June 2, 2010 — The American Academy of Pediatrics (AAP) is again changing its policy on ritual female genital cutting (FGC) after advocacy groups protested the academy's recently revised policy statement regarding the excision of girls' external genitalia, which some African, Middle Eastern, and Asian cultures perform as a rite of passage.

The AAP board of directors voted on May 22 to retire the new policy, published in the May issue of the journal Pediatrics, and to immediately revise it because of the confusion it generated, AAP President Judith Palfrey, MD, told Medscape Pediatrics.

That policy statement expressed concern that girls from cultures that practice FGC who now live in the United States may be sent by their parents back to their native countries for a genital-altering procedure that can be harmful and even life-threatening. In the statement, which revised the academy's 1998 policy, the AAP's Committee on Bioethics wrote, "It might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual [clitoral] nick as a possible compromise to avoid greater harm."

Opposes "All Forms" of FGC

In an official statement that the AAP released to Medscape Pediatrics, the board writes: "The AAP does not endorse the practice of offering a 'clitoral nick.' This minimal pinprick is forbidden under federal law and the AAP does not recommend it to its members."

"The ethics committee will do a rewrite, which will reassert the AAP opposition to all forms of female genital cutting," stated Dr. Palfrey, a pediatrician at Children's Hospital Boston.

During a telephone interview with Medscape Pediatrics, Dr. Palfrey said the original comment about performing a medically unnecessary nick represented an academic discussion of options to stop this "awful" practice.

"This was never a recommendation," she stressed. "Obviously, having a discussion inside a policy statement is confusing. We regret this."

The new policy revision will appear in the July print issue of Pediatrics.

Committee members will explore noncutting options in working to eliminate all forms of FGC, Dr. Palfrey said.

Female genital mutilation, as many opponents of FGC call it, includes 4 types of cutting, according to the World Health Organization, which views it as a human rights violation. They are:

removal of part or all of the clitoris;

clitoridectomy with or without excision of the labia majora;

infibulation, the most severe form, which involves excision of the clitoris and some or all of the labia minora, as well as suturing the remnant labia majora together to create a skin flap covering the urethra and vaginal opening except for a small hole; and

picking, piercing, incising, scraping, and/or cauterizing the genital area for nonmedical purposes.

Controversy about the AAP policy arose after a May 6 New York Times article, in which a member of the academy's bioethics committee, Lainie Friedman Ross, MD, was quoted as saying a nick of the clitoris is "a last resort" but is as "benign" as ear piercing. "A just-say-no policy may end up alienating these families, who are going to then find an alternative that will do more harm than good," she told the New York Times.

Statement a Step Back

A debate about this less extensive form of FGC already took place in the late 1990s, said Nawal Nour, MD, an obstetrician/gynecologist at Brigham and Women's Hospital in Boston and director of the hospital's African Women's Health Center, which cares for African women who have undergone FGC in their home countries. That debate led to a US federal law against performing any nonmedical procedure on a female minor's genitals.

"Putting out a statement in 2010 trying to be culturally sensitive [by suggesting a procedure that is illegal in the United States] is going back 10 steps," Dr. Nour said about the now-retracted AAP policy.

She did not, however, object to the Academy's change in term from female genital mutilation in its 1998 policy to the more neutral female genital cutting in the revision, as some critics of FGC did. Many of the African women she treats use the term circumcision and do not see themselves as victims, Dr. Nour said. Cultures that practice female circumcision believe it promotes cleanliness, protects virginity, and provides group identity.

Born in the Sudan, Dr. Nour did not undergo FGC, although many girls she knew did, and is against it. Yet she says the media often portray parents who have their daughters circumcised as barbaric. "These are genuinely good, caring parents who are trying to preserve a culture," she said.

She said she talks in a nonjudgmental way to pregnant African mothers who are considering circumcising their daughters after birth. "I take every single argument why they think they should do it and try to educate them that this is not necessary, is illegal here, and has long-term health consequences," she said.

Problems include recurrent urinary tract and vaginal infections, infertility, painful sexual intercourse, and childbirth complications.

The WHO estimates that up to 140 million girls and women worldwide have undergone some form of FGC, usually between infancy and 15 years of age. In the United States, nearly 228,000 female immigrants or refugees have been cut or are at risk for being cut because they come from ethnic communities where FCG is prevalent, according to an analysis of 2000 US Census data. Conducted by the African Women's Health Center, the analysis found that this number grew by 35% from 1990.

A bill proposed last month in the US House of Representatives, the Girls Protection Act of 2010 (HR 5137), would also make it a crime to take a minor girl living in the United States outside the country for the purpose of FGC.