Three families from the nation of the Gambia have become socially acquainted in the greater Metropolis area where they have relocated from their native country. All three families have preadolescent daughters. None of the girls has as yet undergone the ritual "female circumcision" commonly practiced in their native country. Five of the six parents think it would be a good idea to hold such a ritual ceremony in Metropolis next month. The sixth parent is uneasy about the procedure and wonders if it is appropriate anyway. The parent comes to talk with you, a physician or mental health professional, about this. The parent describes concerns about the procedure and the practice in general, but notes that some groups in the United States do "similar things," referring to the ritual circumcision of Jewish boys at 8 days of age. The parent adds that if the procedure is not possible in the United States, it could be done in the Gambia when the family returns there on holiday.

Discussants were asked for their opinions regarding advice to the parent's ethical obligations (especially in the case of mandated reporting of suspected child abuse)?

Discussants. Our discussants for this case include a child psychiatrist with forensic expertise whose clinical caseload includes many sexually abused children, a behavioral science expert of sexual behavior in cultural context, and a history professor with expertise in African culture. Renée Brant, MD, is a child psychiatrist on the faculty of Harvard Medical School and in private practice in Newton, Massachusetts. She has worked with cases involving sexual abuse of children for more than 2 decades and has testified as an expert witness in many "high profile" cases. Tony Martin, PhD, provides a unique international perspective. He is a historian by training (Michigan State University) and a barrister-at-law (Gray's Inn, London). He has authored, edited, or compiled eleven books, including Race First: The Ideological and Organizational Struggles of Marcus Garvey and the Universal Negro Improvement Association. He is Professor of Africana Studies at Wellesley College in Massachusetts. Gail Elizabeth Wyatt, PhD, is Professor of Psychiatry and Biobehavioral Sciences at the University of California, Los Angeles, a National Health Institute of Mental Health Research Scientist, licensed sex therapist, and clinical psychologist. Her research and practice have often involved evaluating and separating culture-specific issues from those involving mental and physical health of ethnic people of color. She received the American Psychological Association's Award for Distinguished Contributions to Research on Public Policy and has authored (with Drs. Michael Newcomb and Monika Riederle) Sexual Abuse and Consensual Sex (Sage Publications, 1993 ).

 

Child Psychiatrist's Response

Renée Brant

What ethical issues must a child psychiatrist consider when confronting the cultural or religious practice of "female circumcision" on children?

First, one must understand what such a practice entails. The term "female circumcision" is medically misleading. Male circumcision involving surgical or ritual removal of the foreskin of the penis is generally accepted to be a procedure that does not have significant medical morbidity or impair male sexual functioning and capacity for sexual pleasure. Rarely does female circumcision simply involve a symbolic small cut on the hood of the clitoris; more often it involves clitoridectomy. This is anatomically equivalent to amputation of the penis. Clitoridectomy is often followed by a more drastic procedure, infibulation, in which the external genitals are excised and the labia sewn together, leaving only a small opening for drainage of menstrual blood and urine. Ritual "circumcision" is often performed on girls under age 12 without anesthesia using crude tools. There are frequent medical complications, including infection, hemorrhage, and even death. In contrast to male ritual circumcision, two of the consequences of female genital surgery are the diminishment of a woman's sexual pleasure and the drastic alteration of her sexual functioning so that she remains chaste before marriage. In addition, should a woman become pregnant, genital surgery may result in severe complications during vaginal delivery ( Brownlee, Seter, Streisand, & Turnbridge, 1994).

Female genital surgery is practiced in a cultural context and has complex social, political, and religious significance. Justifications and explanations for the practice include ensuring the virginity of a woman before marriage, inducing chastity for divorced women or women whose husbands are away, birth control, initiation into and celebration of womanhood, hygienic reasons, and religious requirements ( Gunning, 1991-1992).

Approximately 100 million women in Africa, the Middle East, and Southeast Asia have undergone ritual female genital surgeries. As women from these countries have migrated to other countries with different cultural practices and legal standards, medical professionals have been confronted with medical, legal, and ethical dilemmas involving the women who have undergone ritual female surgeries and their female children ( Hansen & Scroggins, 1992).

Although individuals in Western cultures usually view female genital surgeries as a foreign practice, history reveals that this type of surgery was practiced in the United States and Europe ( Barker-Benfield, 1975). In the late 1800s clitoridectomies were performed as cures for women's disorderly behavior and "mental disorders" in Europe and the United States. The practice continued in the United States until the late 1930s ( Barker-Benfield, 1975).

