The American Academy of Pediatrics new position paper on female genital mutilation (FGM) has been greeted with howls of protest. When I scanned the newspaper, website and blog reports on the issue, I thought that the AAP had lost its ethical moorings and recommended FGM. But reading the actual position paper, I learned that the AAP was recommending something very different, and that the storm of protest reflects a preoccupation with our own moral certitude at the expense of the health and well being of young girls.

The AAP position paper attempts to deal with a specific problem and that problem is not female genital mutilation. The AAP is unalterably opposed to FGM, which it refers to as female genital cutting:

The American Academy of Pediatrics:

1. Opposes all forms of FGC that pose risks of physical or psychological harm.

2. Encourages its members to become informed about FGC and its complications and to be able to recognize physical signs of FGC.

3. Recommends that its members actively seek to dissuade families from carrying out harmful forms of FGC.

4. Recommends that its members provide patients and their parents with compassionate education about the physical harms and psychological risks of FGC while remaining sensitive to the cultural and religious reasons that motivate parents to seek this procedure for their daughters.

 The problem that the AAP has identified is that in the face of opposition to FGM, American parents of certain religious backgrounds are opting to send their daughters out of the country for FGM or to have lay practitioners illegally perform FGM here. The position paper asks a very important question: is there anything that American pediatricians can do to divert parents from making other arrangements to amputate the clitoris of their daughters?

The AAP paper explains the cultural significance of FGM:

When parents request a ritual genital procedure for their daughter, they believe that it will promote their daughter’s integration into their culture, protect her virginity, and, thereby, guarantee her desirability as a marriage partner. In some societies, failure to ensure a daughter’s marriageable status can realistically be seen as failure to ensure her survival… Parents are often unaware of the harmful physical consequences of the custom, because the complications of FGC are attributed to other causes and are rarely discussed outside of the family.

 Obviously the ideal is for the pediatrician to educate the parents about those harms. But what is the pediatrician's responsibility to a young girl when he cannot persuade her parents to forgo FGM. Is the pediatrician permitted to offer a ritual mimicking the procedure in an attempt to forestall a more radical procedure? The AAP says yes.

Some physicians, including pediatricians who work closely with immigrant populations in which FGC is the norm, have voiced concern about the adverse effects of criminalization of the practice on educational efforts. These physicians emphasize the significance of a ceremonial ritual in the initiation of the girl or adolescent as a community member and advocate only pricking or incising the clitoral skin as sufficient to satisfy cultural requirements. This is no more of an alteration than ear piercing. A legitimate concern is that parents who are denied the cooperation of a physician will send their girls back to their home country for a much more severe and dangerous procedure or use the services of a non–medically trained person in North America…

 Most American commentators strongly disagree. This piece from the NY Times is typical:

Georganne Chapin, executive director of an advocacy group called Intact America, said she was “astonished that a group of intelligent people did not see the utter slippery slope that we put physicians on” with the new policy statement. “How much blood will parents be satisfied with?”

The human rights organization Equality Now has reacted with outrage:

FGM is a form of gender-based violence and discrimination that is performed on girls to control their sexuality in womanhood, guarantee their acceptance into a particular community, and safeguard their virginity until marriage. Taina Bien-Aime, Equality Now's Executive Director explains, "Encouraging pediatricians to perform FGM under the notion of 'cultural sensitivity' shows a shocking lack of understanding of a girl's fundamental right to bodily integrity and equality. The AAP should promote awareness-raising within FGM-practicing immigrant communities about the harms of the practice, instead of endorsing an internationally recognized human rights violation against girls and women."

 No doubt the commentators feel justified in their self-righteous condemnation of any attempt at compromise, but they've failed to ask the most important question: Is there anything we can do to protect girls whose parents will not forgo FMG? That question can only be addressed with empirical answers, not moral arguments.

Will offering to mimic the procedure with a ritual "nicking" reduce the incidence of traditional FMG and the health problems that go with it? Research suggests that the answer is not clear. Data from the World Health Organization shows that substituting ritual nicking has reduced the incidence of traditional FMG in countries where it is commonly practiced. On the other hand, evidence from Scandinavia has shown that harsh penalties (including the threat of loss of child custody) is also effective at reducing FGM.

It is all well and good for FGM activists to proclaim that compromise is unacceptable, but does that position help the girls it is intended to protect? At the moment, the response of activists appears to little more than flaunting a sense of moral superiority, but that moral superiority, no matter how admirable, does nothing for the girls facing some form of FGM.

Obviously, as the AAP strenuously insists, the ideal is to prevent any form of FGM, ritualized or otherwise. But if that goal cannot be reached is it morally unacceptable to offer a medically harmless compromise? It is difficult to make a compelling moral argument against anything that will reduce the overall incidence of real FGM.

Let's not lose sight of the real question asked by the AAP. The question is not whether we should oppose FGM. We should and the AAP strongly opposes it. The question is whether anything can be done to prevent the serious health and psychological problems due to FGM by replacing it with a ritually acceptable, but medically harmless compromise. It is a reasonable question, and the  AAP's response deserves serious consideration.