Genitals and ethnicity: the politics of genital modifications

Abstract

The discrepancy in societal attitudes toward female genital cosmetic surgery for European women and female genital cutting in primarily African girl children and women raises the following fundamental question. How can it be that extensive genital modifications, including reduction of labial and clitoral tissue, are considered acceptable and perfectly legal in many European countries, while those same societies have legislation making female genital cutting illegal, and the World Health Organization bans even the “pricking” of the female genitals? At present, tensions are obvious as regards the modification of female genitalia, and current legislation and medical practice show inconsistencies in relation to women of different ethnic backgrounds. As regards the right to health, it is questionable both whether genital cosmetic surgery is always free of complications and whether female genital cutting always leads to them. Activists, national policymakers and other stakeholders, including cosmetic genital surgeons, need to be aware of these inconsistencies and find ways to resolve them and adopt non-discriminatory policies. This is not necessarily an issue of either permitting or banning all forms of genital cutting, but about identifying a consistent and coherent stance in which key social values – including protection of children, bodily integrity, bodily autonomy, and equality before the law – are upheld.

Résumé

Le décalage des attitudes de la société à l'égard de la chirurgie plastique des organes génitaux féminins en Europe et de la mutilation sexuelle féminine principalement chez les fillettes et les femmes africaines conduit à poser une question fondamentale : pourquoi beaucoup de pays européens jugent-ils acceptables et parfaitement légales des modifications génitales poussées, notamment la réduction des lèvres et du clitoris, alors qu'ils interdisent les mutilations sexuelles féminines et que l'Organisation mondiale de la santé proscrit même de « piquer » les organes génitaux féminins ? Présentement, la modification des organes génitaux féminins suscite de toute évidence des tensions, et la législation et la pratique médicale sont contradictoires selon l'origine ethnique des femmes. En ce qui concerne le droit à la santé, on peut se demander si la chirurgie plastique des organes génitaux féminins est toujours exempte de complications et si la mutilation sexuelle féminine s'accompagne toujours de complications. Les militants, les décideurs et d'autres acteurs, dont les chirurgiens plastiques, doivent prendre conscience de ces incohérences et trouver le moyen de les résoudre et d'adopter des politiques non discriminatoires. Il s'agit non pas forcément de permettre ou d'interdire toutes les formes d'incision génitale, mais plutôt d'adopter une position cohérente qui respectera les valeurs sociales, y compris la protection de l'enfance, l'intégrité physique, l'autonomie corporelle et l'égalité devant la loi.

Resumen

La discrepancia en las actitudes de la sociedad hacia la cirugía cosmética genital femenina en mujeres europeas y la mutilación genital femenina principalmente en niñas y mujeres africanas suscita la siguiente interrogante fundamental. Cómo puede ser que extensas modificaciones genitales, como la reducción del tejido de los labios y el clítoris, se consideren aceptables y perfectamente legales en muchos países europeos, mientras que en esas mismas sociedades existe legislación que penaliza la mutilación genital femenina, y la Organización Mundial de la Salud prohíbe incluso la perforación de los genitales femeninos? Actualmente, las tensiones respecto a la modificación de los genitales femeninos son obvias, y la legislación y prácticas médicas en vigor muestran contradicciones con relación a mujeres de diferentes etnias. En cuanto al derecho a la salud, es cuestionable si la cirugía cosmética genital siempre está libre de complicaciones y si la mutilación genital femenina siempre las causa. Es imperativo que los activistas, formuladores de políticas nacionales y otras partes interesadas, incluso los cirujanos cosméticos, sean conscientes de estas contradicciones, encuentren formas de resolverlas y adopten políticas no discriminatorias. No se trata necesariamente de permitir o prohibir todas las formas de mutilación genital, sino de identificar una postura constante y coherente, que respete importantes valores sociales como la protección de los niños, la integridad corporal, la autonomía corporal y la igualdad ante la ley.

