 million women and girls in 29 countries in Africa and the Middle East.”45 Without specification, the reader is led to believe that 125 million African and Middle Eastern women have been infibulated. In fact, infibulation accounts for less than 10% of African ritual genital alterations.46 In “Female Circumcision Comes to America,” Linda Burstyn sets a fearful tone, describing a young mother, trying to escape her own mother, who has threatened to cut her daughter with a razorblade.47 Female genital mutilation is often described as a practice performed without anesthesia and with basic tools such as knives, razorblades or shards of glass. There is no attention paid to communities that have medicalized the practice, and the anti-FGM movement reprimands countries if they attempt to make the practice safer or encourage ritual pricks, for example, instead of a more severe form of cutting. The anti-FGM movement insists that FGM is a way to ensure virginity and make sex more pleasurable for men.48, 49 This description further points to the exaggerated prevalence of infibulation. First, infibulation often makes intercourse remarkably painful                                                                                                                 45 Ibid. 46 Stanley P. Yoder and Shane Khan, Numbers of women circumcised in Africa: The Production of a Total (DHS Working Paper, Macro International Inc., United States Agency for International Development, USAID, 2008), 6. 47 Burstyn, "Female Circumcision Comes to America.” 48 The AHA Foundation, Female Genital Mutilation, Fact Sheet, (New York: The AHA Foundation, 2011). 49 The United Nations Population Fund, Promoting Gender Equality, http://www.unfpa.org/gender/practices2.htm#13 (accessed March 2014).   18   for the woman, as her vaginal opening is extremely small and scarred, making it inflexible. Many women who have undergone infibulation have to be deinfibulated, that is, they must have the vagina cut open to allow for intercourse or childbirth. Many women are then reinfibulated, again making intercourse extremely painful if not impossible without another deinfibulation. Infibulation also involves damage to the clitoris and labia, which the anti-FGM movement explains removes pleasure, ensuring loyalty. Second, men assumedly experience more sexual pleasure when the vaginal opening is smaller, which would only occur after infibulation. Other common forms of third-world genital alterations would not have any effect on a man’s pleasure. These instances are a real and serious problem. Many women and girls around the world are forcibly infibulated, and the rarity of the practice does not have any bearing on eradication efforts. Ending forcible infibulations is certainly worth any amount of resources. Anti-FGM campaigns that focus on patriarchy and forced infibulation are problematic because they ignore many other circumstances under which genital alterations occur. The anti-FGM movement exploits the worst form of third-world practices and rarely campaign on or pays any attention to the women that are coerced into or voluntarily undergo a ritualistic cut in adulthood or girls that are cut in hospital settings. There are uncountable forms of genital alterations and accompanying rituals in Western and third-world countries, and few look like the pictures above. It is simply unfair to reduce the experiences of millions of women and girls to one sort of situation. Why does the anti-FGM movement exaggerate the worst sorts of practices and encourage us to say, “yuck?” Disgust is persuasive, and it can potentially lead to change.   19   Bioethicist Leon Kass argues that disgust is evidence that we are doing something wrong, and it can give good reason to make something illegal.50 Similarly, Martha Nussbaum suggests, “by cultivating our ability to see vividly another person’s distress, to picture ourselves in another person’s place — we make ourselves more likely to respond with the morally illuminating and appropriate sort of response.”51 However, she also explains, “Disgust does not provide the disgusted person with a set of reasons that can be used for the purposes of public argument and public persuasion.”52 It is not a reason to do away with a practice, but a tool for advocacy.53 ARE AFRICAN PRACTICES YUCKIER THAN WESTERN COUNTERPARTS? We do not usually discuss the way different cultures oppress women and compare our modes of oppression to theirs, but instead we ask, completely oblivious to our own vices, How can they do that to them? … When we look closely at these practices, the differences start to fade. — Yael Tamir54                                                                                                                 50 Julian Sanchez. "Discussing Disgust: On the folly of gross-out public policy. An interview with Martha Nussbaum ." Reason.com, July 15, 2004. 51 Martha Nussbaum, Love's Knowledge, (New York: Oxford University Press, 1990), 39. 52 Ibid. 53 Consider, for example, the use of disgust or the “yuck” factor by campaigns against legalizing gay marriage. 54 Tamir, “Hands Off Clitoridectomy.”   20   Do Americans get orthodontia for their children because they are compelled to do so by ritual? Why is it that when Africans do something it is a ritual, but when Americans do something it is for reasons? —Gerry Mackie55 What is it that justifies the word “mutilation” when referring to third-world genital alteration practices? When does a practice go from a genital alteration or a cosmetic surgery to mutilation? Where can the line be drawn? It cannot be taken for granted that because a practice occurs in a developing country that it is necessarily primitive or worse in principle than a similar practice in the West. Martha Nussbaum gives eight reasons to consider female genital mutilation worse than Western practices: 1. Female genital mutilation is carried out by force. 2. Female genital mutilation is irreversible. 3. Female genital mutilation is usually performed in dangerous, unsanitary conditions. 4. Female genital mutilation is linked to lifelong health problems, even death. 5. Female genital mutilation is usually performed on children too young to consent. 6. Female genital mutilation is carried out on women in countries with low literacy rates, which limits notion of consent and choice. 7. Female genital mutilation irreversibly damages a type of valuable sexual functioning.                                                                                                                 55 American Academy of Pediatrics Committee on Bioethics. "Ritual Genital Cutting of Female Minors." Pediatrics (American Academy of Pediatrics) 102, no. 1 (May 2010).   21   8. Female genital mutilation is linked to customs of male domination.56, 57 Each of these points stands as a suggestion for where we ought to draw the line between surgery and mutilation. Point three deals with a danger to health, which I will explain is an extremely problematic place to draw a line between surgery and mutilation. Points two, four and seven deal with permanence, which I will again show is a problematic line. Point eight suggests we ought to draw a line at practices that involve routine male domination, though this only points to the anti-FGM movement’s double standards. Points one, five and six suggest a line ought to be drawn at consent, which I will address as a proper place to draw the line, though oversimplified by the anti-FGM movement. In extreme cases, Nussbaum’s points successfully explain why a practice is mutilating. However, in examining the huge variety of genital alteration practices, none of these points can explain where a line ought to be drawn between surgery and mutilation. Even if Nussbaum’s conditions are taken in conjunction, there are certain cases in which many of the conditions are met, yet the practice in question is not considered mutilating by the anti-FGM movement. Conversely, there are cases in which many of the conditions are not met, yet the practice is considered mutilation.                                                                                                                 56 Nussbaum, Martha C. Sex and Social Justice. (Cary, NC: Oxford University Press, 1999), 123-124. 57 Nussbaum notes that when she uses the term female genital mutilation, she is referring only to practices that involve removal of tissue. Part of the discussion to follow will address that how much harm is committed is not a good place to draw the line between surgery and mutilation. Even if it were, though Nussbaum is cautious in lumping ritual pricks with infibulation, the anti-FGM movement does not specify which forms of FGM they are referring to at any given time, carelessly making claims on Nussbaum’s list in reference to FGM, in general. I chose to use Nussbaum’s criteria because it is straightforward and thoroughly reflects the anti-FGM movement’s reasoning.   22   A number of genital alteration practices will be addressed in showing how this list does not serve well in distinguishing surgery and mutilation. At the very least, it will show that the anti-FGM movement does not adhere to these criteria when determining the practices on which to focus. UNSANITARY CONDITIONS Nussbaum’s third point suggests that surgery and mutilation differ in the conditions in which they are practiced. Mutilation, she explains, “is usually performed in conditions that in and of themselves are dangerous and unsanitary, conditions to which no child should be exposed.”58 Would Nussbaum be willing to say that if the third-world practices she had in mind were performed in sanitary conditions, that they would be more acceptable? The anti-FGM movement is certainly not. Many third-world ritual cuts occur in unsanitary conditions. It is often because of these unsanitary conditions that young girls suffer from persisting infections, which lead to lifelong health problems and sometimes death. For example, some communities use ashes on cuts to prevent infection. This practice not only worsens infection, but increases pain and prevents cuts from ever healing. Scars can also become black from healing around the ashes and essentially seal in infection. Women undergoing cosmetic surgeries in Western states are also prone to infection. However, doctors take preventative measures in avoiding infection, and further care is available in the event of infection. It seems that health education and providing proper medical equipment could easily solve this problem, reducing both short-term and lifelong harms.                                                                                                                 