https://jme.bmj.com/content/early/2025/09/25/jme-2025-110961
Starter comment:
Saw this making the rounds today and would love to get this community's input on this essay. Some of their concerns include the stigmatizing effect of titling these cases mutilation, the ethnic, racial, and religious stereotypes associated with these cases, and concerns that victims of FGM will harbor mistrust of the medical system due to our stigmatizing these practices at medical professionals.
From the article. I don't know what to say.
I was shocked when I read that as well. But it makes a little more sense if you read the full paragraph:
So the actual point appears to just be "consider other factors as causes of distress, too" but they phrased it such in a way that feels needlessly loaded and deliberately tendentious.
Just yapping
Sharing a story here from 2024 on efforts led by local activists in the Gambia to maintain a ban on the practice: https://www.npr.org/2024/07/16/nx-s1-5040481/female-genital-mutilation-gambia
The multinational collaborative group claim they want to hear voices from the very women who had FGM done on them in Africa, but the only author with an affiliation of an African institution is the first one. The rest are in the US, Canada, or Europe (and a few from Singapore and Australia). That rings hollow to me.
Slavery was culturally accepted by many societies for centuries - societies have now accepted that it's a crime against humanity
This is cultural relativism instead of ethics.
I don't believe most doctors subscribe to the notion of all cultures being equal - one is exposed to the reality of the world too much to think that.
These people would have been whining about the British forcefully ending the slave trade in the 1800s too I suspect.
I think it’s not hard to recognize the fingerprints of anthropology departments on this. This isn’t a medical paper.
What tipped you off there, Sherlock? Was it the 4 separate anthropology departments listed in the affiliations?
I am just curious though, after reading the article, what specific fingerprints of anthropologists are so concerning to you? The nuanced discussion of how language affects trust in the healthcare system and leads to biased surveillance and policing? The discussion on how attributing all symptoms to a single event leads to clinicians ignoring the other sources of trauma in a patient’s experiences?
Obviously! It’s a medical ethics paper!
Why are you being such an asshole? There's no need to respond like that.
Complaining about “anthropology departments” is just the early 2000s version of complaining that everything is “woke.” Instead of reading the article or responding to it in any meaningful way, they gave a lazy right wing dog whistle.
That's fair. I guess I didn't read the comment as that initially but now I can see what you mean. I think there is a point to be made about the danger of tolerating violence and oppression in other cultures for some perceived sense of equality and balance. I know the paper is in no way advocating for FGM to continue, to be clear.
For what it’s worth, the angry guy is right about my intent, largely. It’s a low-effort jab.
Anthropology departments over the last few decades have taken a wild political swing towards ideological conformity, which I was very much eye-rolling about.
To the extent right-wingers know where to find an anthropology department they would probably be correct with whatever snide criticism they had. As evidence, I’d gesture wildly at this paper.
Props to you for admitting it.
What is your specific criticism of this paper?
>I don't believe most doctors subscribe to the notion of all cultures being equal - one is exposed to the reality of the world too much to think that.
I think i know what you mean, but i think it is important for the more softie-thinkers among us (counting myself as one) to notice that we don't need to elevate "one culture" above another, to maintain that certain practices that exist in one culture are worse than others.
So if one has trouble comitting to an ethereal statement that "Ghanaian culture is worse than"... we don't need to do that. No one knows how to synthesize and appraise/evaluate a whole culture. We don't even always use the word culture for a "proprium" (excuse i don't know the english word)
When i say "my culture" it's not = danish culture. It's a weird amalgam of the socially transmitted norms, behaviours, historical knowledge, contextual understanding. etc.
The cultural behaviour of FGM can be thought of much more simply.
ANd there's nothing unnatural about changing such practices.
I believe many Rabbi's used to perform a practice of oral suction of the wound of a penis during circumcision, which, among other infections caused a ton of herpes transmission.
It's very possible to retain religiosity, traditionalism, etc. and adapt ones practices to more modern humane attitudes. IT doesn't have to be this big "either or" culture-war issue.
In fairness, slavery is still alive and thriving today though. There's more humans in slavery conditions today than any generation before.
Just because formal chattel type slavery has been abolished doesn't mean it hasn't continued at full steam utilizing different loopholes or outright violent exploitation.
There far beyond the underground child/labor/sex/domestic/state-imposed (work/re-education camps) slavery still happening too. "Debt Servitude," and "Indentured Service" are still perfectly contractually legal in far too many countries as well, and all too often violence/extortion/fraud is used to get those contracts signed.
Certainly slavery continues on today as human trafficking. Just it wasn't as widespread as about 150 years ago in the US when slavery was much more obvious as an economic institution (and the primary moneymaker for the southern US) that sparked a civil war.
The US, Canada, Australia/NZ, and western Europe are essentially the only countries without visible slavery, and that's even arguable.
You're looking at this with a very ethnocentric bias. On a species basis, slavery is much more rampant today than it was 160+ years ago.