Key Words:

• female genital mutilation/cutting
• genital cosmetic surgery
• law and policy
• beliefs/norms/values
• Western Europe
• Africa

Genital modifications take place in a sphere where biology, medicine and culture are intertwined. How we comprehend and describe biological sex (and its genital manifestations) is closely linked to cultural concepts about gender, which are thus inescapably ideological by nature. The prevailing attitudes toward genital cosmetic surgery and traditional female genital cutting have their own histories, and the dominant discourses have completely separate sources. Not until recently have scholars begun to juxtapose these practices and highlight the discrepancy in attitudes towards them.^1–6

In this article we position certain types of modification of the female external genitals in the ideological arena. The research presented in this paper is part of an ongoing research project that aims to map how various genital modifications are related to politics and to claims that certain practices are social problems.

Gender, sex and genitals

A now classic division is that between “sex” and “gender”,⁷⁸ where “sex” designates the biological properties that lead us to classify people as either male or female, while the term “gender” refers to social and cultural constructions of femininity and masculinity. The philosopher Judith Butler took the discussion further,⁹ by claiming that there is reason to question the assumption that biological sex, in contrast to “gender”, is thought to be “objective” and lacking cultural elements. She argued that biological sex has its own cultural history, which indeed reveals its cultural quality. Illustrative examples are offered by the biologist Anne Fausto-Sterling¹⁰ in her historical review of changing criteria for which biological properties are essential for the classification of “male” and “female” sex. A recent example arose after the most recent Olympic games. Up to 1968, whether a person was considered female was decided after visual examination of the external genitals by a board. The purpose of the procedure was to ensure that no male competitors enrolled in events for women. For several decades from 1968, the sex of a woman was established through a medical certificate or, if needed, a chromosome test.¹⁰ Today, however, there are no routine procedures that are used to establish the biological sex of female athletes; instead, specific women may have to undergo a medical investigation. Ongoing debate concerns the South African middle-distance runner, Caster Semenya, whose achievements have been questioned because of difficulties in establishing her biological sex.

One attempt to resolve this dilemma was to talk about “sex” with a lower case “s”, in contrast to the culturally constructed biological “Sex” with a capital “s”. Sex is there in reality, but the very moment there is an attempt to describe it (even in scientific terms) sex is turned into the culturally constructed “Sex”.¹¹ In fact, every cultural group tends to have its own criteria for distinguishing between male and female bodies and sex, but there is no scientific, objective, culture-free way of describing sex differences.¹⁰¹¹ This, however, is not the same as saying that there are no biological differences.

This very brief theoretical overview is sketched here to provide a backdrop to the discussion below, where we argue that prevalent discourses on female genital cutting and genital cosmetic surgery are characterised by the infusion of cultural ideas into the genitals and into female biological “sex”. In other words, body parts such as the clitoris or labia are not purely anatomical entities in these discourses. They are also infused with cultural meanings and values. Societal views of the relationship between sex, gender and genitals have given rise to politically-based decisions to advocate, accept or criminalise certain genital modifications, including through surgical procedures.

Claims-making

Claims-making is a process whereby key actors (e.g. activists, experts, the mass media) define certain acts or situations as undesirable, or as being a “social problem”. A social problem does not exist until it has been identified as such. To qualify as a social problem, an act or situation must meet certain criteria: it must be “wrong”, it must concern more than a few people, and there must be room for change.¹² Acts and situations carry no meaning in themselves. They are ascribed meaning through human activity such as claims-making. For claims-makers to be successful – that is, to be able to convince other people that something is going on that is wrong, is widespread and ought to be changed – the claims they make need to be in harmony with existing cultural values and meanings.

How we comprehend various procedures for changing the female genitals is also a result of claims-making.

