CULTURAL CIRCUMCISION IN EU PUBLIC HOSPITALS – AN ETHICAL DISCUSSION

The paper explores the ethical aspects of introducing cultural circumcision of children into the EU public health system.
We reject commonplace arguments against circumcision: considerations of good medical practice, justice, bodily integrity, autonomy and the analogy from female genital mutilation.
From the unique structure of patient-medicine interaction, we argue that the incorporation of cultural circumcision into EU public health services is a kind of medicalization, which does not fit the ethos of universal healthcare. However, we support a utilitarian argument that finds hospital-based circumcision safer than non-medicalized alternatives.
The argument concerning medicalization and the utilitarian argument both rely on preliminary empirical data, which depend on future validation.     

SHOULD WE PREVENT NON‐THERAPEUTIC MUTILATION AND EXTREME BODY MODIFICATION?

In this paper, I discuss several arguments against non-therapeutic mutilation. Interventions into bodily integrity, which do not serve a therapeutic purpose and are not regarded as aesthetically acceptable by the majority, e.g. tongue splitting, branding and flesh stapling, are now practised, but, however, are still seen as a kind of 'aberration' that ought not to be allowed. I reject several arguments for a possible ban on these body modifications. I find the common pathologisation of body modifications, Kant's argument of duties to oneself and the objection from irrationality all wanting. In conclusion, I see no convincing support for prohibition of voluntary mutilations.     

Concern mounts over female genital mutilation

According to estimates by the WHO, up to 140 million girls and women have undergone female genital mutilation (FGM), and each year another 2 million are thought to be at risk of it. Most girls who undergo this ritual live in Africa and to a lesser extent in Asia and the Middle East. However, there has been an increasing occurrence of genital mutilations among migrants from these countries who have settled in the US, Europe, and Australia. Although some countries prohibit the practice, evidence suggests that these laws are defied. In the UK, Baroness Ruth Rendell, the prime mover behind a cross-party parliament inquiry into FGM is convinced that some health professionals are still carrying out the operation on request. To this effect, she is advocating some prosecutions under the 1985 act. Rendell is also pressing for resources to be put into education and awareness campaigns for girls and women to have an informed choice as to whether to submit to the procedure or not.     

Body Dysmorphic Disorder: Contraindication or Ethical Justification for Female Genital Cosmetic Surgery in Adolescents

Is Female Genital Cosmetic Surgery for an adolescent with Body Dysmorphic Disorder ever ethically justified? Cosmetic genital surgery (specifically labioplasty) for adolescent girls is one of the most ethically controversial forms of cosmetic surgery and Body Dysmorphic Disorder is typically seen as a contraindication for cosmetic surgery. Two key ethical concerns are (1) that Body Dysmorphic Disorder undermines whatever capacity for autonomy the adolescent has; and (2) even if there is valid parental consent, the presence of Body Dysmorphic Disorder means that cosmetic surgery will fail in its aims. In this article, we challenge, in an evidence‐based way, the standard view that Body Dysmorphic Disorder is a contraindication for genital cosmetic surgery in adolescents. Our argument gathers together and unifies a substantial amount of disparate research in the context of an ethical argument. We focus on empirical questions about benefit and harm, because these are ethically significant. Answers to these questions affect the answer to the ethical question. We question the claim that there would be no benefit from surgery in this situation, and we consider possible harms that might be done if treatment is refused. For an adolescent with Body Dysmorphic Disorder, the most important thing may be to avoid harm. We find ourselves arguing for the ethical justifiability of cosmetic labioplasty for an adolescent with Body Dysmorphic Disorder, even though we recognize that it is a counter intuitive position. We explain how we reached our conclusion.     

A rose by any other name? Rethinking the similarities and differences between male and female genital cutting

In this article, we offer a critical examination of the tendency to segregate discussion of surgical alterations to the male and female genitals into separate compartments--the first known as circumcision, the second as genital mutilation. We argue that this fundamental problem of definition underlies the considerable controversy surrounding these procedures when carried out on minors, and that it hinders objective discussion of the alleged benefits, harms, and risks. We explore the variable effects of male and female genital surgeries, and we propose a scale of damage for male circumcision to complement the World Health Organization's categorization of female genital mutilation. The origins of the double standard identified are placed in historical perspective, and in a brief conclusion we make a plea for greater gender neutrality in the approach to this contentious issue.     

