Monday, 24 April 2017

“Gender and Genital Cutting: A New Paradigm” – bioethicist Brian Earp’s and my recent paper for the European Parliament

My bioethicist colleague, Brian Earp, and I have recently published a paper for the European Parliament on the non-therapeutic cutting of children’s genitals.

In it, we explain that though moral and legal opposition to the non-therapeutic cutting of children’s genitals has traditionally focused on female children, a growing movement of scholars, activists, and individuals affected by childhood genital cutting have argued that all children, regardless of sex or gender, should be protected from such intimate violations.

In our paper, we argue, first, that the conventional distinctions based on sex or gender do not reliably reflect the actual harms that are entailed by various forms of NGC; and secondly that distinctions based on autonomy and informed consent do provide coherent grounds for an empirically justifiable analysis of the moral permissibility of NGC.

These conclusions have significant implications for policy. At a recent WHO-sponsored conference on female NGC held at Geneva University Hospitals, we argued that a gender-inclusive approach, based on an individual’s capacity to provide informed consent to NGC, is not only better supported by the available evidence, but also offers several practical advantages:

  1. It deflects accusations of sexism by recognizing that boys and intersex children are also vulnerable to non-therapeutic genital alterations that they may later come to seriously resent. 
  1. It clarifies the moral confusion that stems from Western-led efforts to eliminate only the female “half” of childhood NGC practices in communities that practice both male and female NGC in parallel. 
  1. It neutralizes accusations of cultural imperialism by applying the same standards to medically unnecessary genital cutting practices primarily affecting white minors in North America, Australasia, and Europe (i.e., medicalized routine or religious male circumcision, and intersex genital normalization surgery) as it does to such practices primarily affecting minors of color in Africa, the Middle East, and Southeast Asia (i.e., male and female peripubertal initiation ceremonies and other customary forms of childhood NGC). 
Adopting such an approach does not necessarily mean seeking to prohibit all pre-consensual forms of NGC. Experience shows that the enactment of strict legal prohibitions prior to cultural readiness can backfire, creating intense resistance among those who are dedicated to the practice, and often driving it further underground. Prohibition of childhood female NGC, for example, has been largely unsuccessful in many countries where it is customary and deeply embedded, and recent attempts to criminalise circumcision of boys have been blocked, ignored or overturned.

There are, however, many “levers” society that can pull to discourage harmful practices: the law is only one among many, and not necessarily the most desirable or effective. Some authors have proposed step-wise regulation of childhood NGCs, along with community engagement and education, as alternatives and/or supplements to formal prohibition.

Whatever specific policies are implemented, it is clear that fundamentally different treatment of female, male, and intersex children, in terms of their protection from nontherapeutic genital cutting, will become increasingly difficult to justify, morally, legally or medically, in years to come.


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Our thanks go to Eduardo Zugasti, assisting MEP Teresa Giménez Barbat, for inviting us to prepare this essay, and to Professor Elizabeth Reis and Dr. Robert Darby for feedback on an earlier draft.

Wednesday, 15 March 2017

FGM/C Geneva conference presentation: Could efforts to eliminate female genital cutting be strengthened by extending protections to male and intersex children?

Over the last two days, I participated in an inspiring and enriching conference on Female Genital Mutilation/Cutting at the Geneva University Hospitals. There, I met so many incredible people working so hard on such complex issues. 

I also shared some of my bioethicist colleague Brian Earp's and my research on whether efforts to eliminate female genital cutting could be strengthened by extending protections to male and intersex children. We created and displayed this eposter to summarise our analysis and arguments: 



In my presentation, I recognised that comparing female genital cutting with male and intersex genital alteration is controversial. At the same time, I emphasised that there are significant areas of overlap between these practices that necessitate reconsideration of their divergent ethical statuses and policy treatments.


I explained that some argue that efforts to reduce FGC are undermined by failing to apply principles of bodily integrity to children of all sexes. While a sex-based approach is incompatible with equality principles, it could also backfire because some defenders of male circumcision call for 'nicking' of females' genitalia for intellectual consistency. Essentially they're seeking to 'equalise down' by rolling back existing protections for females. 