Female genital cutting

Female genital cutting/mutilation/circumcision has been discussed by Westerners for centuries, often as a bizarre and cruel practice far away in Africa. Explorers, anthropologists and some doctors in the African colonies ran into various forms of it and described it in specialist literature. The general public did not know much about it until the 1970s. An American researcher and radical feminist activist, Fran P Hosken, was the one who forged public opinion. She can be seen as the key claims-maker as regards female genital cutting, being the strongest voice among radical feminists opposing the practice. Hosken rejected the term “female circumcision” and coined the phrase “female genital mutilation” (FGM). She advocated the use of FGM for many years and it is today the term used by the World Health Organization (WHO) and many governments. However, many NGOs have abandoned this term in favour of the more neutral “female genital cutting”, or use both. The term “FGM” is considered to be too offensive and possibly counter-productive in preventive work.¹³¹⁴ We therefore use “female genital cutting” in this paper.

In 1978 Hosken published The Hosken Report: Genital and Sexual Mutilation of Females. Her views of female genital cutting, in addition to descriptions offered by other radical feminists, have had an enormous impact on public views of these practices in Africa. A few examples showing how Hosken defined men's role in upholding female genital cutting:

“FGM is a training ground for male violence. It is used to assert absolute male domination over women not only in Somalia but all over Africa.”¹⁵

“Somalia is a classic example of the results of male violence: the practice of infibulation as family custom teaches male children that the most extreme forms of torture and brutality against women and girls is their absolute right and what is expected of real men.”¹⁶

Other radical feminist writers in the US and Western Europe admitted there was a discrepancy involved in labelling female circumcision as a form of male violence when women are generally the ones arranging the procedure and are often the most fervent advocates of the tradition. A way to resolve this paradox was to ascribe “false consciousness” to all the female actors who uphold and defend these practices, e.g. see Daly and Thiam.¹⁷¹⁸

“Mentally castrated, these women participate in the destruction of their own kind – of womankind – and the destruction of strength and bonding between women.”¹⁷

One may argue that everything evil that afflicts women has to do with the patriarchal order in one way or another. But it is important to note that this standpoint is ideological – not empirically proven, through observation, for instance. Nevertheless, due to the fact that the dominant discourse has its origin in radical feminism, the public view is that African women are victims per se. Rather than being seen as reflexive actors and decision-makers, they are mirrored as passive “bearers of tradition”,¹⁹ as for instance when women practising female genital cutting are labelled “prisoners of ritual”.²⁰ This has influenced legislation in many Western countries, where laws on “female genital mutilation” were passed to prohibit any procedure on the external female genitals, irrespective of age.

The prevailing attitude toward female genital cutting in Western countries has been characterised by zero tolerance. In Seattle (US) in the middle of the 1990s, staff at the Harborview Medical Center suggested a symbolic procedure to be performed on Somali girls' clitoral hood in order to enable the parents to consider their girls as “circumcised”. It was argued that the medically safe pricking of the clitoris by a physician was preferable to the much more extensive infibulation that these girls might risk on visits to their home country, and far less invasive than male circumcision of male infants. However, the hospital abandoned this practice of “symbolic blood-letting”. It was unclear whether it violated any law, as no tissue was removed, but it did clash with the WHO definition of female genital mutilation, which includes “pricking” in FGM category IV.²¹ In the Netherlands, a similar situation arose in 1992 when the Ministry of Welfare, Health and Culture suggested that doctors should be allowed to perform ritual perforation of the clitoral hood, also a form of pricking. The recommendation was withdrawn as it met with a storm of protest. Among the protesting parties was the chair of the Inter-African Committee, who declared that “official approval of the Dutch compromise would have set a dangerous precedent, reconfirming the subjugation of women”.²¹

Genital cosmetic surgery

There is a growing occurrence of procedures wherein Western women are having their genitals altered through surgery.^1,2,22–24 The commonest of these include reduction of the inner labia (labia minora), vaginal tightening, hymen “reconstruction”, clitoral “lifts” and liposuction of the mons veneris (fatty tissue over the pubic bone, these are performed in order to create a sense of proportion when the inner labia have been shortened), clitoral hood reductions and clitoral repositioning.²²²³ Little research has been carried out to map the prevalence and consequences of these procedures, but health professionals in for example the United States and Britain talk about a growing demand in the population,²³²⁴ and the subject is becoming more visible in newspaper and magazine articles, e.g. where surgeons are interviewed about these practices.

