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An educational program about FGC requires, above all, sensitivity to the cultural background of the patient and her parents and an appreciation of the significance of this custom in their tradition.5 Objective information should include a detailed explanation of female genital anatomy and function, as well as a thorough review of the lifelong physical harms and psychological suffering associated with most forms of FGC. It should be emphasized that many countries in Africa have supported efforts to educate the public about the serious negative health effects of FGC and that prominent physicians from Africa are advocates for the elimination of these practices because of their adverse consequences. Pediatricians and pediatric surgical specialists who care for patients from populations known to practice FGC commonly, such as Somalian, Ethiopian, Eritrean, and Sudanese communities, should be aware of local counseling centers. Successful educational programs typically require the active involvement and leadership of immigrant women, whose experience and knowledge can address the health, social status, and legal aspects of FGC. Health educators must also be prepared to explain to parents from outside North America why male genital alteration is routinely practiced here but female genital alteration is routinely condemned.31
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.32 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.33,34 In some countries in which FGC is common, some progress toward eradication or amelioration has been made by substituting ritual "nicks" for more severe forms.2 In contrast, there is also evidence that medicalizing FGC can prolong the custom among middle-class families (eg, in Egypt).35 Many anti-FGC activists in the West, including women from African countries, strongly oppose any compromise that would legitimize even the most minimal procedure.4 There is also some evidence (eg, in Scandinavia) that a criminalization of the practice, with the attendant risk of losing custody of one's children, is one of the factors that led to abandonment of this tradition among Somali immigrants.36 The World Health Organization and other international health organizations are silent on the pros and cons of pricking or minor incisions. The option of offering a "ritual nick" is currently precluded by US federal law, which makes criminal any nonmedical procedure performed on the genitals of a female minor.
The American Academy of Pediatrics policy statement on newborn male circumcision expresses respect for parental decision-making and acknowledges the legitimacy of including cultural, religious, and ethnic traditions when making the choice of whether to surgically alter a male infant's genitals. Of course, parental decision-making is not without limits, and pediatricians must always resist decisions that are likely to cause harm to children. Most forms of FGC are decidedly harmful, and pediatricians should decline to perform them, even in the absence of any legal constraints. However, the ritual nick suggested by some pediatricians is not physically harmful and is much less extensive than routine newborn male genital cutting. There is reason to believe that offering such a compromise may build trust between hospitals and immigrant communities, save some girls from undergoing disfiguring and life-threatening procedures in their native countries, and play a role in the eventual eradication of FGC. It might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick as a possible compromise to avoid greater harm.
Efforts should be made to use all available educational and counseling resources to dissuade parents from seeking a ritual genital procedure for their daughter. For circumstances in which an infant, child, or adolescent seems to be at risk of FGC, the American Academy of Pediatrics recommends that its members educate and counsel the family about the detrimental health effects of FGC. Parents should be reminded that performing FGC is illegal and constitutes child abuse in the United States.
