A small surgical 'nick' or minimalist procedures that slightly change the look, but not the function or sensory capacity of a young woman's external genitalia, should be legally permitted as a compromise solution to the vexed issue of FGM, argue gynaecologists in the Journal of Medical Ethics.

This more nuanced approach would uphold cultural and religious traditions without sacrificing the health and wellbeing of girls and young women, contend the US authors.

Despite 30 years of campaigning, the practice of cutting women's genitalia continues to flourish in many African countries and in immigrant African communities elsewhere. To date, attempts to stamp it out with legislation have failed, and may instead be driving it underground, they suggest.

"We are not arguing that any procedure on the female genitalia is desirable," they emphasise. "Rather, we only argue that certain procedures ought to be tolerated by liberal societies."

To begin with, the term 'female genital mutilation' (FGM) should be replaced with the less emotive 'female genital alteration' (FGA) to reflect the different types of procedure and their associated risks, and to minimise 'demonisation' of important cultural practices, they say.

FGM is not an appropriate term to use for the type of procedures they advocate, which are akin to cosmetic dentistry (orthodontics), breast implants, or the type of vaginal lip sculpting (labiaplasty) "for which affluent women pay thousands of dollars," they insist.

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 1 and 2 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 3 and 4 of FGA, we must adopt a more nuanced position that acknowledges that categories 1 and 2 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 1 and 2 FGA and male circumcision.

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

And she concludes: "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 D 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."

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 writes.

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."

The evidence suggests that at least 200 million girls and women alive today have been subjected to genital cutting, he says.

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