The United States lags behind other Western countries in developing laws that directly address female genital surgery. Great Britain banned female circumcision in 1985, calling it child abuse. France criminalized female circumcision in 1978. The World Health Organization and the United Nations have debated the issue for years ( Gunning, 1991-1992). After a 1984 international conference on the issue, 23 African countries set up national committees and an umbrella group, the Inter-African Committee, to fight genital mutilation ( Garb, 1990). Although genital surgeries are still the subject of much controversy, there has been a growing worldwide movement to condemn female genital surgeries and view the practice as a humanitarian problem, a human rights and child rights violation, and a health problem ( Gunning, 1991-1992).

The United States does not have laws that directly address female genital mutilation. Many would argue that child abuse laws in the United States that prohibit the infliction of physical injury on a child should be applied to female circumcision. However, there is only one 1986 case in Georgia in which a nurse was prosecuted for child abuse for '"botching" a clitoridectomy on her niece. The nurse was acquitted ( Hansen & Scroggins, 1992). In 1994 a Nigerian woman fought deportation on the grounds that her daughters would face ritual mutilation if she returned to her native country. A United States immigration judge granted her asylum ( Neary, 1994). In October 1993 Representatives Pat Schroeder and Barbara Rose Collins introduced legislation forbidding the practice of female genital mutilation on girls under 18 years of age. This bill proposed that immigrants be educated about the operation's illegality and dangers ( Beck, 1994). The bill did not pass and was resubmitted (H.R. 941) in 1995.

How then would I, a child psychiatrist, respond to the Gambian mother who came to me to discuss her uncertainty about having her daughter undergo female circumcision? Ethical practice requires that I respect and try to understand the cultural and religious practices of this mother from her perspective. Ethical practice also requires that I professionally act to promote the physical and psychological well-being of her child and that I do not condone parenting

practices that, according to the social values and laws of Metropolis, constitute child abuse.

This woman already comes with "concerns about the procedure." I would listen to her concerns with curiosity, respect, and cultural sensitivity. I would anticipate that her concerns will reflect her own misgivings or the clash of Gambian cultural and religious practices with the social, cultural, and legal values and practices of her new community in Metropolis. I would inquire in detail about the practice of female circumcision in her community and the significance of the ritual. I would ask about the impact of moving to Metropolis and how exposure to the culture of Metropolis has affected her thinking about the practice. I would try to understand how this mother views me and what she anticipates in terms of my racial, cultural, or political bias. I would try to understand the stigma or risk that would result for her child or herself in her community if she decided not to have her child undergo ritual surgery. I would also try to ascertain the extent of medical risk and morbidity associated with ritual circumcision as practiced by this woman and her community.

If the Gambian community's practice includes procedures that involve physical mutilation, pain and suffering, or medical morbidity and risk, I would inform the mother that in Metropolis these practices would likely be considered child abuse even though the practice is viewed very differently in Gambian culture. I would educate this mother about probable physical and psychological risks to her daughter if she proceeds with female circumcision, as seen from the perspective of a physician practicing in Metropolis. I would make a distinction between her community's practice of female circumcision and secular or ritual male circumcision as practiced in Metropolis using hygienic techniques with minimal risk, morbidity, and disfigurement, and no detrimental effect on sexual functioning.

My meeting with this mother would, I hope, be the beginning of a dialogue. It is likely that her conflict will continue and that she may be in conflict with the other mothers in her community. She may be skeptical about my advice and comments because of my cultural difference from her. I would therefore attempt to put her in contact with other African and Gambian women who are struggling with this dilemma. I would be available for continuing dialogue with her and others in her community.

Because this mother was seeing me to discuss her dilemma before ritual circumcision was performed on her daughter, I would not be obliged to make a child abuse report. Her willingness to consider and confront her dilemmas constitutes good parenting. If I had knowledge that this mother was planning to perform ritual female circumcision on her child or that it had been performed, I would inquire about details including the specifics of surgery, who performed it, hygienic practice, and management of pain, bleeding, and infection. I would try to make allowances for cultural and religious differences in

parenting practices. However, if these practices involve physical pain, injury, medical risk, morbidity, or disfigurement of a child, it is my opinion that according to the laws of Metropolis they could be construed as child abuse. I would be mandated to make a protective service report. This would be an action I would undertake reluctantly and only if there were no other option and I believed the child to be at risk. I would much prefer to intervene through ongoing dialogue and mutual education. This mother is obviously attempting to act in what she considers to be the best interests of her child and has no intent to harm her.

REFERENCES

Barker-Benfield, B. ( 1975 ). Sexual surgery in late nineteenth century America. International Journal of Health Services, 5, 279.

Beck, J. ( 1994, September 19 ). Female mutilation a tradition that should not be tolerated anywhere on earth. Sun Sentinel [Fort Lauderdale], 9A.