I really don’t think you read the article. Nowhere to they endorse or advocate for FGM.
Well. It’s not really comparable on any metric though.
Male circumcision is not a tradition in my country and I don’t find it medically justifiable.
However in Western countries? Male circumcision is done under anesthesia. It’s got very low complication rates and almost zero mortality rate.
While according to a Nature article :
And most circumcised men can orgasm and they can have painfree sex. They can also have children without risking fatal complications. This is not true for FGM.
Let’s use some common sense here. Not all culturally practices are good. Some cultures you hit your children. Should we support that too to avoid alienating the parents?
FGM is a practice that has its roots in how making women unable to get pleasure from sex acts as a guarantee for paternity. There are better ways to have healthy adult relationships.
I agree completely. Building on your analogy relating to corporal punishment, though, I think one good point the essay had was in talking about how to approach survivors as medical professionals.
The essay points out that not all people who have experienced FGM consider their experience 'traumatic', which is also true of people who have experienced corporal punishment.
In both cases, assuming trauma (instead of asking) can feel invalidating or judgmental, and may reduce trust - making people less willing to talk openly or seek care.
Fair point. You should always talk to people in an open, kind way that make them feel comfortable.
I’m a midwife and I’ve worked with a few women who’ve experienced it. I don’t use the term FGM and use the specific clinical terms like cliterectomy or infibulation, or female genital cutting when speaking broadly. Mutilation is a stigmatizing and not clinically useful term. Does it serve the patient, our relationship, and their relationship with the healthcare system to tell them they have a mutilated vulva?
When I was a student I had a patient who disclosed cliterectomy during a prenatal appointment. My preceptor thanked her for sharing that with us and invited her to hold a mirror and show us her anatomy and then we explained how we could handle the delivery/repair. It was a really cool learning experience for me, seeing how we can help a patient have agency, understand her anatomy, and be an active participant in her care. On the other hand, I heard a story from one of my colleagues who was doing a repair (I think the patient had been infibulated but I’m not sure) and spent the whole time just ranting about how the patient had been mutilated and how horrible her vulva was. I can only imagine how vulnerable and shitty that felt for the patient, and I wonder how she felt about her experience in the healthcare system and how that would affect how she seeks care in the future.
Obviously I think FGC is horrifying and Wrong and I wanted to throw up when I first read about it. But as a clinician my job is to provide care to the individual in a way that’s sensitive, non-stigmatizing, compassionate, and focused on the clinical concerns. And doesn’t scare them away from seeking medical care in the future, or make them hesitant to seek care for their family/community members
I hate to be that guy, but this is published in the Journal of Medical Ethics, not the “ethics section of The BMJ.”That’s misleading OP.
(Yes, this journal is in the BMJ family of journals, but that is not remotely the same thing)
Feels like a fairly unimportant distinction. A quick Google image search shows that the Journal of Medical Ethics has a big BMJ logo on the bottom right of the print edition. It's hosted on a .bmj domain. It is essentially a branch off of the BMJ and is inextricably linked to the main journal.
It’s an enormous distinction. There are 73 journals in the BMJ journal family. JME is not a “branch off of the main journal,” it is a completely different journal with different editors, scope, peer review standards, and readership. It is an excellent ethics journal, but passing this off as being in The BMJ is wrong and misleading.
Do you genuinely expect the average person to have any grasp of that? Even say the average college graduate? The typical person who encounters this is going to see the BMJ branding all over it and consider it one in the same. And this sort of drivel harms the trust in that brand and drive anti-science ideas in the general population.
I expect you, as a physician, to be representing things accurately, not amplifying the very kind of misinformation you seem so concerned about.
Incredibly disappointed by the refusal of you and others to acknowledge this is a problem. Does the typical person who encounters this see this as any different from BMJ? Yes or no? Do you think there can be a physician around every time someone sees it to say "No actually this isn't one of the most prestigious medical journals in the world running cover for a barbaric practice, it's just an offshoot with lesser standards"?
Genuinely, I want to know your answer to that problem. The average person reading this in their social media feed or reading a newspaper article about it is not going to care about this distinction. They're going to say "This is what the medical establishment thinks? Why should I take their word on anything?" They are not going to care about our nuanced distinctions on whether it's actually BMJ or a separate (but still related) journal.
What do you propose as a solution to that, at a time when faith in science and medicine is cratering?
If you care so much about the lay public’s perception of this article, don’t contribute to the problem by re-posting it and saying it was published in one of the most authoritative journals in the world. It wasn’t. Use your platform as a physician to contribute to an accurate narrative.
You might be interested to know that ethics journals cover sticky topics all the time, and there are some real hot takes out there. This is nothing new and you can’t stop journals from publishing what they want to publish. But you can write a letter to the editor if you want to dispute the paper, or publish your own analysis on the topic.
