The On-Going Issue Of Female Genital Cosmetic Surgery

The incidence of female genital cosmetic surgery (FGCS, sometimes referred to as labiaplasty, although this is not the only procedure) is thought to be increasing, and this type of surgery continues to cause concern. Is it in fact licensed female genital mutilation (FGM), as some allege – in which case it is illegal? And is it ever permissible in juveniles? Is it hypocritical and ‘racially’ biased?What follows is my small contribution to the debate which continues in the British Medical Journal (BMJ) and elsewhere in the legal and medical literature.

>>>   There are surely few if any exceptions to the legal position that children – in the UK, those under the age of 18 – may not give consent at any point to clinically inessential or non-urgent physically or psychologically intrusive procedures; and there are even more surely no exceptions for people of any age to the position that consent may not be claimed as a basis for delivering procedures (in common parlance perhaps ‘assault’?) which the law forbids.  Presumably in these instances there is not even the required professional licence or insurance to proceed.

It is therefore difficult to see why doctors, whether referrers or those who offer such procedures, apparently continue to consider female genital cosmetic surgery on minors.   In the words of the British Society for Paediatric and Adolescent Gynaecology Position Statement (2013),

“In the absence of any identifiable disease and until the evidence demonstrates to the contrary, labiaplasty should not be performed on girls under the age of 18 years.”

… and many of us would argue that current FGM legislation in the UK says it should not, in the absence of severe physical or psychological pathology, be performed on women over the age of 18 either.

The debate on female genital cosmetic surgery on minors is at risk of being conducted in a vacuum.  There are indeed adolescent girls with serious concerns about the appearance or ‘normality’ of their external genitals, but referral routes for almost all of them need to be non-escalatory: where are the child psychologists and school nurses who can address these issues in a less dramatic setting?  Why is it not routinely expected that the genitals of all young children will be examined, and their normality (as it usually is) recorded overtly in the Red Book, to provide reassurance without unnecessary and perhaps more traumatic inspections later on?

Proper provision of these routine services would help to assuage the anxieties of some girls concerned about whether they are normal, and would also if necessary give them confidence to dismiss the voices of others who tell them differently.  And the same services – school nurses, child and adolescent mental health services [CAMHS] etc – would do much to support efforts to eradicate FGM and also to support children who experience other forms of abuse.

It could also be argued that the focus on possible surgical procedures to accommodate concerns about female juvenile genital normality offers an excuse to put aside issues around the elective male circumcision of minors.  I invite anyone to explain why that, when not overtly clinically indicated, is also not assault.

There are numerous reasons why clarity on the legitimacy of procedures like female adolescent genital cosmetic surgery is urgently required*.  Prof Susan Bewley [writing on the BMJ website: UK doctors performing labial reduction on minors need clarity about the law on FGM] is absolutely right to press this issue.  The actual legitimacy of juvenile cosmetic surgery, the risks of intervention to young women’s health, and wider questions such as whether cosmetic genital surgery is actually FGM, must be resolved.

Is the silence in part because those who have provided or are currently providing this ‘service’ are keen not to see the issues addressed?  And also, from another perspective, because if such matters are fully acknowledged, the massive gaps and omissions in the provision of care, and especially of pastoral and psychological care, for young people would be even more starkly revealed?

…

*Here is a quote on the issue of FGCS legitimacy (and hypocrisy) by an anonymous contributor (Mr K, a UK-based legal professional) to my book, Female Mutilation: The truth behind the horrifying global practise of female genital mutilation:

The fight to eradicate FGM requires both that the criminal justice system works in conjunction with the education, health and social services and the third sector (NGOs), and that, through engagement, there is a willingness in the practising communities to eradicate this custom. A number of unresolved questions around the status of female genital cosmetic surgery make this objective more difficult.

Some of the main issues to address regarding FGM within the African community include

• training front line professionals on awareness of the practice,
• better referrals of FGM incidents to the police from other frontline agencies,
• a Statutory Mandatory Reporting Law to protect children at risk,
• addressing the issue of female genital cosmetic surgery (FGCS) and
• co-operation from the affected community.