Female college students and cosmetic surgery: an investigation of experiences, attitudes, and body image

This large, multisite study investigated female college students' experiences with and attitudes about cosmetic surgery. The study also assessed the relationship between several aspects of body image, including appearance satisfaction and investment and symptoms of body dysmorphic disorder, and interest in cosmetic surgery. Thirty (5 percent) of the 559 women surveyed reported that they had undergone cosmetic surgery. Two thirds of respondents reported knowing someone who had received cosmetic surgery, and approximately one third indicated that a family member had undergone surgery. Overall, participants held relatively favorable attitudes about surgery. Regression analysis suggested that a greater psychological investment in physical appearance and greater internalization of mass media images of beauty predicted more favorable attitudes toward cosmetic surgery. Fourteen women (2.5 percent) screened positive for body dysmorphic disorder based on the nature and severity of their self-reported body-image concerns. Results of this study provide new information on young women's experiences and attitudes about cosmetic surgery and how these attitudes relate to body image.     

Impact of mucosal inflammation on cervical human immunodeficiency virus (HIV-1)-specific CD8 T-cell responses in the female genital tract during chronic HIV infection

The female genital tract is the major route of heterosexual human immunodeficiency virus (HIV) acquisition and transmission. Here, we investigated whether HIV-specific CD8 T-cell-mediated immune responses could be detected in the genital mucosa of chronically HIV-infected women and whether these were associated with either local mucosal HIV shedding or local immune factors. We found that CD8⁺ T-cell gamma interferon responses to Gag were detectable at the cervix of HIV-infected women but that the magnitude of genital responses did not correlate with those similarly detected in blood. This indicates that ex vivo HIV responses in one compartment may not be predictive of those in the other. We found that increased genital tumor necrosis factor alpha (TNF-α) and interleukin-10 (IL-10) levels correlated significantly with levels of Gag-specific CD8⁺ T cells at the cervix. Women who were detectably shedding virus in the genital tract had significantly increased cervical levels of TNF-α, IL-1β, IL-6, and IL-8 compared to women who were not detectably shedding virus. We were, however, unable to detect any association between the magnitude of cervical HIV-specific responses and mucosal HIV shedding. Our results support the hypothesis that proinflammatory cytokines in the female genital tract may promote HIV replication and shedding. In addition, we further show that inflammatory cytokines are associated with increased levels of HIV-specific CD8 effector cells at the genital mucosa but that these were not able to control genital HIV shedding.     

Female Genital Surgeries: The Known, the Unknown, and the Unknowable

This article reviews the literature on female genital surgeries and examines the extent to which available research supports commonly accepted "facts" about the prevalence and harmful effects of these practices, in particular their possible health complications, and their effect on sexuality. While information regarding the prevalence of female genital surgeries is becoming increasingly available, the powerful discourse that depicts these practices as inevitably causing death and serious ill health, and as unequivocally destroying sexual pleasure, is not sufficiently supported by the evidence. The article discusses some of the implications of research on female genital surgeries for the societies that are involved—not merely those where the practices are found, but also those whose gaze has been so intensely focused on the customs of others, [female genital surgeries/mutilation, prevalence, health complications, sexuality]     

Is there a link between paternity concern and female genital cutting in West Africa?

Here we explore the relationship between female genital cutting (FGC), sexual behaviour, and marriage opportunities in five West African countries. Using large demographic datasets (n 72,438 women, 12,704 men, 10,695 couples) we explore key (but untested) assumptions of an evolutionary proposal that FGC persists because it provides evolutionary fitness benefits for men by reducing non-paternity rates. We identify and test three assumptions implicit in this proposal. We test whether cut women have reduced extra-pair sex before or within marriage; whether FGC is associated with a younger age at marriage as an indication of partner preference; and whether individual and group-level indicators of paternity concern are associated with a stronger preference for marriage to women with FGC.Our results show that FGC status does not affect the odds of women engaging in several indicators of premarital sex, however women with FGC have significantly lower odds of having more than one lifetime sexual partner. We also show that women with FGC get married at a younger age which supports the argument that FGC status influences women's marriage opportunities, even when it does not restrict sexual activity. Finally, we find that in population groups where reported sexual activity and perceived risk of women's extra-pair sex is high, men have higher odds of marrying a first wife with FGC. Together, these results indicate that paternity certainty may be one of several factors contributing to the persistence of FGC in this sample, and that group-level sexual norms are key to maintaining the practice of FGC through the marriage market.     

