On 'Ritual Nick' or 'Pinprick' Female Circumcision
Aug 14, 2011

On 'Ritual Nick' or 'Pinprick' Female Circumcision

Whenever the topic of female genital mutilation or circumcision is brought up, most people experience a poignant and visceral reaction at the mere thought of such atrocity. Almost everything to do with female circumcision is to be strongly rejected, but there is actually one procedure lumped into the category which is, at least, worth having an open debate out. This is the idea of a 'ritual nick' or 'pinprick' circumcision. It got a fury of attention last year because the American Association of Pediatrics came out in support of the procedure but was forced to reverse the comment after extensive public backlash.

Essentially, this is a procedure that is gaining cultural acceptance which is meant as a harmless representative of the harmful cultural procedure of larger scale female genital circumcision or mutilation. A doctor makes a pinprick intended to draw a single drop of blood from a girl's clitoris, usually shortly after birth. With a localized sterilizing agent and anesthetic applied, and under the careful application of a medical doctor, this procedure results in only a very short term and minor pain without lasting health, sexual or visual consequences. The goal is for the procedure to symbolize the more extreme cultural practices so that they can be replaced with this far more benign procedure. This procedure has been blanket banned in most of North America and European countries but is gaining popularity in Africa and Asia (where the actual genital mutation is happening, in some places rampantly)

There are definitely two sides to the issue. Both sides have two main arguments for or against; one argument deals with the expected social and health consequences and the other deals with the human rights and symbolism involved. Let us consider the pro side first.

Firstly, it can be argued that this is simply better for the girls. Certainly if it were possible to replace, in regions with full on female circumcision, that horrific cultural phenomenon with a cultural desire to do this pinprick procedure instead and thus reducing the higher level FGM it would be an enormous humanitarian success. I think there is probably legitimate reason to think that pushing for reducing the severity first to this representative procedure is going to be a more successful way of reducing actual FGM than just a blanket ban on anything related to it. Approaches to entirely eliminate FGM by identifying its health consequences have had limited effect and this is due to the fact that health concerns often do not manage to trump cultural desires. Working to transition the existing cultural desire - and we must certainly recognize that it is a strong cultural force - into a more healthy form seems like a far better approach. This is not unlike the Catholic Church's ban on condoms which ignores the reality that people want to have sex outside of when they want children. However well intended it may or may not be, it simply is not effective and we have seen time and time again that one must work with the base desire to have frequent, extramarital sex and transform that into something done in safer ways.

In North America, any form of female circumcision is much less common than in, say, the horn of Africa where prevalence in certain regions is 95%+.  Because it is illegal, in all forms, there is essentially no good statistics out there for how common it is or isn't in the west. However, we do know that it isn't nonexistent and there remains a tendency to still engage in such practices underground (which exacerbates the health risks) and, more commonly, to send girls back to Africa or the Middle East to get the procedures done there. Incidentally, the pressure to do this is largely matriarchal and not patriarchal. If the pinprick female circumcision procedure was made legal in the west, it would undoubtably save some number of girls from either the same procedure done in unsafe settings or much worse procedures being done either in the west or sent back to Africa/ME.

The other aspect along this vein is the idea that acceptance in the west could push acceptance in places where it really matters such as the Horn of Africa. The diaspora from these places could inform their home regions about the possibility of pinprick female circumcisions in the west and how much safer and humane they are. Aid groups and human rights groups, or more importantly their western donors, could be more willing to work on pushing the pinprick practice as a substitute were it to be normalized in the west.

Secondly, one can look at the ritual nick from a cultural perspective with consideration for the human rights of religious and cultural expression. Once the health consequences have been removed, the procedure is effectively a cultural one: people have a desire, for religious reasons, to have this done with little to no meaningful physical consequences. The standard model of human rights is that unless a compelling case can be made for distinct harm being caused, we must accept the cultural and religious practices of others.