….  The issue of female genital cosmetic surgery (FGCS) is therefore the only issue listed above that is not being actively looked into. The Government has largely failed to consider formally the application of the current legislation in relation to FGCS. This quandary has been described as follows:

FGM and female genital cosmetic surgery may involve partial excision of external female genital tissue for cultural reasons. Both are based on cultural expectations of how female genitalia ought to look. Similarly, FGCS can be chosen for reasons of aesthetics, the transcendence of shame and a desire to conform to a certain cultural ideal — and yet, female genital mutilation is ethically condemned and banned in many countries, including the UK, while FGCS is unregulated: Michaela et al (2012:205)

The paper did however make a distinction, saying informed consent is present in cosmetic surgery and, at least in the case of under-18s, is necessarily absent in FGM.

The government has disregarded the Home Affairs Select Committee’s recommendation for a consideration to what it called a ‘presumed double standard’ in the application of the law.

The Association of Chief Police Officers (ACPO) and the corporate position of the Metropolitan Police Service (MPS) is that there is a perceived double standard in which focus on FGM is placed on black and ethnic minority communities, with a different set of standards for the wider community to do FGSC in a flourishing private medical industry. 

The government is failing in its duty to legislate a clear distinction between the two practices.

Instead of interpreting the spirit of parliament in passing the 2003 Act, i.e. whether the current law includes FGCS for non-therapeutic needs, the government has shifted the burden to the judiciary.  In 2014 the Home Department position was that, ‘Ultimately, it would be for a court to decide if purely cosmetic surgery constitutes mutilation and is therefore illegal.’

Legitimacy and trust in the criminal justice system will be undermined if this issue is not addressed. The debate about procedural justice and its relationship with police legitimacy, trust and community co-operation has placed ACPOs and the MPs in contradictory positions in respect of the current legislation. The fact that those performing FGCS are overlooked, and the actors of FGM are persecuted, undermines due process.

Can you secure the interest of the affected community, expecting them to report those in their midst that offend against this statue, when nonetheless society at large are seemingly allowed to offend against the same law? Will they be willing to come forward if they see through this alleged double standard?  

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[A note on terminology: The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, which has a primary focus on FGM, is clear that in formal discourse any term other than ‘mutilation’ concedes damagingly to the cultural relativists – though the terms employed may of necessity vary in informal discussion with those who by tradition use alternative vocabulary. See the Feminist Statement on the Naming and Abolition of Female Genital Mutilation,  The Bamako Declaration: Female Genital Mutilation Terminology and the debate about Anthr/Apologists on this website.]

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Books by Hilary Burrage on female genital mutilation

For more detail and discussion of female genital mutilation please see my textbook, which considers in some detail the situation globally, but also explores the issues relating specifically to Western nations:  Eradicating Female Genital Mutilation: A UK Perspective (Ashgate/Routledge, 2015). My second book, Female Mutilation: The truth behind the horrifying global practice of female genital mutilation (New Holland Publishers, 2016), contains narrative ‘stories’ (case studies) from about seventy people across five continents who have experienced FGM, either as survivors and/or as campaigners and activists against this harmful traditional practice.

FURTHER INFORMATION AND ACTION

There is a free FGM hotline for anyone in the UK: 0800 028 3550, or email:fgmhelp@nspcc.org.uk

The (free) #NoFGM Daily News carries reports of all items shared on Twitter that day about FGM – brings many organisations and developments into focus.

Also available to follow at no cost or obligation is the #NoFGM_USA Daily News.

Twitter accounts:          @NoFGM_UK  @NoFGMBookUK @FemaleMutlnBook  @FGMStatement  @NoFGM_USA @NoFGM_Kenya  @NoFGM_France  @GuardianEndFGM [tag for all: #NoFGM] and @StopMGM.

Facebook page: #NoFGM – a crime against humanity

More info on FGM here. Email contact: via Hilary