58 Nussbaum, Sex and Social Justice, 123-124.   23   So why not provide medical training, anesthesia and antibiotics to the practicing communities with unsanitary conditions and poor methods of preventing infection? Why not advocate to medicalize the practice, reducing both short-term and long-term health risks and consequences? This goal might even be easier than eradicating ritual practices altogether. The anti-FGM movement, however, is largely against medicalizing thirdworld female genital alterations. As London-based charity Orchid Project explains: Even if the practice is medicalized, “it remains a practice that denies a woman her right to bodily integrity” and can “’lead to sexual, psychological and physical problems.’”59 WHO states that it is “particularly concerned about the increasing trend for medically trained personnel to perform FGM. WHO strongly urges health professional not to perform such procedures.”60 The anti-FGM movement is largely unwilling to allow a solution to the danger that comes with ritual genital alterations, which presents a problem in condemning all female genital alteration practices. In 2003, February 6 was named International Day of Zero Tolerance for Female Genital Mutilation. The 2012 UN resolution, “Intensifying global efforts for the elimination of female genital mutilations,” called upon states to promote programs of zero tolerance. Eradication efforts have not always taken a zero-tolerance approach, however. In 2010, the American Academy of Pediatrics issued a policy stating:                                                                                                                 59 Orchid Project, Indonesia - Ministry of Health's guidelines on female genital cutting, August 31, 2011, http://orchidproject.org/2011/08/indonesia-ministry-of-healthsguidelines-on-female-genital-cutting/ (accessed February 2014). 60 WHO Media Centre, Female genital mutilation, Fact Sheet, (Geneva: World Health Organization, 2013).   24   The ritual nick suggested by some pediatricians is not physically harmful and is much less extensive than routine newborn male genital cutting. There is reason to believe that offering such a compromise may build trust between hospitals and immigrant communities, save some girls from undergoing disfiguring and lifethreatening procedures in their native countries, and play a role in the eventual eradication of FGC. It might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick as a possible compromise to avoid greater harm.61 This suggestion was made with the knowledge that federal law precluded ritual nicking.62 It was based on the understanding that harmful social norms are nearly impossible to eradicate without support of the entire community.63 The policy was revised only six days later, after more than 25 published letters opposing the policy and extreme backlash from the media. I am outraged by your policy statement endorsing Type IV FGM as a “compromise to avoid greater harm.”—Sherry K. Rinell, Nurse-midwife Girls that had said no to FGM are now interested in the new type of FGM called the “AAP FGM” Your policy has almost destroyed [Woman of Paradise’s] work in eliminating this culture. — Esther Nkatha, President CEO, Woman of Paradise                                                                                                                 61 American Academy of Pediatrics Committee on Bioethics, "Ritual Genital Cutting of Female Minors," Pediatrics (American Academy of Pediatrics) 102, no. 1 (May 2010): 153. 62 Ibid. 63 See Gerry Mackie’s “Female Genital Cutting: A Harmful Pracitce?” (2003).   25   Encouraging pediatricians to perform FGM under the notion of “cultural sensitivity” shows a shocking lack of understanding of a girl’s fundamental right to bodily integrity and equality. —Taina Bien-Aime, Executive Director, Equality Now64 As Bettina Shell-Duncan explains: Although the adverse health consequences of female “circumcision” form the basis of opposition to the practice, anti-circumcision activists, as well as many international medical associations, largely oppose measures to improve its safety.65 It seems unfair of the anti-FGM movement to attack a practice on particular grounds, but refuse to endorse improvement. The anti-FGM movement justifies its zero-tolerance approach on the grounds that medicalization does not promote abandonment, but legitimizes third-world ritual cuts. There is still debate about whether medicalization or the promotion of less severe cuts would be worthwhile, considering a harm-reduction strategy could be useful while awaiting other effective strategies or where abandonment of particular practices in not immediately attainable.66                                                                                                                 64 American Academy of Pediatrics Committee on Bioethics, “Ritual Genital Cutting of Female Minors.” 65 Bettina Shell-Duncan, "The medicalization of female "circumcision": harm reduction or promotion of a dangerous practice?" Social Science & Medicine 52, no. 7 (April 2001): 1013. 66 See Bettina Shell-Duncan’s “The medicalization of female “circumcision” for more detail.   26   Although the anti-FGM movement stands by its zero-tolerance policy, it largely ignores medicalized practices. Consider, for example, vaginal rejuvenation surgeries or Western and third-world male circumcisions. These double standards and whether harm is a clear line between surgery and mutilation will be discussed in more detail in subsequent sections. IRREVERSIBILITY AND LOSS OF PLEASURE Points two and seven address the irreversibility of mutilating practices, including the irreversible loss of pleasure. WHO insists that there is only harm and no health benefit to FGM. Harms include, but are not limited to severe pain, shock, hemorrhage, recurrent bladder and urinary tract infections, cysts, infertility, risk of childbirth complications and newborn deaths, and the need for later surgeries.67 As Bettina Shell-Duncan explains: This laundry list of adverse health outcomes is repeated in the introduction of nearly all papers in the voluminous literature on female “circumcision”. Yet, one serious problem with these accounts of the medical “facts” is that they largely fail to distinguish differences in the types and frequency of complications associated with different types of genital cutting … Nonetheless, noteworthy case studies on infibulation are generalized to describe the health risks of all forms of genital cutting.                                                                                                                 67 WHO Media Centre. Female genital mutilation. Fact Sheet, (Geneva: World Health Organization, 2013).   27   Put simple, unsanitary infibulations and reinfibulations lead to the long list of side effects. However, surely a ritual prick of a needle would not lead to “severe pain or risk of childbirth complications.” The 2012 UN resolution, “Intensifying global efforts for the elimination of female genital mutilations,” firmly recognizes the irreversibility of female genital mutilation.68 If the definition of female genital mutilation includes piercing, which is reversible by simply removing body jewelry, or pricking, a practice that causes no damage that requires reversal, then the irreversibility claim falls short. Although Nussbaum clarifies the sorts of practices to which she is referring, the UN fails to do so. And there are many irreversible practices that are not referred to as mutilation. But would Nussbaum be willing to admit that if a practice does not irreversibly damage sexual pleasure that it would not be considered mutilation? Ritual pricks or nicks cause no sexual dysfunction, and, as discussed in a previous section, the American Academy of Pediatrics briefly recommended ritual nicks in 2010 to “appease parents who might otherwise subject their daughters to a more invasive and traumatic procedure.”69 The anti-FGM movement maintained, during this controversy, that all forms of FGM, including “nicks” and “pricks” are harmful, traumatic, and painful.70                                                                                                                 68 "Intensifying global efforts for the elimination of female genital mutilations." 69 Norra MacReady, "AAP retracts statement on controversial procedure," The Lancet 376, no. 9734 (July 2010): 15. 70 American Academy of Pediatrics Committee on Bioethics, "Ritual Genital Cutting of Female Minors."   