Female genital mutilation and monandry in an orb-web spider

Monandry, in which a female has only one mating partner during the reproductive period, is established when a female spontaneously refrains from re-mating, or when a partner male interferes with the attempts of a female to mate again. In the latter case, however, females often have countermeasures against males, which may explain why polyandry is ubiquitous. Here, I demonstrate that the genital appendage, or scape, of the female orb-web spider (Cyclosa argenteoalba) is injured after her first mating, possibly by her first male partner. This female genital mutilation (FGM) permanently precludes copulation, and females appear to have no countermeasures. FGM is considered to confer a strong advantage to males in sexual conflicts over the number of female matings, and it may widely occur in spiders.     

Female circumcision in multicultural Singapore: The hidden cut

In recent years discussion about female genital mutilation (FGM) has expanded and the UN has recently called for a universal ban of the practice. The practice in Southeast Asia is widespread among Malay Muslims and, although different styles and practices exist, procedures conducted in medical clinics are extremely minor and, according to gynaecological research, have no effect on sexuality due to the clitoris being left totally untouched. One of the states in which Malay Muslims maintain such a tradition is Singapore. Nonetheless, Singapore is rarely mentioned in academic studies or even in reports discussing the ritual. Even inside Singapore, only Malays tend to know of the tradition, while other ethnic groups remain oblivious to the fact that Singapore is among the states that allow such an operation. The present article does not discuss FGM per se and avoids contributing to the diatribe about labels and values, although these are, of course, extremely relevant. Instead it focuses on the reasons for the practice remaining hidden and undiscussed in Singapore, so much so that some respondents did not know that they had been circumcised.     

What is the best age to circumcise? A medical and ethical analysis

Circumcision is often claimed to be simpler, safer and more cost-effective when performed in the neonatal period as opposed to later in life, with a greater benefit-to-risk ratio. In the first part of this paper, we critically examine the evidence base for these claims, and find that it is not as robust as is commonly assumed. In the second part, we demonstrate that, even if one simply grants these claims for the sake of argument, it still does not follow that neonatal circumcision is ethically permissible absent urgent medical necessity. Based on a careful consideration of the relevant evidence, arguments and counterarguments, we conclude that medically unnecessary penile circumcision—like other medically unnecessary genital procedures, such as ‘cosmetic’ labiaplasty—should not be performed on individuals who are too young (or otherwise unable) to provide meaningful consent to the procedure.     

Repeated evolution of male sacrifice behavior in spiders correlated with genital mutilation

According to sexual cannibalism theory, male complicity in terminal mating can be adaptive when the male's future reproductive value is low relative to the benefits of self sacrifice. Spiders and insects that exhibit male sacrifice behavior (either complicity in cannibalism or spontaneous death associated with copulation) often also have male genitalia that stereotypically become broken or disfigured the first time they are used for copulation, potentially lowering his future reproductive value. Theoretical work on monogamy has identified male bias in the effective sex ratio as a precursor to the evolution of monogamy (including male sacrifice) as an adaptive form of paternity protection. Using phylogeny-based statistics and drawing on several phylogenetic studies of araneoid spiders, I investigate relationships between male sacrifice behavior, genital mutilation, extreme sexual size dimorphism, and the accumulation of multiple males in the female web (as an indicator of a male-based effective sex ratio). This investigation focuses on araneoid spiders because several independent origins of sacrifice behavior are known for this group and the phylogenetic structure of the lineage is relatively well studied. I report that male genital mutilation is significantly correlated with sacrifice behavior and argue that this finding is consistent with sexual cannibalism theory. Male sacrifice behavior is also correlated with male accumulation, a result that is consistent with theoretical work on the evolution of monogamy. Male accumulation and extreme sexual size dimorphism are correlated suggesting that sex-based differences in maturation time can lead to a male biased effective sex ratio. Similar patterns of correlated characters may hold for some insect taxa. Studying traits that have appeared independently in multiple lineages is a powerful method for developing general theories about the evolution of biological phenomena.     