You didn't answer my question. I encountered this on multiple social media feeds that aren't at all connected to medicine. Posts about it had tens of thousands of reposts, shares, etc. This has already made its way into the general public. And they are not going to look on it kindly. And this is also fundamentally different than calling for an increase in the rates of MAID, changing how clinical trials are run, changes to healthcare policy, or anything like that. This is running cover for an act that is seen throughout the developed world as savage and dressing it up in academic language. That's not ethical. Trying to brush it under the covers isn't going to work here. And a letter to the editor isn't going to put the cat back in the bag. We cannot allow medicine to be associated with this type of thing.
You’ve got some valid concerns but I think you’re a little confused. I’m not offering to solve public relations between science and society. I’m just a person on the internet and my only point was don’t deliberately misrepresent where this piece came from.
Is this a piece worthy of publishing in an excellent ethics journal, as you called it? Does this journal benefit or not from being under the umbrella of BMJ? It really is truly nuance to the point of making the whole conversation useless to try and draw this distinction. You can continue to say that it's a different journal and it's going to continue to not make a meaningful difference to the impact that ths has on the broader conversations about societal trust in medicine and the capture of our institutions by people aiming to push ideologies over seeking truth. And trying to focus on technicities is not going to help. See the forest rather than the trees and try to remember that you're not in an undergrad philosophy class anymore.
There are plenty of college graduates that have very little to no concept of what a peer reviewed journal is at all.
I mean, it is undoubtedly true that it leads to stigmatisation.
I remember when I first read the now classic ‘wild swans’ as a kid. It’s about 3 generations of Chinese women, and it has this fabulous description of a a mother crushing and binding her daughters feet.
It’s so especially harrowing because there is definitely immense love behind this “mutilation”.
It made me think A LOT about how we treat kids, and even when I see a kid make a full tantrum meltdown in a supermarket in Denmark, I think, leaving/ignoring that child to cry there on the floor - that’s a type of violence.
We allow the child to feel that pain to make them fit into the social order. The mother in Wild Swans knows her daughter would be undesirable without these “three inch golden lilies” so she soaks her kids feet in warm water and bends the toes underneath the sole, literally crushing bones with her full body weight above the bending foot. This is repeated for months as the foot conforms. Wounds appear. Flesh rots. And the mother frets! Not because of the suffering or infection danger - but afraid of whether the foot becomes small enough…
Now, what is a stigma? It’s a funny word. In Greek it was a wound/puncture I believe. But who is having the wound in our use? So the way we use it, I think is a metaphor of there being a kind of social/cultural wound produced in the reputation or understanding others have us. “the social stigma” of being gay is all about how others/society view homosexuality and what it does to their treatment.
Has Wild Swans not stigmatised the tradition of foot-binding by giving me this story?
Yes… but it was done very beautifully and with meaning. Is it necessary for us to discovery the meaning of FGM practices? I would certainly personally think it interesting to read a lot - but I think question is whether the suffering endured in a specific case of child mutilation is so severe that rather culturally blind campaigns to end that suffering are okay. Then others can write the anthropology later.
I think it’s important to be nuanced and forexample in my country Denmark Male circumcision is seen as very weird and wrong by most. But when I go to some conference a huge percentage especially if the US MDs will be circumcised.
I don’t personally think that suffering warrants the kind of activism some of my countrymen feel is appropriate.
In the case of FGM and foot binding, I would fall on the other side. It’s not that the culture cannot be extremely interesting, even paradoxically beautiful in examples. But then suffering/ruin of function is severe enough that that becomes a very secondary worry.
The article talks a lot about these differences in how we view different practices of “modification” by surgery to boys and girls. However I do think it takes a position by mentioning how peoples reasons for being outraged often comes down to “contested claims” of differences in harm.
I must say that the differences between forexample the male circumcising happening in the states fx and the “female genital mutilation” are quite concrete and substantial enough for the difference in approach.
I looked at a lot of “surgical manuals” of these in med school when I had a period of interest. That really was a completely different level of incurred suffering and destruction of function.
I think the equivalent of male circumcision would be removing the labia majora. To me, FGM at it's most extreme example is more equivalent to making a enuch. I don't know if there is anywhere in the world that complete castration and emasculation are acceptable anymore. But even then...fgm can be a lot worse.
Anatomically the closest equivalent would be removing the clitoral hood but leaving the clitoris and labia intact.
Starter comment:
Saw this making the rounds today and would love to get this community's input on this essay. Some of their concerns include the stigmatizing effect of titling these cases mutilation, the ethnic, racial, and religious stereotypes associated with these cases, and concerns that victims of FGM will harbor mistrust of the medical system due to our stigmatizing these practices at medical professionals.
Please edit this and put it into your OP.
Edited.
Thanks!
Well. You gotta handle this delicately.
But it’s obviously also a practice that’s bad for human health and with more severe medical consequences than male circumcision. It’s like other unhealthy cultural and social practices. We have to be honest about it. Just in a kind way.
Mmmmmmm