Procedures should be divided into 5 categories, with first two akin to male

Milder forms of female genital mutilation should be classified in the same way as male circumcision and breast implants to stop it being 'demonized,' a controversial new report has claimed.

Changes to the way female genital mutilation is defined and viewed are needed to protect young women from more serious forms of cutting, a team of experts argued.

The gynaecologists suggest a small surgical 'nick' - a minimal procedure they compare to male circumcision - that slightly changes the look of a young woman's external genitalia should be legally allowed.

In a paper published in the Journal of Medical Ethics, they say mild forms are no worse than cosmetic procedures such as breast implants or 'designer vaginas' western women pay for.

But the experts stress the procedure should not alter the function or the sensory capacity of a young woman's genitalia.

They contend this more nuanced approach would uphold cultural and religious traditions without sacrificing the health and wellbeing of girls and young women.

However, their views have met with a raft of conflicting opinions.

Two gynaecologists argue the term female genital mutilation should be replaced with female genital alteration and that minor procedures that do not alter a woman's sexual sensation or function, should be legally allowed. The compromise would protect young women from serious forms of cutting, they say (file image)

In a series of editorials published alongside the paper, other leading experts in the field claim there is 'no doubt that in whatever form, female genital alteration has its origin and purpose in controlling women', and as such should remain illegal.

Sometimes referred to as female circumcision, FGM refers to procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons.

More than 125 million girls and women alive today have been cut in the 29 countries in Africa and the Middle East where FGM is concentrated.

The World Health Organization considers the practice 'a violation of the human rights of girls and women'.

The WHO states: 'FGM has no health benefits, and it harms girls and women in many ways.

It involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls' and women's bodies.'

Despite 30 years of campaigning, the practice of cutting women's genitalia continues to flourish in many African countries and within immigrant African communities elsewhere.

To date, attempts to stamp it out with legislation have failed, and may instead be driving it underground, the authors Kavita Shah Arora of the MetroHealth Medical Center in Cleveland, and Allan Jacobs of Case Western Reserve University, also in Cleveland, suggest.

'We are not arguing that any procedure on the female genitalia is desirable,' they said.

'Rather, we only argue that certain procedures ought to be tolerated by liberal societies.'

They suggest the term female genital mutilation (FGM) be replaced with the less emotive 'female genital alteration'.

Ultimately, I suggest that children of whatever sex or gender should be free from having healthy parts of their most intimate sexual organs either damaged or removed, before they can understand what is at stake in such an intervention and agree to it themselves Brian Earp, of the Bioethics Research Institute in New York

That, they argue, would reflect the different types of procedure and their associated risks, and minimise 'demonisation' of important cultural practices.

FGM is not an appropriate term to use for the type of procedures they advocate, which are akin to cosmetic dentistry, breast implants or labiaplasty, 'for which affluent women pay thousands of dollars', they said.

Current categorisation covers four types of female genital cutting, with type IV the most invasive and dangerous.

But, the authors call for a new system of categorisation that is based on the effects of the procedure, rather than the process.

Category 1 would include procedures that should have no long lasting effects on the appearance or function of the genitalia, if performed properly: an example would be a small nick in the vulvar skin.

Category 2 would include procedures that change the appearance slightly but which are not expected to have any lasting effects on reproductive capacity or sexual fulfilment. Examples include pulling back the hood of the clitoris and labiaplasty.

Categories 3-5 would include procedures, such as clitoris removal and vaginal cauterisation that maim or harm and impair sexual fulfilment, pregnancy and childbirth. These should be banned, they say.

Categories one and two are no different to male circumcision, which is rarely performed for therapeutic benefit, but which is tolerated and legal in liberal societies, the authors argue.

And restricting these categories of FGA is 'culturally insensitive and supremacist and discriminatory towards women', they contend.

Rather, permitting this compromise would better protect girls and young women from the long term harms of the more severe forms of female genital cutting, they suggest.

'In order to better protect female children from the long term harms of categories three and four of FGA, we must adopt a more nuanced position that acknowledges that categories one and two are different in that they are not associated with long term medical risks, are culturally sensitive, do not discriminate on the basis of gender and do not violate human rights,' they conclude.

But in one of a series of commentaries in response to this paper, Professor Ruth Macklin of Albert Einstein College of Medicine, New York, insists that there is no parity between categories one and two FGA and male circumcision.

More than 125 million girls and women alive today have been cut in the 29 countries in Africa and the Middle East where FGM is concentrated. The World Health Organization considers the practice 'a violation of the human rights of girls and women'. Pictured, items used in female genital mutilation, in Somalia

'That may be true regarding the degree of harm the procedure causes, but it is not true of the origins or the continued symbolic meaning of FGA as a necessity for being an 'acceptable woman,' she said.

'There is no doubt that in whatever form, FGA has its origin and purpose in controlling women.'

And she concluded: 'Cultural change proceeds slowly.

'But with strong support from non-governmental organisations, especially those comprising local and regional women, a cultural tradition designed to control women--even in its least harmful form--is best abandoned.'

In another commentary, Brian Earp, visiting scholar at the Hastings Center, Bioethics Research Institute in New York, argues that permitting minimalist FGA would generate a litany of legal, regulatory, medical, and sexual problems, leading to 'a fiasco'.

Rites of passage are important to all of us, but one must not cause irreversible changes to the body of another person without their consent Dr Arianne Shahvisi, at the University of Sussex

Rather than continuing to tolerate male circumcision, and using this as a benchmark for allowing 'minor' forms of FGA, it may instead be time to consider taking a less tolerant stance towards both procedures, he says.

'Ultimately, I suggest that children of whatever sex or gender should be free from having healthy parts of their most intimate sexual organs either damaged or removed, before they can understand what is at stake in such an intervention and agree to it themselves,' he says.

In a further commentary, Dr Arianne Shahvisi, of the Department of Ethics at the University of Sussex, says that a minimalist approach to FGA is unlikely to fulfil the intentions of the procedure - to change the aesthetic appearance of the female genitalia, and to control women's sexual appetites.

And she wonders why the authors don't take the opportunity to recommend a more minimalist approach to male circumcision.

'Rites of passage are important to all of us, but one must not cause irreversible changes to the body of another person without their consent,' she writes.

Finally, in a linked editorial, Dr Michael Dunn, of the Ethox Centre, University of Oxford, points out 'The main argument is controversial, but its airing on the pages of the journal has a clear purpose: by subjecting FGM in its many forms to ethical analysis, we will be in a stronger position to develop and tailor interventions that function to prevent indefensible practices of this kind.'