28   Piercings, unlike pricks or nicks, are often sought to increase sexual pleasure.71 Anecdotal information suggests that piercings are useful in treatment of types of female sexual dysfunction, but there is no strong evidence that a piercing has a significant effect in increasing sexual desire or arousal.72 There is some evidence that piercings increase sensitivity to the point of discomfort, but not enough for people to regret their piercings.73 “Female circumcision” for the enhancement of sexual pleasure was once referred to as “love surgery” in the United States, and both Playboy and Cosmopolitan magazines endorsed female circumcision in the 1970s. More recently, the Pacific Standard published an article called “Female Circumcision as Sexual Therapy: The Past and Future of Plastic Surgery.”74 The article is sensitive to the fact that circumcision, i.e., removing the clitoral hood, may not work to enhance sexual pleasure, though it shamelessly leaves the option open and acknowledges the viable future of female circumcision to enhance sexual pleasure. According to WHO’s definition of FGM, both piercing and clitoral unhooding are forms of mutilation. Yet both of these are thought to cause an increase in pleasure, rather than irreversibly damage it.                                                                                                                 71 Caliendo, et al., "Self-reported characteristics of men and women with intimate body piercings,” 482. 72 Millner, Vaughn S., Bernard H. Eichold, Thomasina H. Sharpe, and Sherwood C. Lynn. "First glimpse of the functional benefits of clitoral hood piercings." American Journal of Obstetrics and Gynecology (Mosby, Inc.) 193, no. 3 (September 2005). 73 Caliendo, et al., "Self-reported characteristics of men and women with intimate body piercings.” 74 Rodriguez, "Female Circumcision as Sexual Therapy: The Past and Future of Plastic Surgery?"   29   “Female circumcision” is also an example of a double standard. That is, female “circumcision,” as FGM was once called, is judged to be a primitive, pleasurediminishing practice for Africans, but a means of increasing sexual pleasure for white women. On the opposite end of the spectrum, infibulation is the most severe form of female genital alteration. The clitoris, labia majora and labia minora are removed, and most of the vaginal orifice is stitched closed, leaving a small hole for urination and menstruation. In some cultures, smaller openings are coveted and become extremely problematic for women’s entire lives.75 Infibulation, as explained in more detail in a previous section, is sometimes thought to decrease a woman’s desire for sexual activity, as infibulation makes sex extremely painful, thus decreasing a woman’s desire to seek sexual activity, ensuring virginity. Although removal of the clitoris and labia intuitively suggests a loss of sexual pleasure, there is question as to much sensation is lost and how much of it can be restored. There is no shortage of conflicting evidence on the matter. Women who have undergone forms of female genital mutilation from type I to IV have been shown to have orgasms and to enjoy sex.76 Even infibulated women report desire, arousal, orgasm and satisfaction during sexual intercourse.77 Carla Makhlouf Obermeyer, associate professor of population and international health at Harvard                                                                                                                 75 Ali, Infidel. 76 Lucrezia Catania, Omar Abdulcadir, Vincenzo Puppo, Jole Baldaro Verde, Jasmine Abdulcadir, and Dalmar Abdulcadir. "Pleasure and Orgasm in Women with Female Genital Mutilation/Cutting (FGM/C)." J Sex Med (International Society for Sexual Medicine) 4 (2007): 1670. 77 Ibid., 1672.   30   University, after an extensive examination of existing research on the adverse health affects of third-world genital alterations, found that no statistically significant associations are documented.78 Further, Obermeyer explains, “Concerning sexuality, the available evidence does not support the notion that circumcision precludes sexual activity of the enjoyment of sexual relations.”79 There is a need for more and for better research done on the possible damage to sexual functioning, but the existing evidence is not compelling. One of the most objective studies performed to examine the association between type II cutting and reproductive health consequences found no statistically significant evidence that cut women experience higher rates of damage to the perineum or anus, vulval tumors, painful sex, infertility, prolapse and other reproductive tract infections.80 The anti-FGM movement’s description of health consequences of FGM, particularly of less severe forms of FGM, is highly exaggerated. Even infibulation is reversible. Some hospitals have de-infibulation clinics with outpatient reversal procedures that take under an hour.81 Not only will a reversal                                                                                                                 78 Obermeyer, Carla Makhlouf. "The Consequences of Female Circumcision for Health and Sexuality: An Update on the Evidence." Culture, Health & Sexuality (Taylor & Francis Group) 7, no. 5 (2005): 458. 79 Ibid. 80 Linda Morison et al., "The long-term reproductive health consequences of female genital cutting in rural Gambia: a community-based survey," Tropical Medicie and International Health (Blackwell Science Ltd.) 6, no. 8 (August 2001): 643-653. 81 The Women's. Well Women's De-infibulation Clinic: Reversing your circumcision. Fact Sheet, Victoria, Australia: The Royal Women's Hospital, 2014.   31   procedure ease urination, menstrual flow and intercourse, but in 80% of cases, it pleasurable sensation is successfully restored.82 However severe or reversible a practice is, as Yael Tamir explains, the anti-FGM movement’s focus on the damage to capacity for sexual pleasure is problematic. [This focus] reveals a patronizing attitude toward women, suggesting that they are primarily sexual beings … We should remind ourselves that women are not merely sexual agents, that their ability to lead rich and rewarding lives does not depend on the nature of their sex life.83 If damage to women’s sexual life really is the concern, “We should be much less forgiving of parents who, for religious reasons, teach their daughters that sex in general and masturbation in particular are obscene, thus eliciting fear and revulsion at sexual activities.”84 Further, plenty of acceptable Western genital alterations are equally if not more irreversible. Consider, for example, vaginal rejuvenation, laser hair removal, and female “circumcision.” Not to mention, most surgeries are irreversible, yet they are not called mutilating. To a certain degree, the capacity to harm oneself is a component of autonomy. It is certainly not the case that all type IV practices lead to an irreversible loss of pleasure. It is not even the case that the most severe forms necessarily lead to an irreversible loss of pleasure. It’s possible to perform FGM in a hospital setting with sanitary medical equipment. Still, infibulation, in particular, seems obviously mutilating.                                                                                                                 82 Eve Conant., "In the U.S., Hope for Victims of Genital Mutilation," Newsweek, June 16, 2010. 83 Tamir, “Hands Off Clitoridectomy.” 84 Ibid.   32   The irreversibility of a practice, even the harmfulness, is a not a fair criterion in drawing the line between surgery and mutilation. The arguments for eradication on the basis of irreversibility or harm include possibly non-mutilating practices, but exclude possibly mutilating practices. In light of the controversy in the harm approach to genital alteration practices, the anti-FGM movement has moved to a human rights-based argument, which comes with its own set of problems, to be discussed in the following section. MALE DOMINATION AND MOTIVATIONS TO CUT The anti-FGM movement attributes third-world genital alterations to patriarchy, or as Nussbaum says, male domination. As cultural anthropologist Richard Shweder explains, rejecting third-world female genital alteration practices “has become a symbol of opposition to the oppression of women and of one’s support for their emancipation around the world.”85 This section will discuss how although male domination may play a role in origin stories, it is not explanatory in many practicing communities. It will also show that Nussbaum’s final distinction between Western and third-world practices actually draws on something that these practices hold most in common. Nussbaum explains that third-world genital alteration practices are motivated by the desire to preserve chastity in women and to make intercourse more enjoyable for men. A previous section has already explained that these points are only true in communities that practice clitoridectomy or infibulation. Although the chastity                                                                                                                 85 Richard A. Shweder, "What about "Female Genital Mutilaton?" And Why Understanding Culture Matters in the First Place," Daedalus (The MIT Press) 129, no. 4 (Fall 2000): 209-232.   