On the con side, there are again two major arguments against this procedure. From a social health perspective, there is an argument that by normalizing the symbolic procedure one is, in turn, normalizing the more horrific procedures. As such, it is possible that by pushing the pinprick replacement procedure it will be harder to bring down overall rates. Experience seems to suggest that it is easier to modify a practice into something healthier than it is to simply eliminate it and so I will let the reader judge whether this effect would appear to dominate or be dominated by the converse effects above. Ultimately, we will need a statistical analysis comparing rate changes in countries that do and do not push this procedure to really lock in how powerful this amplifying effect is.

The other argument against it belittles it because it is tacitly condoning (and thus might encourage ala the other point) much of what female circumcision symbolizes. Namely, to the extent that female circumcision symbolizes things like sexual slavery, female submission to males, and the repression of female sexuality, then the pinprick symbolizes all these things as well and so is bad.  I certainly agree. My goal would not be to have a society with rampant female pinprick circumcision. However, symbolizing sexual repression is nonetheless better than a procedure which actually represses the sexuality of females. It is the lesser of two evils and is a useful transition to some future time when the entire procedure and everything it symbolizes is irradiated.   A deontologist might claim that things which symbolize such violence are simply bad and to be rejected, but the utilitarian in me is forced to accept the benefit of a less bad thing over a more bad thing.

To see how these various arguments apply, consider the comparison with the enormously prevalent cultural and religious procedure of male circumcision. In the west, male circumcision is a significantly more extreme procedure than pinprick female genital circumcision as one is removing living tissue that irreversibly and obviously alters the appearance of a person. Both procedures are fairly harmless and low risk nonetheless and, importantly, both are done for reasons that are largely cultural in nature. To say one is fine and the other is not is a pretty deeply hypocritical thing and would require an enormous burden of proof. It is possible that one can demonstrate the negative effects along the lines of how I previously identified such as entrenching the cultural practice, but my causal impression is that the good consequences out weigh the bad consequences and, recall, we need to be convinced the bad outweighs if we are going to restrict religious and cultural practices.

In discussing this issue with people, there have been two major responses to the  male circumcision comparison (which I find to be very compelling in the human rights issue). This seems centered around the fact that male circumcision itself remains a controversial issue; my guess is that depending on whether one is circumcised or not, one on occasional will try to defend that position as being the right one. Firstly, some argue that male circumcision has health benefits (which the pinprick certainly does not, it is effectively neutral) and so is distinct from the pinprick and cannot be used in comparison. There are a lot of studies that investigate this question; some show a very small positive health consequences, some show a very small negative health consequences and many show that it is neutral or too small to detect. So sure, I will allow that this is up for debate but I think it is clear that it is a cultural practice first and foremost and a health issue as a distant second usually relegated to apologists. Most people who actually engage in the practice are doing it for the cultural or religious reasons and not because of an informed study of the scientific literature on the health consequences. Even if we accept this narrative, the risks of negative consequences form male circumcision and complications can remain significant to a degree the pinprick is not.

Secondly, some argue that male circumcision is itself morally wrong, that it is the permanent mutilation of the flesh from a defenseless baby, and similar narratives. I typically find these narratives to be overblown, largely because the consequences are minimal at best. Parents, for obvious practical reasons, must have the rights to influence their children and impose cultural and religious practices provided there is not a strong case for harm done. I would submit that on the scale of consequences that parents imbed into their children (such as which religion to be, for which ones parents is the dominant indicator) are far more extreme and influential than any minor differences between being circumcised or not.

Let me add one more comparison to the list, the Indian practice of piercing the ears of their babies. This is either of the same level or perhaps more extreme than the pinprick as it does leave an at least semipermanent mark on the bible if left with earrings on for several years. If one takes either of the two opposing male circumcision views above and is unpersuaded by my objections, consider the comparison with this instead. It doesn't have the kind of health or sexual benefit some might claim male circumcision has and is giving a deliberate pain and long lasting effect to a baby like male circumcision. Yet is someone going to attempt to claim that this is wrong? I think not, and the difference, I suspect, is that ear piercings do not have any of the sexual stigmas that male or female circumcision has.

The World Health Organization gives a four part classification for different categories of female genital circumcision. The ritual nick is included in the Type IV category which includes numerous other "harmful" procedures sufficiently ghastly that I will let my non squeamish readers look them up on their own. This is an unfair categorization of the procedure based on its health consequences and the WHO needs to include a fifth category for the symbolic procedure that will de-stigmatize it and make it open to a public debate about the benefits or consequences of the procedure.