Brownlee, S., Seter, J., Streisand, B., & Turnbridge, L. ( 1994, February 7 ). In the name of ritual. U. S. News & World Report, 116, 56.

Federal Prohibition of Female Genital Mutilation Act of 1995, H. R. 941, 105th Cong., 1st. Sess. ( 1995 ).

Garb, M. ( 1990, April 27 ). U. S. doctors seeing 'circumcised' female immigrants. American Medical News, 33(16), 3.

Gunning, I. ( 1991-1992 ). Arrogant perception, world-travelling and multicultural feminism: The case of female genital surgeries. Columbia Human Rights Law Review, 23, 189-248.

Hansen, J., & Scroggins, D. ( 1992, November 15 ). Female circumcision; U.S., Georgia forced to face medical, legal issues. The Atlanta Constitution, Section A, 1.

Neary, L. ( 1994, March 23 ). "Activists denounce female genital mutilation". All Things Considered, National Public Radio, Transcript #1430-9.

Ethical Issues in Culturally Relevant Interventions

Gail Elizabeth WyattThere are several steps that I would take to offer help to this client.

1.	As a licensed clinical psychologist and researcher who specializes in ethnic and cultural issues in research, my first concern would be to examine my own feelings and whether they would interfere with the best interest of the case. In so doing, a clinician can become aware of limitations and biases and can refer the parents to someone who is better able to offer advice. Consultation or supervision should be considered if the case is accepted.
2.	I would obtain information about the prevalence of female circumcision in The Gambia. Far too often, American mental health professionals have little knowledge of cultural practices or the circumstances of their occurrence in the country of origin. Assumptions about behaviors that appear to be widespread are frequently the source of premature interpretations of behavior. Additional information will help to influence decisions about what to ask the one parent who questions the practices. It would be important to know what part of the country these families come from and whether they share common tribal religious beliefs or economic circumstances. The nature of their visit to Metropolis at that particular time should also be determined. In other words, I would first want to place the interest in female circumcision into its cultural perspective in order to organize my conversation with the parent.
3.	I would determine what is meant by female circumcision and who would perform it, should it be performed in Metropolis.
4.	I would confirm what procedures meet the criteria for child abuse in Metropolis. Unless I am mistaken, although Representative Patricia Schroeder has introduced a bill banning female circumcision, state laws about this procedure, depending on exactly what is done, vary.
5.	I would encourage the parent to bring the parents of the other children, or better still, ask that a meeting with parents be arranged at the home of one of the families at a convenient time for all. Children should not be able to overhear the discussion. If the parent was not comfortable about including others, I would encourage him or her to invite someone of their culture to our meeting, who might be supportive of efforts to offer an alternative perspective to the parents about circumcision. It is important to respect the context of parental authority as much as possible and not expect the adult who expressed   concern about the circumcision to effectively convey information alone that might influence decisions about the procedure. It may be inappropriate for them to openly express a dissenting opinion about an established cultural practice in the presence of a clinician who is not of the same cultural group. 6. If a supportive family or community member can also be present at the meeting, I would also suggest attempting to invite a health professional (if this is not your area of expertise) who can discuss the health implications of female circumcision. Incorporating the example of male circumcision, a discussion of hygiene and reproduction in circumcised males and uncircumcised females highlight the benefits of viewing circumcision within a public health context. In other words, the discussion should be broadened to minimize the issues of culture and highlight the importance of hygiene, health, and reproductive benefits. A longer term issue of childbirth complications and diminished sexual feelings that girls may encounter later in life should also be discussed as consequences of female circumcision. 7. If possible, with help from a community contact or the concerned parent, I would ask the other parents if they would like to discuss these issues with others of their ethnic and cultural group who are local and have not circumcised their daughter(s). It is important to open discussion about how parents are to handle questions about their decision regarding female circumcision. If they can be provided with responses that others have given, or coping strategies used, the likelihood of their managing these issues outside of a counseling context is strengthened when they discuss their decision with others of their cultural group. 8. If possible, I would get resource information for the families. The Population Council in New York is a good referral source for agencies that educate individuals about female circumcision. I would encourage the families to obtain this information as they discuss their impending decision. 