33   motivation is present in some communities, even in some communities that practice clitoridectomy and infibulation, these are not the goals. The argument that communities practice ritual genital alterations to suppress women’s sexuality does not hold up in communities where both male and female genital alterations are practiced. In the Kono, genital alteration practices exist for both boys and girls. The Kono believe that in their “natural” states, the male anatomy has feminine characteristics, e.g., the foreskin, and the female anatomy has masculine characteristics, e.g., the clitoris. The Kono believe that the respective cuts must be performed to make the gender of the child clear. There is no intention to inhibit sexual pleasure, and the Kono has “no cultural obsession with feminine chastity, virginity, or women’s sexual fidelity.86 In the Kono and in most practicing third-world communities, both boys and girls are cut out of the belief that it is in the best interest of the child’s health and social status. In some communities, infibulation is not intended to preserve virginity, but to enhance fertility and protect the womb.87 Nussbaum and the anti-FGM movement also underestimate the coercive power that patriarchy has on Western women. The UN General Assembly of the Convention for the Elimination of All Forms of Discrimination Against Women (CEDAW) has firmly committed to eliminating “customary and all other practices which are based on the idea of the inferiority or the superiority of either of the sexes or on stereotyped roles for men                                                                                                                 86 Fuambai Ahmadu, "Rites and Wrongs: An Insider/Outsider Reflects on Power and Excision," In Female "Circumcision" in Africa: Culture, Controversy, and Change, by Bettina Shell-Duncan and Ylva Hernlund, (Boulder, Colorado: Lynne Rienner Publishers, 2000). 87 Janice Boddy, "Womb as Oasis: The Symbolic Context of Pharaonic Circumcision in Rural Northern Sudan." American Ethnologist 9 (1982): 682-698.   34   and women.”88 The global conversations surrounding harmful practices affecting women, however, are largely focused on non-Western practices. Nussbaum explains: The ideal female body image purveyed in the American media has multiple and complex resonances, including those of male domination, but also including those of physical fitness, independence, and boyish nonmaternity.89 Nussbaum emphasizes the preservation of human dignity, which she explains, Is usually taken to involve an idea of equal worth … But human dignity is frequently violated on grounds of sex. Many women all over the world find themselves treated unequally with respect to employment, bodily safety and integrity, basic nutrition and health care, education and political voice.90 It is outside the scope of this paper to discuss in detail to what extent Western body norms affect women’s decisions. However, there is no doubt that the norms unequally affect women. Take, for example, that in 2012, 91% of all cosmetic procedures, both surgical and minimally invasive, were performed on women. There are very few communities, if any, that perform genital alterations on girls but not on boys. Third-world communities with rituals surrounding cutting practices often recognize the genital alteration as a symbol of maturity and empowerment. In these                                                                                                                 88 UN Women, Convention for the Elimination of All Forms of Discrimination Against Women (CEDAW), United Nations, 5(a). 89 90 Nussbaum, Sex and Social Justice, 125. Martha Nussbaum, "Women and Equality: The capabilities approach," International Labour Review (International Labour Organization) 138, no. 3 (1999): 227.   35   communities, the boys and girls are treated arguably more equally than in the West where body norms disproportionately affect women. While Nussbaum is right to note that Western norms that require certain beauty practices are complex, she is wrong to assume that third-world norms are any less so. WHO cites “a mix of cultural, religious and social factors” as the cause of third-world female genital alterations.91 Although religion may play a role in perpetuating the practice, Muslim, Christian, Jewish, traditional and pre-Islamic religious communities participate in the practice. However, most Muslim, Christian, Jewish, traditional and pre-Islamic religious communities do not have female genital alteration rituals. In some communities, religion and tradition are not easily differentiated. Religion cannot explain why female genital alteration practices are perpetuated, however, as they are not mandated in any religious law. Likewise, though the origins of third-world female genital alteration rituals are linked to paternity confidence in female slavery, ascribing third-world genital alteration practices to patriarchy does not explain the non-universality of practices under universal patriarchy.92 Gerry Mackie, professor at the University of California, San Diego and expert on harmful social practices, cites three societal motivators for third-world genital alterations:                                                                                                                 91 WHO Media Centre, Female Genital Mutilation. 92 Gerry Mackie, "Ending Footbinding and Infibulation: A Convention Account," American Sociological Review (American Sociological Association) 61, no. 6 (December 1996): 1000.   36   patriarchy, culture, and marriageability.93 None of these is sufficient to explain why female genital alteration rituals are perpetuated. Mackie explains the way in which social convention theory applies to third-world female genital alterations. In game theory: The choice made by one player depends upon the choice of another player. In an interdependent larger group, the choice of each member depends on the choice of all members.94 In most practicing third-world communities, genital alterations are a condition for marriage, and mothers-in-law will confirm a bride has been cut prior to consummation of marriage. In communities where marriageability is a social convention, it is in each individual’s interest to comply.95 It would be better for the women and girls if no one in the community practiced female genital alterations, but the social consequences are, in many cases, worse than the cut for any individual that does not participate. A mother in a practicing community may understand the risks in having her daughter cut, but she may not have the option not to engage. The decision not to cut could lead to unmarriageability or ostracism, resulting in a worse situation for both the girl and her family. In this way, compliance is in the girl’s interest, but the negative sanctions are at least as, if not more, motivating and indicate that the convention has become a self-enforcing norm. Promoting                                                                                                                 93 Mackie and LeJeune, Social Dynamics of Abandonment of Harmful Practices. 94 Ibid., 9. 95 Ibid., 20.   37   greater awareness of medical hazards is often insufficient for a mother to risk her daughter’s marriageability.96 A common explanation among women in practicing communities is, “such is the custom or tradition here,” though they unaware of exactly how their particular practice originated or of the reasons for practicing.97 These cases warrant the most concern, as the following section will address. However, the reason for concern is not as simple as male domination. In addition to marriageability, which has roots in patriarchy, and cultural motivations, various communities’ motivations include many of those cited for Western genital alterations. These will be discussed further in subsequent sections. CONSENT Many women who followed the tradition of Sati seem to do it as a matter of choice. Did their “consent” make this tradition defensible? Women “consent” to such practices because the alternative is even more painful — a life of solitude, humiliation, and deprivation. —Yael Tamir98 As it stands now, someone who is harmed under oppression is held responsible for everything that happens to her — not only for her choices, but for the situation itself … Alternatively, she is perceived as a total victim, as if she                                                                                                                 96 Mackie, “Ending Footbinding and Infibulation,” 1015. 97 Ibid., 1004. 98 Tamir, “Hands off Clitoridectomy.”   38   were not making choices and trying to survive and go on. —Sarah Hoagland99 Because of the problematic harm approach, the global anti-FGM movement now takes a rights approach in eradication efforts. The most recent UN resolution on FGM commits to “the protection and promotion of the human rights of women and girls.”100 This includes “rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death.”101 One of these rights is that of self-governance. The UK Department of International Development says, “One of the clearest examples of women’s lack of choice, voice and control is female genital mutilation or cutting (FGM/C).”102 Nussbaum argues that autonomy is a general good for all humans and that “fostering of personal autonomy [is] an appropriate goal of the state.”103 “Rights language,” as Nussbaum explains, places emphasis on people’s choice and autonomy, though she chooses to articulate rights as capabilities. This is useful                                                                                                                 99 Sarah Lucia Hoagland, Lesbian Ethics: Toward New Values. (Palo Alto, CA: Institute of Lesbian Studies, 1989), 215. 100 “Intensifying global efforts for the elimination of female genital mutilations 101 “International Day of Zero Tolerance for Female Genital Mutilation.” 2012.” 102 Lynne Featherstone, Voice, choice and control: Tackling FGM in Burkina Faso, Crown Copyright, January 30, 2014, https://dfid.blog.gov.uk/2014/01/30/voicechoice-and-control-tackling-fgm-in-burkina-faso/ (accessed 2014 February). 103 Clare Chambers, "Are Breast Implants Better than Female Genital Mutilation? Autonomy, Gender Equality and Nussbaum's Political Liberalism," Critical Review of international Social and Political Philosophy (Routledge) 7, no. 3 (January 2007): 3.   