Copulatory mechanism in a sexually cannibalistic spider with genital mutilation (Araneae: Araneidae: Argiope bruennichi)

Genitalia are among the fastest evolving morphological traits as evidenced by their common function as diagnostic traits in species identification. Even though the main function of genitalia is the successful transfer of spermatozoa, the presence of diverse structures that are obviously not necessary for this suggests that genitalia are a target of sexual selection. The male genitalia of many spider species are extremely complex and equipped with numerous sclerites, plates and spines whose functions are largely unknown. Selection on male genitalia may be particularly strong in sexually cannibalistic spiders, where mating success of males is restricted to a single female. We investigated the copulatory mechanism of the sexually cannibalistic orb weaving spider Argiope bruennichi by shock freezing mating pairs and revealed a complicated interaction between the appendices and sclerites that make up the male gonopods (paired pedipalps). The plate that covers the female genital opening (scape) is secured between two appendices of the male genital bulb, while three sclerites that bear the sperm duct are unfolded and extended into the female copulatory opening. During copulation, females attack and cannibalise the male and males mutilate their genitalia in about 80% of cases. Our study demonstrates that (i) genital coupling is largely accomplished on the external part of the female genitalia, (ii) that the mechanism requires an interaction between several non-sperm-transferring structures and (iii) that there are two predetermined breaking points in the male genitalia. Further comparative work on the genus Argiope will test if the copulatory mechanism with genital mutilation indeed is an adaptation to sexual cannibalism or if cannibalism is a female counter adaptation to male monopolisation through genital plugging.     

When an adult female seeks ritual genital alteration: ethics, law, and the parameters of participation

Ritual genital cutting for women, a common practice in Africa and elsewhere around the world, remains dangerous and controversial. In recent years, a 14-year-old girl living in Sierra Leone exsanguinated and died following a ritualistic genital cutting. Hoping to avoid that fate, women with backgrounds that accept ritual genital cutting may, when they reach majority age, ask plastic surgeons to perform genital alterations for cultural reasons. Although plastic surgeons routinely perform cosmetic procedures, unique ethical and legal concerns arise when an adult female patient asks a surgeon to spare her the tribal elder's knife and alter her genitalia according to tradition and custom. Misinformation and confusion about this issue exist. This article explores the ethical and legal issues relevant to this situation and explains how the thoughtful surgeon should proceed.     

Sex selection in India: Why a ban is not justified

When widespread use of sex‐selective abortion and sex selection through assisted reproduction lead to severe harms to third parties and perpetuate discrimination, should these practices be banned? In this paper I focus on India and show why a common argument for a ban on sex selection fails even in these circumstances. I set aside a common objection to the argument, namely that women have a right to procreative autonomy that trumps the state's interest in protecting other parties from harm, and argue against the ban on consequentialist grounds. I perform a pairwise comparative analysis of sex selection and its plausible alternatives and argue that that the ban fails to improve the state of affairs relative to a scenario without a ban. The ban makes the situation worse, especially for mothers and their daughters. India should therefore repeal its ban on sex selection.     

Spontaneous male death and monogyny in the dark fishing spider

Monogyny (male monogamy) is found in a diverse assemblage of taxa, and recent theoretical work reveals that a male-biased sex ratio can favour the evolution of this relatively rare mating system. We integrate this theoretical framework with field observations and laboratory experiments involving the sexually size dimorphic fishing spider, Dolomedes tenebrosus, to test the prediction that this species exhibits monogyny. Field surveys revealed a male-biased sex ratio, likely resulting from different life-history strategies (early male maturation). Results from mating trials supported our prediction of monogyny as we discovered that males mate with a single female. Unexpectedly, however, we observed that mating results in obligate male death and genital mutilation. Additional field observations of released individuals suggest that males are not limited by their ability to encounter additional females. Controlled laboratory assays demonstrated that males discriminate among virgin and non-virgin female silk cues, consistent with predictions of first-male sperm precedence. In summary, we report a novel case of male self-sacrifice in a species that exhibits female-biased sexual size dimorphism, male-biased sex ratio, genital mutilation and a suggestion of first-male sperm precedence; all of which are consistent with theoretical predictions of the evolution of monogyny.     