An increasing number of women in Western societies shave their genitals. In Sweden, for example, women born in the 1970s or later tend to depilate or shave their genital area (Personal communication with several Swedish gynaecologists). This trend, making parts of the vulva more visible, may contribute to the rise of a new genital aesthetic ideal: many young women seem to believe that nothing should protrude in their genital area. This belief and trend may originate from mainstream pornography, in which some porn actresses are shaved and have had their inner labia reduced.^22,24,25 What are perceived as the boundaries demarcating “normal” female genitals in the eyes of the public, especially among youth, seem to have moved remarkably in recent years.

There is claims-making and critical discussion in this field too: scholars are raising this issue and analysing it within a broader framework, including its socio-cultural aspects. Canadian scholar in gender studies, Fiona Green, has argued that these procedures strengthen the normative heterosexuality and create a generic view of body and sex.² Victoria Braun, researcher in psychology from New Zealand, discusses genital cosmetic surgery in terms of a “ready-made surgical solution” to a new problem for women, and stresses the importance of further discussion.²³ Swedish feminist theorist Kerstin Sandell has analysed the double role of plastic surgery, which works both as saviour and oppressor. The practitioners “help” individual women, but at the same time they contribute to the creation and establishment of new ideals and boundaries of what is seen as “normal” as opposed to “pathological”.²⁶ American sexologist Leonore Tiefer has argued that the rise of genital cosmetic surgery shows similarities to other trends where market forces and culturally-based views of body and sexuality intertwine.²⁷ In medical circles, some physicians have pointed to the fact that genital cosmetic surgery is often performed without therapeutic indications, and some of them also draw parallels with the practices labelled female genital cutting.³⁶

Genital cosmetic surgery procedures, albeit contested in some contexts, are associated with widely accepted other cosmetic procedures in the West, such as face lifts, rhinoplasty (nose alteration), and breast augmentation for aesthetic reasons and upon the request of women themselves. Women who are choosing to “fix” their bodies in various ways may be seen as victims – victims of patriarchy, of the beauty industry, of the pressuring ideals of today, or of their own inner insecurities. But another central cultural value seems to take precedence over the status of potential victim: that of their right to make free choices and to be the ultimate decision-makers where their own bodies are concerned. The prevalent discourse on genital cosmetic surgery, focusing on free choice and women's agency, has been analysed in detail by Braun.²⁵

Female genital cutting versus genital cosmetic surgery

Some may say that female genital cutting and genital cosmetic surgery are not comparable procedures, primarily based on the fact that the one is performed on consenting adult women, while the vast majority of the other are performed on girl children and infants with no regard for their wishes. In addition, many instances of female genital cutting are performed under unsanitary conditions while genital cosmetic surgery is about precision work in high-technology environments. But if we disregard context and only focus on what in the anatomy is removed, the modifications are indeed comparable. Female genital cutting covers everything from the most extensive procedures, such as infibulation, to the mildest of only “pricking” the genitals to draw a drop of blood. Genital cosmetic surgery, on the other hand, may entail removal of labia, but also removal of clitoral tissue (in so-called “clitoris lifts”). When clitoris reduction is discussed here (regarding both female genital cutting and genital cosmetic surgery), it is important to bear in mind that the clitoris stretches far into the body past the vaginal canal. The visible tip, which is usually what is understood as the clitoris in lay discourse, is but a fraction of the whole.²⁸

Scrutiny of the laws prohibiting female genital cutting in various Western countries makes it obvious that it is difficult to ban female genital cutting while condoning genital cosmetic surgery. The legal formulations are very exact. For example, the FGM Act 2003 in England and Wales²⁹ explicitly prohibits “the partial or total removal of the external female genital organs for cultural or other non-therapeutic reasons”. In Sweden, which was the first Western country to ban female genital cutting in 1982, the offence is described with the words: “Operations on the external female genital organs which are designed to mutilate them or produce other permanent changes in them (genital mutilation) must not take place, regardless of whether consent to this operation has or has not been given.” There are laws against “mutilation” in all Western countries. However, a number of European countries have also adopted specific criminal laws aiming at forbidding “female genital mutilation”. Besides Britain and Sweden, Austria, Belgium, Denmark, Italy and Spain also have such laws, sometimes excepting piercing and tattoos.³⁰ Clearly, genital cosmetic surgery falls within what is illegal in these technical descriptions.