39   because although the UN secures rights for women and children on paper, the women and children may not be in a position to exercise those rights. She clarifies that “The language of capabilities was designed to leave room for choice, and to communicate the idea that there is a big difference between pushing people into functioning in ways you consider valuable and leaving some choice up to them.”104 In this comment, Nussbaum begins to touch on an important issue with the rights approach. That is, the anti-FGM movement justifies eradication efforts on the basis of human rights, including the capacity to govern oneself. However, in focusing on human rights, the anti-FGM movement violates certain rights, particularly the right to selfgovern.105 The anti-FGM movement is justifiably concerned with the rate at which ritual genital alterations are performed on girls between birth and 15 years old — below the legal age of consent. There may be reason, however, to worry about adult consent as well. Nussbaum’s sixth point, for example, suggests that adult consent can be problematic, as lower literacy rates mean women are not fully informed before they consent to undergo a ritual genital alteration practice. Education level, however, is not as good of a predictor of behavior as other factors, such as culture.106 Kono women with college educations, for example are circumcised, while illiterate, uneducated Senegalese                                                                                                                 104 Nussbaum, “Women and Equality: The capabilities approach.” 105 WHO Media Centre, Female Genital Mutilation. 106 Shweder, "What about "Female Genital Mutilaton?" 217.   40   Wolof women are not.107, 108 Educated Western women undergo harmful practices, such as vaginal rejuvenation, tattooing or extreme dieting, knowing the risks. Nussbaum suggests that third-world genital alteration rituals are significantly worse than Western alterations because there is physical force in the former, but not the latter. This is simply not the case in many communities. Consider, for example, Leyla Hussein’s experience in Somalia: You may find it hard to believe, but many girls who have undergone FGM asked to be cut … I’ll never forget my first day at school in Somalia. A little girl from my class asked me, "Leyla did you have Gudniin?" (FGM in Somali) I answered yes. She pointed at the girls waiting on the other side of the playground. "Girls she can now play with us". At that moment I felt I belonged … If I hadn't gone through it, I would have been ostracised. I would have been all alone. It's no wonder girls can be so scared of the stigma, that they're willing to ask to be cut.109 Kono women that have lived in the West and have received Western educations still often voluntarily return to their communities to undergo a ritual cut. There is only physical restraint during the actual procedure. During male infant circumcision, infants must be restrained in a similar way, as it seems any procedure without anesthesia would require. The Declaration of the Rights of the Child grants parental responsibility for care                                                                                                                 107 Shweder, "What about "Female Genital Mutilaton?" 217. 108 Ahmadu, “Rites and Wrongs.” 109 Hussein, "When Is It a Choice.”   41   of the child, and in many countries this translates to informed parental consent being sufficient in cases such as medical treatment. In the United States, parents are legally capable of consenting to painful procedures for their children. Whether a practice is painful, possibly even harmful, sometimes plays no factor in whether a minor is subjected to that practice. Pain ought to be avoided wherever possible, though the circumstances under which it occurs are more relevant in whether pain is mutilating. There is a temptation to argue that the painful practices Western children undergo are medically necessary. However, painful practices such as piercings and tattoos, which parents can and regularly provide consent for, cannot be justified as medically necessary. Parents may consent to painful procedures such as bone marrow donations for the medical benefit of someone other than the child. Approximately 25 million children undergo orthodontic procedures every year.110 Parents may even consent for cosmetic surgeries. In 2012, 236,000 cosmetic procedures were performed on teenagers. 76,000 of these were surgical.111 The belief among some plastic surgeons is, “Aesthetic female genital surgery involves surgery on normal female external genitalia; therefore, it fall into the same category as liposuction, breast augmentation, facial rejuvenation, cosmetic dental surgery, or any other aesthetic surgery procedure to the body.”112                                                                                                                 110 Richard J. Manski and Erwin Brown, Dental Procedures, United States, 1999 and 2009, Statistical Brief, U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, (2012). 111 American Society of Plastic Surgeons, Plastic Surgery for Teenagers Briefing Paper, 6. 112 Julie M.L.C.L. Dobbeleir, Koenraad Van Landuyt, and Stan J. Monstrey, "Aesthetic Surgery of the Female Genitalia," Seminars in Plastic Surgery 25, no. 2 (2011): 1.   42   The American Society of Plastic Surgeons gives specific guidelines for teens between ages 13 and 19 wishing to undergo cosmetic surgery, but “has no formal position on plastic surgery for teenagers.”113 Like any other surgery, teenage girls can undergo genital alterations or breast enhancement surgeries with parental permission. If the cosmetic surgery is motivated out of a cultural practice, however, parents in the United States cannot consent for their children and could face legal repercussion. The United States banned performing female genital mutilation on minors, which seems to be a reasonable solution to the consent issue. Yet even if genital alterations are only permitted for adult women, there is still reason to question the extent of consent. In communities that routinely practice ritual genital alterations, especially in those where the consequences for not participating are high, there is reason to believe that even an adult woman cannot consent. Even if a woman says, “I want this done to my body,” to what extent was she coerced? Taking consent as sufficient does not account for the coercive power of social norms. However, simply placing a ban on all female genital alterations does not solve the coercion problem, as it would only limit another sort of autonomy, which is already a problem with genital alterations. While there are many ways to define autonomy and dozens of nuances and feminist critiques, at the very least, “autonomy involves choosing and living according to standards or values that are, in some plausible sense, one’s ‘own.’”114                                                                                                                 113 American Society of Plastic Surgeons, Plastic Surgery for Teenagers Briefing Paper, 6. 114 Marilyn Friedman, "Autonomy, Social Disruption, and Women." In Relational Autonomy: Feminist Perspectives on Autonomy, Agency, and the Social Self, by Catriona Mackenzie and Natalie Stoljar, 35-51. (New York, New York: Oxford University Press, 2000: 37.   43   This notion of autonomy can be broken down into what will be called first-order and second-order autonomy: (1) One is first-order autonomous if one is governed by rules that one sets for oneself or endorses for oneself. (2) One is second-order autonomous if one is able to lead the way of life that one chooses for oneself.115 The anti-FGM movement focuses on situations in which women and girls have neither first- nor second-order autonomy. That is, women and girls that undergo a genital alteration are living a non-autonomous life, which they did not autonomously choose. They cannot question the rules and actively choose how to respond to them, and they were born into the communities where they cannot govern their own lives. In most third-world communities, however, women appear second-order autonomous. That is, the women endorse and consent to their respective communities’ practices. They also consent to having their daughters undergo the same practices, often even awaiting the day with anticipation. Nussbaum places emphasis on this sort of second-order autonomy. It is important for people to be able to choose to live nonautonomous lives. That is, we want to preserve the option to first-order autonomously choose a nonautonomous life. However, as Chambers notes, “If preferences have already been socially influenced, then protecting autonomy cannot simply be a matter of allowing individuals to follow their preferences.”116 Women in practicing third-world communities understand that genital alterations are required to receive certain benefits from the                                                                                                                 115 Chambers, "Are Breast Implants Better than Female Genital Mutilation?” 133. 116 Ibid., 12.   44   community, so choose to undergo the alterations, seemingly with second-order autonomy. But because social pressures are so extreme, they might not have a plausible option not to endorse or consent to the practices. So, can we really say that these women are leading autonomous lives? To deal with this dilemma, the anti-FGM movement advocates for states “to take all necessary measures, including enacting and enforcing legislation, to prohibit female genital mutilations and to protect women and girls from this form of violence.”117 As the current definition of female genital mutilation includes any non-medical alteration to the body, bans on FGM remove women’s capacities to act on their desires. The definition of FGM that guides states’ bans, does not take into account the formation of women’s preferences. Enforcement of current legal restrictions is largely biased against black women. Bans on female genital mutilation promote the infantilization of African women, refusing them a choice that Western women are awarded. The anti-FGM movement takes for granted that Western women have less social coercion than women in developing countries. In the UK, consenting African adults are forbidden to undergo cosmetic genital alterations, as the ban on FGM applies to both women and girls.118 Leyla Hussein, cofounder of anti-FGM charity Daughters of Eve, says, “If an African girl wanted FGM we would be outraged … Yet when a girl from a non-FGM practicing community wants to                                                                                                                 117 “Intensifying global efforts for the elimination of female genital mutilations,” 4. 