This issue touches such a provocative nerve that we should expect it to be highly contentious. I don't think everyone will agree with my thesis that we should be pushing for the pinprick circumcision to be both allowed in the west and to be promoted through aid groups in Africa, the Middle East and Asia. However, I would hope that we can agree that this issue is one that should at the very least be investigated, discussed, and genuinely considered opposed to being dismissed on its face. The consequences of larger scale female genital mutilation is too important not to consider all options.

Thoughts on this post? Comment below!

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linda massie said...

you seem to be totally ignoring the fact that male babies and children die from circumcision, why?

bazie said...

The American Academy of Family Physicians estimates 1 in 500,000 babies die from circumcision, a number that utterly pales in comparison to any number of other things that parents do to their children. We don't have studies on this, but it can be presumed that a pinprick in the female case would be far lower than this one in half million number.

Regardless, it is worth noting that I DID actually address the issue (along with non fatal consequences)

"There are a lot of studies that investigate this question; some show a very small positive health consequences, some show a very small negative health consequences and many show that it is neutral or too small to detect...the risks of negative consequences form male circumcision and complications can remain significant to a degree the pinprick is not.

deBeauxOs said...

Given the cultural tradition is based on the patriarchal belief that women's sexuality must be kept under control and thus female genital mutilation by making intercourse painful for women achieves this purpose, how can this *pinprick* satisfy the believers?

bazie said...

Apparently it is actually pushed often via matriarchal structures rather than patriarchal, as counter-intuitive as that may be. The WHO identifies numerous specific cultural motivations and the narrative that it is entirely about patriarchal creation of painful intercourse is not true.

And it IS used in various places. One probably ought to dig deeper, but the AAP mentioned in the post states: “in some countries where FGC is common, some progress toward eradication or amelioration has been made by substituting ritual ‘nicks’ for more severe forms.”

But even if none of that was true, even if nobody ever used this as a replacement, then we don't lose much. We waste our breath and aid dollars, perhaps, advocating for a procedure no one ends up being used but if doesn't get used then it doesn't actually cause any harm and we are right where we started.

linda massie said...

elsewhere many young men die from ritual circumcision in the tribal setting and elsewhere and no medical association in the world advocates this practice. In fact the reverse is the case, it is recognised as a violation of children's rights, harmful and without any "medical benefits" . When i suggest to people in Ireland that there is this idea in the United States they are applalled.
http://mensnewsdaily.com/2010/05/30/royal-dutch-medical-association-male-circumcision-medically-unnecessary/y You are culturally blind to the harm caused by male circumcsion.

bazie said...

The case for not banning male circumcision isn't that it is "medically necessary" or has "medical benefits", it is that if we are going to ban the cultural practice of something a half billion people have then we need a really compelling case for it actively causing harm in a large way. And one in a half million deaths (or whatever it might be in other countries) is not sufficient, in my view - especially when you compare to, say, 1 in 11,000 backyard pools cause deaths. For the overwhelming majority of people, the only difference is aesthetic. This is very different than in the case of, say, stage I FGM.

Now if we move away from the first world where almost certainly death rates are somewhat higher, you can start looking at positives such as the WHO which identifies that male circumcision is an effect way to reduce the transmission of HIV and so, while debatable, it may make for a cost effective method of protection against HIV in Africa.

I would also not that there is a big difference between coming up with a case for why you, as an individual, should not perform circumcisions on your children and coming up with a case for why society should ban circumcisions of all children. The standard of evidence for the latter is much higher, and one has to be cognizant of the fact that one is directly preventing a large scale cultural phenomenon.

Returning to the subject in the post, since you don't recognize male circumcision, I would ask whether pierced earings of Indian babies is allowable in your view? And what of the pinprick? Both are much less dangerous and extensive than male circumcision and I would ask whether any of the arguments I espoused (such as replacing the more extreme procedure with the less extreme one) is compelling to you?

linda massie said...

Male circumcision not only kills it maims and injures many with a range of medical complications and is the leading cause of impotence. How can you ignore these facts?

bazie said...