9. I would discuss strategies to follow with the concerned parent should other parents choose to have their daughter(s) circumcised. The legal consequences of such actions in the United States should be clearly described. I would also recommend Alice Walker ( 1992 ) book, Possessing the Secret of Joy, for discussion and attempt to encourage future contact and support. You need only one person who effectively negotiates change to make others consider similar actions. Defiance of culturally sanctioned practices has very negative consequences unless a support network can help to buffer the pressure to conform. I always use the Birmingham, Alabama, bus boycott as an example of how one person can set change in motion. CONCLUSIONS As a clinician, these efforts just described require sensitivity, commitment, and tenacity. Agents of change must come from within a culture, and your greatest source of change is the concerned parent who is asking for help and informa tion. Most people, regardless of culture, want good health for themselves and their children. If female circumcision is framed as an unhealthy practice, it is more likely to be reconsidered than if it is framed abusive, sexist, or illegal. To some, the latter are subject to cultural and legal definitions and may not be perceived as reasons to change culturally sanctioned practices. Although the ethical considerations of preventing such a procedure to be performed may be clear in the United States, they may be equally as convincing in another country. Consequently, discussions about ethics must span the cultures that influence sexual practices and the treatment of children. REFERENCE Walker, A. ( 1992 ). Possessing the secret of joy. New York: Pocket Books. Cultural Contexts Tony Martin A people's culture demands the highest respect. And there is nothing inherently superior in Western culture that would warrant Western dictation to the cultures of less powerful people. Yet, traditional culture is ultimately no less inviolable than religions, constitutions, and other entrenched artifices of human beings. The Roman Catholic church seriously debated its position on birth control in the 1960s. I distinctly recall a lecture by an envoy from Rome at the time, in which he expressed certitude that the church would abandon its hostility to some forms of birth control. (Great must have been his chagrin when the church affirmed its traditional position.) In 1992 the Pope apologized for his church's role in the slaughter and enslavement of Native Americans and Africans. Supreme Courts overturn themselves. Governments amend constitutions. Protestants have reversed themselves on the accession of women to the priesthood. Nothing in human rules, regulations, and traditions is, or ought to be, eternally immutable in principle. Human sacrifice, the dismembering of criminals, castration of would-be eunuchs, immolation of widows, and the burning of witches have all, at various places and times, enjoyed the sanctity of religion or tradition. So have the lynching of African Americans, the imposition of chattel slavery on Africans and their descendants, trial by ordeal, male circumcision, purdah for women, and untouchable status for millions of people. All of these practices have come under attack at one time or another. Some have disappeared. Others persist despite legal condemnation. For custom, tradition and religion are not easily uprooted. Some are extremely impervious to criticism. Yet the principle seems to be that no human practice is beyond questioning. Standards of morality and behavior are not hewn in stone. They are susceptible to change over time. Sometimes change is slow and evolutionary. Sometimes it comes quickly in response to external stimuli. Karl Marx argued convincingly in his essay on "The British Rule in India" that objectively positive change can come even at the hands of intolerant conquerors. Which brings us, at last, to the question of female circumcision. To say that it is a cultural tradition is no necessary defense, if it can be shown to be medically dangerous, unhygienic, psychologically harmful, or otherwise out of place in the modern world. This is not to give credence to the offensively ethnocentric pontifications of Western ultrafeminist op-ed writers (e.g., Ellen Goodman in the Boston Sunday Globe, March 27, 1994), or their equally offensive male counterparts (e.g., A. M. Rosenthal, New York Times, November 12, 1993). The case of female circumcision is complicated by a genuine debate over its nature and impact. In African societies it is often administered by women and women are often its staunchest supporters. Like male circumcision, which doubtless had a practical hygienic utility for people living without access to plentiful and reliable sources of water, female circumcision too may have evolved out of a practical utility. In this case it may have been the moral utility of a chaste society, the bonding of women into "age groups," and the need for rites of passage into adulthood. It is noteworthy that in many African societies boys also underwent circumcision as part of similarly conceived rites of passage. Yet, if the harmful effects of the practice now outweigh the practical effects of its origin several thousand years ago, then it may justifiably be hastened to its demise. In the instant case I would argue against invoking the laws pertaining to child abuse. This would be an unwarranted criminalization of parents grappling in good faith with a practice that is legal and customary in their home country. I would apprise the six parents of the considerations previously enunciated much as a lawyer would address a jury. They, as the jury, should deliberate and come to an informed decision. Because the girls involved are adolescents, they too should have an input into the deliberations. My recommendation would not preclude lobbying in The Gambia to have the practice reconsidered, medically upgraded, or perhaps discontinued. Should the last option come to pass, then my recommendation for a future case would probably be against the procedure. REFERENCE Marx, K. ( 1968 ). The British rule in India. In K. Marx & F. Engels (Eds.), On Colonialism (pp. 35-41). Moscow: Progress Publishers. NOTES This section of the journal features a fictionalized case vignette that embodies one or more important and complex ethical dilemmas with professional or public policy overtones. Each case is accompanied by two or more independently crafted commentaries of approximately 1,000 words by experts with diverse backgrounds and perspectives. Readers are invited to submit cases and brief follow-up commentaries that raise new and important issues. Requests for reprints of the Forum section should be sent to the Editor, Gerald P. Koocher, Department of Psychiatry, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115.