118 The Crown Prosecution Service, Female Genital Mutilation Legal Guidance, 2014, http://www.cps.gov.uk/legal/d_to_g/female_genital_mutilation/#female (accessed February 2014).   45   be cut, trimmed or tucked, we’re told its her choice. Aren’t both examples of cultural coercion?”119 To return to the question of what takes a practice from surgery to mutilation, the level of social coercion is the best measure. That is, we ought to be concerned with harmful practices when the only benefits in participating are norm-dependent. Consider pregnancy, for example. There are, in almost all cases, harms associated with pregnancy and risk of serious harm to the mother.120 Some of the benefits of pregnancy may be social, but there is an undeniable, non-norm-dependent benefit to motherhood. With most genital alteration practices, the benefits are purely social. For example, often in thirdworld communities, the only benefit to undergoing a genital alteration is marriageability. In this way, the benefits are norm-dependent. These are the cases we ought to be concerned with. In some cases, for example, episiotomies are necessary because of excessive tearing. The benefits to this genital alteration are not norm-dependent. The once routine “husband stitch,” might be problematic in this model, however. In the current legal structure, across the board, overly inclusive bans are only removing women’s capacity to live by the standards they endorse, sometimes leaving women with neither first- nor second-order autonomy and sometimes only harming second-order autonomy. With a poor definition of mutilation and heavy bias surrounding third-world practices, the anti-FGM movement’s approach is problematic in implementation.                                                                                                                 119 Leyla Hussein, "When Is It a Choice," The Huffington Post, (August 12, 2013). 120 See the WHO fact sheet on maternal mortality at http://www.who.int/mediacentre/factsheets/fs348/en/.   46   It might be that it is not any one of Nussbaum’s criteria alone that distinguishes surgery from mutilation, and it is only when taken together we can consider a practice mutilating. Even so, there are certain Western practices that meet many criteria that the anti-FGM movement ignores completely. ROUTINE MALE GENITAL ALTERATIONS The term “female circumcision” has been rejected by international medical practitioners because it suggests the fallacious analogy to male circumcision, which is generally believed to have either no effect or a positive effect on physical health and sexual functioning. Anatomically, the degree of cutting in the female operations described here is far more extensive. —Martha Nussbaum121 Many anti-FGM campaigns refuse to refer to ritual genital alterations as anything but mutilation, in order to sufficiently communicate the atrocity of alterations performed on girls. There is benefit for some organizations working directly with communities to use the more neutral term “cutting,” but the London-based Foundation for Women’s Health, Research and Development “chooses to use the term Female Genital Mutilation (FGM) … [because] it is the term that most accurately depicts the true nature of FGM.”122 On the word circumcision, Orchid Project, a London-based, anti-FGM charity, explains, “The use of the term ‘circumcision’ rather equates [FGM] with male                                                                                                                 121 Nussbaum, Sex and Social Justice, 119. 122 The Foundation for Women's Health, Research and Development, Female Genital Mutilation (FGM), http://www.forwarduk.org.uk/key-issues/fgm (accessed February 2014).   47   circumcision, which can lead to confusion about the gravity and consequences of the procedure.”123 When male genital alterations are compared to female ones, it is actually unclear in many cases why the female practices are so much worse. When compared to Nussbaum’s criticisms of FGM, many male genital alterations meet the criteria to be considered mutilation. First, in considering the physical conditions under which genital alterations occur, the anti-FGM movement suggests that only female genital alterations are performed with “basic” tools, such as knives, scissors, pieces of glass or razorblades, while male circumcision is “performed in a hospital.”124,125 This is largely untrue in the developing world. Though in third-world communities where male circumcision is medicalized, it is only the case because of support from the state and medical organizations, such as the World Health Organization. In Southern Thailand, 100 boys between the ages of 7 and 12 are circumcised together in public every year. Until recently, a traditional circumciser did the procedure. A boy would take a cold bath in a river to desensitize the genital area and the wound would be covered with mercurochrome ointment and ashes. With encouragement from health organizations and the state, however, the ritual has been medicalized, and boys are                                                                                                                 123 Orchid Project, Indonesia - Ministry of Health's guidelines on female genital cutting, August 31, 2011, http://orchidproject.org/2011/08/indonesia-ministry-of-healthsguidelines-on-female-genital-cutting/ (accessed February 2014). 124 The Observer, "Male circumcision: the practice is very different from female genital mutilation," The Guardian, (July 28, 2012). 125 The Foundation for Women's Health, Research and Development, Female Genital Mutilation (FGM), http://www.forwarduk.org.uk/key-issues/fgm (accessed February 2014).   48   sutured and given local anesthesia, though the public ritual remains. The girls in the same region undergo a mild cut or pricking of the clitoris within a year of birth. The Thai government, however, is disinclined to promote medicalization of the female practice, as it would “suggest a legitimization of the practice.”126 When countries or communities make an effort to hospitalize the procedure, as Indonesia did in 2010, the anti-FGM movement insisted, “It is the practice itself that is most harmful to women,” and medicalization “supports a consensus that it is an acceptable practice.”127 The UN also explicitly condemns the practice in medical institutions.128 The anti-FGM movement distinguishes male and female “circumcision” on the basis that the latter has extensive health consequences, such as vaginal infections and obstetrical complications. These consequences, however, are highly probable after infibulation, but not after a prick or an alteration performed in a similar hospital setting like male circumcision. In communities where male circumcision is not medicalized, the risk is no less than many forms of female genital alterations. The anti-FGM campaign is right to make a distinction between male circumcision and infibulation. But consider the parallels between removal of the male foreskin and the removal of the clitoral hood, both normal, protective mucocutaneous tissue.129 By                                                                                                                 126 Claudia Merli, "Male and female genital cutting among Southern Thailand's Muslims: rituals, biomedical practice and local discourses," Culture, Health & Sexuality (Routledge) 12, no. 7 (October 2010): 725-738. 127 Orchid Project, Indonesia - Ministry of Health's guidelines on female genital cutting. 128 “Intensifying global efforts for the elimination of female genital mutilations 2012,” 4. 129 C.J. Cold and J.R. Taylor, "The prepuce," British Journal of Urology (BJU International) 83, no. S1 (January 1999): 34-44.   49   definition, both are circumcision. If male circumcision is thought to be harmless and have no effect on sexual function, there is no reason to believe that removal of the medically female equivalent would have a different effect. However, of men in South Korea that were sexually active before circumcision, less than 20% reported difference in sexuality, but they were “twice as likely to have experienced diminished sexuality than improved sexuality.”130 As previously explained, anti-FGM movements campaign on the permanence of female genital alterations. In fact, male circumcision is significantly harder to reverse than female circumcision. Even the most severe forms of female genital alterations are reversible as outpatient procedures. Reversing male circumcision, on the other hand, can take years, as the male foreskin has to be stretched slowly and gently. Surgical foreskin restorations can take up to a year, as they require three surgeries and a touchup surgery six months later. Surgical uncircumcision only has a 60-70% success rate and prohibitive costs, where surgery to reverse infibulation is almost always successful and can restore sexual pleasure 80% of the time. Male uncircumcision, whether by stretching or surgery, can restore foreskin, natural glans coloration, and length. It cannot restore the erogenous frenar band, sensitive Meissner’s Corpuscles, frenulum, temperature-sensitivity, immunological defense system, lymphatic vessels, estrogen receptors, apocrine glands, lubricating glands, blood vessels, or dorsal nerves.131                                                                                                                 130 M.G. Pang and D.S. Kim, "Extraordinarily high rates of male circumcision in South Korea: history and underlying causes," BJU International 89, no. 1 (2002): 48-54. 