WHO faces the same problem:

“Some practices, such as genital cosmetic surgery and hymen repair, which are legally accepted in many countries and not generally considered to constitute female genital mutilation, actually fall under the definition [of FGM] used here.”¹⁴

However, WHO prefers to maintain a broad definition of FGM “in order to avoid the loopholes that might allow the practice to continue”.¹⁴ In practice – that is, the way the laws are applied – the prohibition against genital modifications in Western countries concerns only African groups. According to WHO, the guiding principles should be grounded in discourses of human rights: e.g. the rights of children, the right to health and the right of non-discrimination on the basis of sex.¹⁴

In short, problems emerge if we are expected to discriminate between European and African female genitals. If this is purely a children's rights issue, then European laws need to include a paragraph stating that a woman above a specific age may choose to have her genitals modified, irrespective of ethnic background. That would protect children while placing adult women, of Western and non-Western origin alike, in the same category – that is, that they have the right to make decisions about their own bodies. In some states in the US, the law on FGM contains a clause regarding age. In countries where FGM is prohibited irrespective of age, some very peculiar legal considerations may arise among physicians as regards race, ethnic background, culture and age. Is a particular patient to be regarded as a victim of African patriarchy (thus, FGM) or as an adult woman, entitled to free choices concerning her own body? Should such ideological considerations pertain to the realm of medical practitioners? We think not.

As regards the right to health, a right emphasised by WHO, we must also question whether genital cosmetic surgery is always free of health complications and whether female genital cutting always leads to them. The Swedish Board of Health and Welfare has declared that cosmetic genital surgery is to be compared to cosmetic surgery on the nose and breasts, and is therefore legal.³¹ However, no legislation explicitly forbids surgery on breasts and noses.

In 2007 a Swedish woman complained that too much tissue had been removed from her labia and clitoris during cosmetic surgery on her genitals and that she felt mutilated. She did not report the case to the police. She did, however, file a report with the Medical Responsibility Board, and the surgeon received a formal warning.³² Surgery entails the risk of medical complications. The higher the prevalence of genital cosmetic surgery, therefore, the higher the likelihood of complications and adverse outcomes.

On the other hand, what is the extent of medical complications with female genital cutting? In its various forms, it does involve pain and may cause immense suffering. Long-term complications often mentioned include obstetric complications, fistula, cysts, urinary tract infections and sexual problems. Nevertheless, some authors have argued that the extent of the complications mentioned in activist literature, the media and some scientific publications is exaggerated and that scientific evidence is lacking.^5,33–37 For example, a study conducted by Morison et al³⁵ showed that medical problems often cited as consequences of female genital cutting were in fact not more frequent among circumcised women than in a control group of uncircumcised women in Gambia, such as damage to the perineum, vulvar tumours, painful sex, infertility, prolapse, and reproductive tract infections. The authors argue that efforts to eradicate these practices “should incorporate a human rights approach rather than rely solely on the damaging health consequences”.³⁵ Indeed, global campaigns have increasingly begun to rely on a discourse about bodily integrity rather than health complications. In a meta-analysis of studies concerning health and sexual consequences in relation to female genital cutting, Obermeyer concludes:

“The evidence on health effects is slowly accumulating, and while it is documenting some harmful effects, it is unlikely that it will demonstrate increased risks for all the serious and less serious complications that have, at one time or another, been attributed to [female genital cutting]. Advocacy efforts, in the meantime, are increasingly encouraging individuals and groups to abandon [FGC], less on the grounds of health complications, but because it represents infringements of bodily integrity and of human rights.”³⁴