Saying that circumcision is the leading cause of impotence is simply false. There are, according to wiki, 9 other factors which they list that cause impotence such as smoking, drugs, aging, kidney failure, etc. There have been many studies on any alleged link between circumcision and impotence. Many show no effect, a few show positive effects and a few show negative effects. In no sense could it be said to be the leading indicator, and it is doubtful whether it is a statistically significant indicator at all.

But to your larger point, I am hardly "ignoring" anything; indeed, I have explicitly referenced and acknowledged this. What I am saying is that the prevalence rates (such as one in a half million deaths) are trivially small compared to an enormous range of other things parents are entirely allowed to do to their kids. It does pass the test of being sufficiently harmful with sufficient prevalence to ban the cultural expression currently on display in a half billion humans. As, mentioned I also don't think the alleged benefits are all that significant either.

This is why I raised the swimming pool example. Its death rate is FAR higher than for circumcision. Do you think we should ban these as well? As one can see, simply noting that deaths occur is not equivalent to saying something should be blanket banned.

linda massie said...

no death is trivial when it is unneccesary all sexual abuse of children is wrong and that is what unnecessary circumcision of children is. http://classprojects.kenyon.edu/wmns/Wmns36/bloodletting/mcircfra.htm

We must protect all children from those who would take a knife or advocate taking a knife or a pin to their genitals.

deBeauxOs said...

I said "patriarchal beliefs"; under a terrorist regime, the oppressed - women - promote and carry out the violence too.

bazie said...

"when it is unneccesary all sexual abuse of children is wrong". This is a tautology and is, essentially, a conversation stopper. One is essentially just defining circumcision as categorically and deontologically wrong and against that no amount of utilitarian analysis could stand. It is like just defining abortion as being "murdering children" which is, categorically, taken to be bad.

"no death is trivial". Sure. So should we ban backyard swimming pools which cause deaths at far higher rates? The example illustrates the problems of such categorical thinking. If we simply use the existence of a bad consequence as equivalent to blanket banning it without further consideration we will probably end up having to ban just about anything.

As for your link, it is basically exactly as I described. It acknowledges, as did I, that there are both some positive and negative consequences.

bazie said...

deBeauxOs: I am not sure I understand what you mean. Are you trying to establish some form of equivalency between violence and/or terrorism, and patriarchal beliefs?

Regardless, it is not at all true to associate the word "terrorist" with people who commit FGM in general. Remember, there are many countries where prevalence is overwhelming and it is essentially a default cultural practice - often led by the women of the family and the community in which 95%+ of girls partake. We can disapprove of it, of course, but there is no meaningful sense in which it can be considered terrorism. In particular, it absolutely cannot be said that all the countries where this occurs operate under "terrorist regimes" and, besides, most of this is done at the community level not the level of the state. Egypt, for instance, has 95% prevalence but its Islamic leaders say NOT to do it.

The word terrorist is so horribly distorted in the media to essentially mean 'anything islamic we don't like' that I would attempt to refrain from its usage as much as possible.

linda massie said...

bazie , as is male circumcision, often led by men in the family and the community. We can surely disagree with all genital mutilation of children, after all there are those who claim female circumcision prevents infections hiv etc. Your arguments with regard to this are nonsensical we have banned female circumcision and must ban the same in males as that is equality. By the way i understand tautalogical arguments and yours does not make any sense. Hows that that for a tautalogical statement.

Anonymous said...

"If we simply use the existence of a bad consequence as equivalent to blanket banning it without further consideration we will probably end up having to ban just about anything."

Egypt has banned all female circumcision after the death this week of a 12-year-old girl undergoing the widely practised procedure.

Budour Ahmad Shaker died from an overdose of anaesthetic

bazie said...

It is worth noting that this case was as a result of full clitoral removal attempted, not the representative pinprick I think is worth, at the very least, taking a few minutes to consider whether it could be beneficial.

Considering that some 95% of Egyptian women have had this procedure done, while I support the ban, there is significant risk that this drives the practice underground into more unsafe venues that results in more cases of death. Perhaps the pinprick could alleviate that.

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