131 Harry Garryman, What is lost due to circumcision? R. Wayne Griffiths and NORM, 2006, http://www.norm.org/lost.html (accessed February 2014).   50   Motivations for male circumcision are the same cited by practitioners of ritual female genital alterations. These include social norms, misguided medical beliefs, and efforts to curb masturbation and increase sexual pleasure. Some believe a ban on male circumcision would be anti-Semitic, while a ban on female circumcision would not be an affront to any religion.132,133 As discussed previously, ritual female genital alterations are not attributed to religion, as certain forms are practiced within Muslim, Christian, Jewish, traditional and pre-Islamic religions.134 Likewise, in the United States, 58.3% of male newborns are circumcised, though less than 2% are Jewish.135,136 In South Korea, 75.8% of males between ages 14 and 29 are circumcised, and the Jewish population is less than .01%.137,138 Of these, 75% believe it to be necessary “to improve penile hygiene,” “to reduce peer pressure,” and “to improve                                                                                                                 132 Tanya Gold, "A ban on male circumcision would be antisemitic,” The Guardian, (October 11, 2013). 133 Mackie and LeJeune, Social Dynamics of Abandonment of Harmful Practices. 134 Sarah R. Hayford and Jenny Trinitpoli, "Religious Differences in Female Genital Cutting: A Case Study from Burkina Faso," Journal for the Scientific Study of Religion (The Society for the Scientific Study of Religion) 50, no. 2 (2011): 252-271. 135 Maria Owings, Sayeedha Uddin, and Sonja Williams, "Trends in Circumcision for Male Newborns in U.S. Hospitals: 1979-2010," National Center for Health Statistics, (August 2013). 136 Sergio DellaPergola, "World Jewish Population, 2012," The American Jewish Year Book (Springer), (2012): 212-283. 137 138 Ibid. DaiSik Kim, Sung-Ae Koo, and Myung-Geol Pang, "Decline in male circumcision in South Korea," BMC Public Health 12, no. 1 (December 2012): 1067.   51   future sexual potency.”139 The rate of circumcision in South Korea “depends on the perpetuation of the cultural beliefs that support it.”140 This is precisely what Mackie shows of ritual female genital alterations. Male circumcision is practiced in Muslim, Christian, Jewish, atheist, pre-Islamic religious communities, though a community’s religious practice are not always predictive of behavior. Like third-world female practices, the decision to circumcise is based on social considerations more often than medical or religious conditions.141 Parents in the United States cite reasons to circumcise such as “the desire that a boy resemble his peers.”142 Parents express concern for boys who look different, and most Caucasian American parents are likely to know only circumcised males.143 Cleanliness is a commonly used rational for male circumcision, but as Edward Wallerstein noted, the same argument could be used for female circumcision: 1. The clitoris is covered by a foreskin; 2. The inner lining of the foreskin secretes smegma; 3. Some, perhaps many, women do not keep the clitoral area clean;                                                                                                                 139 J.H. Ku, M.E. Kim, N.K. Lee, and Y.H. Park. "Circumcision practice patterns in South Korea: community based survey." Sexually Transmitted Infections (British Medical Association) 79, no. 1 (February 2003): 66. 140 Ibid., 65-69. 141 Sarah E. Waldeck, "Social Norm Theory and Male Circumcision: Why Parents Circumcise," The American Journal of Bioethics (The MIT Press) 3, no. 2 (Spring 2003): 56-57. 142 Ibid., 56. 143 Ibid.   52   4. As a result smegma, dirt, germs, and other body materials can accumulate under the foreskin; 5. Such accumulation can be malodorous, irritation, and cause infections and adhesions.144 Cleanliness is also a largely cited motivation in third-world communities that practice female genital alterations. There is fear in some communities that the clitoris is dirty and can negatively affect reproductive health. Though no longer a commonly cited motivation, circumcision was performed in the United States to curb masturbation until the mid-19th century. The anti-FGM movement suggests that third-world genital alterations are performed to reduce sexual pleasure. and clitoridectomies were also both performed in the United States to treat incessant masturbation until at least 1937.145, 146 There is evidence that circumcision reduces the female-to-male transmission of HIV/AIDS, but the mechanism behind this phenomenon is unknown.147 Many studies suggest HIV/AIDS is more easily transmitted through the male foreskin, and a correlation has been found in HIV/AIDS transmission and longer foreskin, suggesting that less foreskin equates less risk. However, male foreskin and the clitoral hood are identical,                                                                                                                 144 Wallerstein, Circumcision: An American Health Fallacy, 72. 145 Ibid., 175. 146 G.J. Barker-Benfield, The Horrors of Half Known Life: Male Attitudes Toward Women and Sexuality in 19th Century America, (New York: Routledge, 2000), 132. 147 Nathan Seppa, "Better-off Circumcised?" Science News (Society for Science & the Public) 165, no. 14 (April 2004): 212-213.   53   both composed of muccocutaneous tissue.148 Using circumcision as a deterrent for HIV/AIDS is “equivalent to what a vaccine of high efficacy would have achieved.”149 According to WHO, FGM is “carried out on young girls sometime between infancy and age 15, while male circumcision is thought to be done on a few-day-old baby.”150, 151 In South Korea, however, a majority of men are circumcised “mostly during their elementary and middle school years.”152 Regardless, both practices are performed on children too young to consent. Parental consent for male circumcision, as seen by the motivations to circumcise, is no more informed than the parental consent for third-world female genital alterations. At least some forms of third-world genital alterations are no more harmful than their Western or male counterparts, and some are even thought to be beneficial. Unless terminology is changed from cosmetic genital surgery to cosmetic genital mutilation or male circumcision to male genital mutilation, it is not fair to call all non-medical alterations to the external genitalia mutilating. Partial or total removal of the external genitalia or other injury to the female genitalia for non-medical reasons is not inherently mutilation.                                                                                                                 148 Cold and Taylor, "The prepuce," 1. 149 Bertran Auvert, Dirk Taljaard, Emmanuel Lagarde, Joelle SobngwiTambekou, Rémi Sitta, and Adrian Puren. "Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial." PLoS Medicine 2, no. 11 (2005): 298. 150 WHO Media Centre, Female genital mutilation. 151 The Observer, "Male circumcision: the practice is very different from female genital mutilation.” 152 Ku, et al., "Circumcision practice patterns in South Korea,” 65-69.   54   INTERSEX SURGERIES Female genital alterations are explicitly banned in the United States: Whoever knowingly circumcises, excises, or infibulates the whole or any part of the labia majora or labia minora or clitoris of another person who has not attained the age of eighteen years shall be fined under this title or imprisoned not more than five years, or both.153 However, the anti-FGM movement ignores a prima facie case of female genital alterations on a regular basis, focusing efforts exclusively on African women and girls. Doctors in the United States deem 1 in 100 births socially unacceptable, labeling them “intersexuals” or “hermaphrodites,” and at least 1 in 1000 have their genitals “normalized.”154 Girls born with what U.S. doctors call too long of a clitoris are routinely excised. Boys with what U.S. doctors deem too small a penis have it carved down into a clitoris, and doctors create a vagina using a piece of colon. These are called “reconstructive surgeries,” not mutilation.155 U.S. doctors evade the standing prohibition on FGM, claiming “a child with ambiguous genitalia constitutes a social emergency” and correction is “necessary to the health of the person on whom it is performed.”156, 157                                                                                                                 153 National Defense Authorization Act for Fiscal Year 2013. 154 Melanie Blackless, Anthony Charuvastra, Amanda Derryck, Anne FaustoSterling, Karl Lauzanne, and Ellen Lee, "How sexually dimorphic are we? Review and synthesis." American Journal of Human Biology 12, no. 2 (2000): 151-166. 155 Though there is a growing movement to end intersex surgeries, the anti-FGM has explicitly refused to align with the intersex movement. 156 American Academy of Pediatrics Committee on Genetics, Section on Endocrinology and Section on Urology, "Evaluation of the Newborn With Developmental Anomalies of the External Genitalia," Pediatrics (American Academy of Pediatrics) 106 (2000): 138-142.   