In a survey investigating obstetric outcomes in relation to female genital cutting, conducted by the WHO in six developing countries, it was shown (statistically) that some forms of female genital cutting seemed to increase the risk of poor obstetric outcomes, perinatal mortality, caesarean section, and post-partum bleeding in circumcised women.³⁸ However, the increased risk did not have the immense proportions often imagined among lay people. Ronán Conroy, an epidemiologist, concludes in a BMJ comment on the WHO study that a comparison of risk factors in pregnancy places female genital cutting (treated as a whole) somewhere behind maternal smoking.³ Further, it has been shown that female genital cutting is not related to prolonged labour or perinatal mortality, at least not in high resource countries.³⁹⁴⁰

Claims about the absence of sexual pleasure due to female genital cutting, a central tenet of anti-FGM campaigns, are increasingly being challenged.^{4,20,34,37,41,42} Two Egyptian studies⁴³⁴⁴ have shown an increased risk of sexual dysfunction: statistically more cut women than uncut (or mildly cut) experienced lack of sexual desire and difficulties in achieving orgasm. In contrast, studies that include women from Sudan²⁰ and Somalia⁴¹ – countries where women go through the most extensive form of female genital cutting, often called “pharaonic circumcision” – have led us to draw the conclusion that cut women have the same ability to feel pleasure and experience orgasm as is found among Western women who have not been cut.⁴¹ Carla Makhlouf Obermeyer concludes in an overview of studies on female genital cutting and sexuality that “the available evidence does not support the hypotheses that circumcision destroys sexual function or precludes enjoyment of sexual relations”.³⁴ It is counter-intuitive that female genital cutting does not have adverse effects on ability to enjoy sex. But perhaps the absence of adverse effects is due to the fact that the clitoris does stretch far into the body;²⁸ what is cut is part of the external clitoris, while the inner structure remains intact. Furthermore, sexuality as an activity has to do with more than anatomy; sexual gratification also involves social, cultural and psychological factors to a higher degree than is usually acknowledged.⁴⁵ The brain has been said to be the most important sexual organ in female sexuality.⁴⁶ Thus, the ability to enjoy sex and to reach orgasm is not only about whether part of the external female genitals have been cut or not.

If sexual pleasure after female genital cutting can be preserved, the public discourse about grave loss of sexual pleasure as an inevitable consequence of female genital cutting needs to be reformulated. On the other hand, if there can be serious consequences for sexual pleasure from cutting away the external female genitals then surgical excision practices among European women also need to be challenged on those grounds.

Conclusions

Perhaps the strongest aversion toward female genital cutting is based in the wish to protect children. A focus on the rights of children emphasises their right to bodily integrity until they have reached an age where they may give consent. If child protection is the major concern in the legal and medical fields, then legislation banning female genital cutting needs to state that all adult women – irrespective of ethnic background or colour of skin – have a right to make decisions about their own bodies. The only alternative is to state that genitals are inherently different from noses and breasts, and to forbid all modifications to the female genitals – again, irrespective of ethnic background and skin colour.

We have argued that procedures involving genital modifications are intertwined with political considerations; they are never purely about anatomy and physiology but are intrinsically entangled with cultural norms and ideology. Even the pricking of the African clitoral hood is condemned, while reduction of clitoral tissue in a European woman is legal and accepted.

Procedures involving the genitals are an arena where medicine and culture and understandings of sex and gender converge. What is “given by nature” can be modified through surgery, but medical practice itself develops within norms that are time- and culture-bound. At present, tensions are obvious as regards the modification of female genitalia, and current legislation and medical practice show inconsistencies in relation to women of different ethnic backgrounds. Activists, national policymakers and other stakeholders, including cosmetic genital surgeons, need to be aware of these inconsistencies and find ways to resolve them and adopt non-discriminatory policies. This is not necessarily an issue of either permitting or banning all forms of genital cutting, but about identifying a consistent and coherent stance in which key social values – including protection of children, bodily integrity, bodily autonomy, and equality before the law – are upheld.

Acknowledgements

Our ongoing study about ideological aspects of genital modifications is financed by the Swedish Research Council in 2009-2011. The project is also supported by Malmö University and Uppsala University, Sweden.