Selection on an antagonistic behavioral trait can drive rapid genital coevolution in the burying beetle,Nicrophorus vespilloides

Male and female genital morphology varies widely across many taxa, and even among populations. Disentangling potential sources of selection on genital morphology is problematic because each sex is predicted to respond to adaptations in the other due to reproductive conflicts of interest. To test how variation in this sexual conflict trait relates to variation in genital morphology we used our previously developed artificial selection lines for high and low repeated mating rates. We selected for high and low repeated mating rates using monogamous pairings to eliminate contemporaneous female choice and male–male competition. Male and female genital shape responded rapidly to selection on repeated mating rate. High and low mating rate lines diverged from control lines after only 10 generations of selection. We also detected significant patterns of male and female genital shape coevolution among selection regimes. We argue that because our selection lines differ in sexual conflict, these results support the hypothesis that sexually antagonistic coevolution can drive the rapid divergence of genital morphology. The greatest divergence in morphology corresponded with lines in which the resolution of sexual conflict over mating rate was biased in favor of male interests.     

“I Don’t See That as a Medical Problem”: Clinicians’ Attitudes and Responses to Requests for Cosmetic Genital Surgery by Adolescents

Labiaplasty is a form of genital surgery to reduce large or protruding labia minora. Internationally, the rates of this surgery among women and girls is increasing and is viewed as a worrying trend. Currently, the main clinical strategy is to reassure adolescents that they are normal by talking about the variation of labia size and appearance and showing pictures demonstrating the wide range of normal female genital appearance. For the most part, policy documents recommend against labiaplasty in adolescents, claiming that it is medically non-essential surgery. In this paper, we contrast findings from our interviews with clinicians with the existing literature and policy documents and we point out areas needing more thought. This is qualitative research using semi-structured interviews. We set out to find out on what basis clinicians decide how to treat or manage adolescent patients seeking labiaplasty. We interviewed clinicians who are likely to be approached by under-eighteens requesting labiaplasty. We use interpretive content analysis and thematic analysis to analyse the data. Our findings support the emphasis on education and reassurance as the first step for all patients, but other issues that have not figured previously in the literature that would alter clinical strategies for managing patients emerge as well. Key findings are that reassurance does not always work and that the distinction between functional and appearance concerns is not a solid foundation in itself for deciding whether surgery is ethically appropriate. We conclude that the distinction between functional and appearance concerns is not ethically relevant. It is open to different interpretations and is not regarded by all clinicians as the definitive factor in relation to surgery. The focus of clinicians should be on relieving distress whatever the cause. Appearance reasons may sometimes justify surgery but, also, functional reasons may sometimes not be sufficient justification for surgery.     

A FRAME response to the Draft Report on Alternative (Non-animal) Methods for Cosmetics Testing: Current Status and Future Prospects--2010

This response on behalf of FRAME to the European Commission's consultation on the five chapters of the Draft Report on Alternative (Non-animal) Methods for Cosmetics Testing: Current Status and Future Prospects--2010, is via a Comment in ATLA, rather than via the template supplied by the Commission. This is principally so that a number of general points about cosmetic ingredient testing can be made. It is concluded that the five draft chapters do not provide a credible basis for the Commission's forthcoming report to the European Parliament and the European Council on the five cosmetic ingredient safety issues for which the 7th Amendment to the Cosmetic Directive's ban on animal testing was postponed until 2013. This is mainly because there is insufficient focus in the draft chapters on the specific nature of cosmetic ingredients, their uses, their local effects and metabolism at their sites of application, and, in particular, on whether their possible absorption into the body would be likely to lead to their accumulation in target sites at levels approaching Thresholds of Toxicological Concern. Meanwhile, there continues to be uncertainty about how the provisions of the Cosmetics Directive should be applied, given the requirements of the REACH system and directives concerned with the safety of other chemicals and products.