55   Fuambai Ahmadu describes her decision to undergo a form of genital alteration in her piece “Rites and Wrongs.” Ahmadu explains that in Sierra Leone’s Kono society, a registered nurse performs female genital alterations with anesthesia, oral painkillers, and antibiotics. Their ritual is not a “manifestation of women’s global subordination” or, as WHO describes, “an extreme form of discrimination against women.”158,159 Both boys and girls are circumcised to be made male or female.160 The Kono concept of natural differs from the Western concept.161 Western anti-FGM campaigns take for granted that because something is natural, it ought to be that way. For the Kono, sex is not something given at birth; the body is incomplete and must be given — or assigned, as we might call it in the United States — a gender.162 The Kono believe the clitoris is a sort of useless, dysfunctional penis.163 There is fear that if it is not tamed, it could grow too long or lead to incessant masturbation. There are communities that believe the clitoris’ similarity to a penis is a manifestation of masculinity in girls and that it should be removed to make a child into a girl. These cultures often also believe the foreskin on a penis is similar to a labia and is a manifestation of femininity and must be removed to make a child into a boy.                                                                                                                                                                                                                                                                                                                                           157 Crimes and Criminal Procedure. 158 Ahmadu, "Rites and Wrongs.” 159 WHO Media Centre, Female genital mutilation. 160 Ahmadu, “Rites and Wrongs,” 295. 161 Ibid., 285. 162 Ibid., 184. 163 Ibid.   56   The Kono picture is not drastically different from Western states. The United States also has ideas about what male and female genitalia ought to look like. Kiira Triea created the “Phall-O-Meter” for intersex activists. Though humorous, the ruler was designed to depict how sex is determined at birth and how arbitrary the measurements are. American doctors decide the boundaries, e.g., how big a clitoris or how small a penis has to be to count as intersex or “ambiguous.” Figure 3: The Phall-O-Meter164 Surgically altering a newborn’s genitals easily falls under WHO’s definition of FGM. According to the American Academy of Pediatrics, “The birth of a child with ambiguous genitalia constitutes a social emergency,” and a gender should be “established” as soon as possible.165 The law in the UK allows “surgical operation necessary for a girl’s physical or mental health.”166 The United States, however, makes no such provision.                                                                                                                 164 Alice Domurat Dreger, “Phallo-O-Meter,” http://alicedreger.com/phallometer.html. 165 Committee on Genetics, Section on Endocrinology and Section on Urology. "Evaluation of the Newborn With Developmental Anomolies of the External Genitalia," Pediatrics: Official Journal of the American Academy of Pediatrics 106, no. 1 (2000): 138-142. 166 Ibid.   57   According to surgeons that perform intersex surgeries, “not one has complained of loss of sensation, even when the entire clitoris was removed.”167 This reasoning directly contradicts the loss of pleasure that the anti-FGM movement campaigns on. Although sex assignment genital alterations happen in much smaller proportions in the United States than in communities that practice ritualistic genital alterations, in principle, the motivations are equivalent. That is, birth does not necessarily define gender, and alteration is necessary to ensure a child fits into a socially defined group. This presents a problem for the anti-FGM movement’s campaign on the natural body. Anti-FGM movements advance the idea that the body is better left natural. However, natural means left as is except for the changes arbitrarily approved of by Western women. The anti-FGM movement perpetuates the idea that it is unnatural for a third-world woman to alter her external genitalia in any way, but natural for a Western woman to shave, wax, get permanent laser hair removal, pierce and bleach hers. Granted, these practices are not on the same scale as a surgical alteration. They are, however, no more natural. Other evidence to consider of the anti-FGM movement’s double standard might be sterilization of female inmates (under investigation, though not called mutilation), routine episiotomies (which many third-world communities recognize as a form of FGM), and labia stretching (removed from the WHO definition of FGM in 2008).                                                                                                                 167 Milton T. Edgerton, “Discussion: Clitoroplasty for Clitoromegaly due to Andrenogenital Syndrome without Loss of Sensitivity,” Plastic and Reconstructive Surgery, 91, no. 5 (1993): 956.   58   IV. A DIFFERENT APPROACH Rather than emphasizing state neutrality, liberals should endorse state prohibition of practices which cause significant harm to those who choose them, if they are chosen only in response to unjust norms. —Clare Chambers168 It is thus time to approach multicultural exchanges with a sharper vision of our own vices, and see the multicultural debate less as a way to understand them and correct their ways than as a way to understand and improve our own culture. —Yael Tamir The anti-FGM movement focuses on female genital alterations in Africa and the African diaspora and largely ignores alterations that happen in other parts of the world. The anti-FGM movement is right to advocate for state intervention, though these interventions ought to proceed with extreme caution to avoid unfairness to Africans and people of African descent. If, instead of focusing on Africa and the African diaspora, the anti-FGM movement took a stance against harmful practices chosen in response to unjust social norms, such as those that require a cut for marriageability or those with no justification at all. If the movement focuses on increasing first-order autonomy, that is, reducing social pressure in desire formation, it can proceed in a less biased manner, without disengaging the very people it is trying to reach.                                                                                                                 168 Chambers, “Are Breast Implants Better than Female Genital Mutilation?” 1.   59   With this approach, normalized Western practices, like labiaplasty, male circumcision and intersex surgeries, will also come into question. As Clare Chambers, professor of philosophy at the University of Cambridge, points out, following Nussbaum’s criteria to ban FGM, this approach might also lead to a ban on breast implants. If these practices’ only benefits are norm-dependent, however, we should be calling our own practices into consideration. I am not advocating that we take a softer approach to eradication of mutilating practices. Rather, we ought to focus on practices that women consent to under questionable circumstances, not on where they are happening or to whom they are happening to, unless they are telling of how a woman came to want the harm to which she is consenting. In addition to state prohibitions, the state can focus its efforts on the norms that force women to harm themselves in order to receive certain social benefits. Medicalization efforts, or at the very least, teaching communities safe cutting techniques could also improve women’s health in settings where abandonment is not immediately attainable.169 Tostan, a nonprofit focused on empowering African communities, takes a twopronged approach in the communities they work with. First, using traditional educations and discursive practices, a facilitator of the same ethnicity opens a discussion about the positive traditions of the community and how new ideas can build a healthier community. Then, Tostan engages the community in a dialogue about their rights. Focusing on reducing the influence of social norms, Tostan has influenced over 7000 communities to                                                                                                                 169 Shell-Duncan, "The medicalization of female ‘circumcision.’”   60   publicly abandon their genital alteration practices. Each of these communities sends people into neighboring communities to facilitate similar conversations. This approach would not work in exactly the same way in Western states, though the anti-FGM movement could similarly focus on changing social norms instead of condemning the people who undergo harmful practices. Prohibitions are not all bad if they clearly focus on harmful practices in which the benefits are norm dependent and remain unbiased. However, states can also make efforts to decrease the influence of social norms, such as regulating advertising that perpetuates harmful norms. V. CONCLUSION The World Health Organization defines female genital mutilation as any alteration to the female external genitalia or genital organs for nonmedical reasons and insists the practice occurs in Africa and the African diaspora. Though such a broad definition includes a huge number of practices performed by both Western and third-world communities, the anti-FGM movement bases its campaigns on the worst type of genital alteration performed in developing countries under severely oppressive circumstances. In doing so, WHO and the anti-FGM movement are guilty of a double standard. In comparing the third-world practices the anti-FGM movement is concerned with to Western practices, I argued that the WHO definition of FGM is both over- and underinclusive. Further, it does not sufficiently explain what makes a practice mutilating. 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