By contrast, Brian and I have identified three advantages of a gender-inclusive approach:
  1. It negates accusations of cultural imperialism by applying the same standards to white children in the USA as to children of colour in Africa.
  2. It weakens accusations of sexism by recognising that boys and intersex children are also vulnerable to non-therapeutic genital alteration.
  3. It clarifies the moral confusion caused by applying a gendered-double standard to communities that modify both sexes' genitals. 
We quoted the Swiss lawyer Sami Abu-Sahlieh, who said: “Female circumcision will never stop as long as male circumcision is going on. How do you expect to convince an African father to leave his daughter uncircumcised as long as you let him do it to his son?”

Finally, we made two arguments for extending protections to male and intersex children. The first was an ethical argument, namely that consent, not sex, should form the basis of policy: All children should be protected from non-consensual, non-therapeutic cutting of their genitalia. 

The second was an effectiveness argument: That efforts to eliminate FGC will only be successful if they expand to include vulnerable persons of all genders.

Participants' reactions to our analysis were very encouraging. Everyone was enthusiastically and vocally supportive of the need to apply principles of bodily integrity consistently to children of all genders. 

Thank you to the organisers for providing the space for this important conversation. Here's to many more discussions like this!


Thursday, 9 March 2017

Some reflections on last night's 'Reproductive Justice in Europe' panel discussion at UCL for #IWD2017

Last night, I contributed to a panel discussion at UCL about 'Reproductive Justice in Europe' for International Women’s Day. Thank you to co-conveners Cara Spelman and Dr. Rory Archer for organising such a great line-up of speakers, and for facilitating a very stimulating discussion. Below I summarise my remarks and reflect on some of the questions posed by attendees. 

During my opening remarks, I explained why ‘reproductive justice’ constitutes such an important intellectual breakthrough. I also identified what I consider some of the most egregious and pressing reproductive injustices in Europe today. This is where I believe we should focus our collective efforts. 

A very brief summary of 'Reproductive Justice:'

As I explained, reproductive justice was coined by feminist women of colour in 1994, who recognised the limitations of focusing on theoretical 'choices' and 'rights.' Instead these academics and activists drew attention to the ways in which the complex interplay of race, class, sexual orientation, disability and age (among other factors) can - and do - influence people’s reproductive experiences, as well as their ability to access reproductive healthcare services. In so doing, RJ broadened the scope of inquiry, expanding reproductive rights to include not only the right not to bear children, but also the right to bear children, and to raise them with dignity. It also moved beyond rights themselves in order to consider people's actual experiences, and specifically the barriers to their accessing services. RJ therefore covers an enormous breadth of important and fascinating topics - everything from contraception, reproductive technologies, surrogacy and pregnancy to birth, infant feeding, parenting, and childcare. It expands the range of settings examined in order to shine a light on those who may be most adversely effected by reproductive injustice: Prisons, refugee camps, detention centres and diseased environments - to name a few. Most importantly, RJ engages with affected communities, eschewing an abstract top-down approach. Researchers committed to the RJ approach work with affected communities, activists and providers (including midwives and doulas), among others. They engage in fully participatory research, from design to execution to publication to evaluation. The research opened up by the RJ framework is complex and controversial. It asks difficult questions, like: 

  • Is contraception birth control or population control?
  • Are non-invasive prenatal tests (NIPTs) at odds with disability rights?
  • What are the social challenges to childbearing?
  • What social and health challenges confront pregnant transgender men?
  • How is teenage motherhood represented?
I for one am convinced that RJ is currently the best way forward for academics and activists working on reproductive issues. 

What are the most pressing reproductive injustices in Europe today?

Clearly this is not an easy question to answer. When I posed it on Facebook though, one response stood out: Refugee women’s lack of access to reproductive healthcare services.

Migration and statelessness are barriers to accessing reproductive healthcare. Refugee women are vulnerable to gender-based violence, but it is difficult for them, in transit, to access emergency contraception, antibiotics to treat STIs, post-exposure prophylaxis to prevent HIV, and psychosocial support. It is estimated that 1 in 10 refugee women in Europe is pregnant. A recent joint field assessment from the UN refugee agency (UNHCR), its Population Fund (UNFPA) and the Women’s Refugee Commission (WRC) regarding the risks for refugee and migrant women and girls in Greece and Macedonia found that women often left hospitals less than 24 hours after giving birth, some having had Caesarean sections. Pregnant and lactating women were reluctant to access services or visit hospitals for fear of delaying their journey, losing their baby or being separated from their family. A preliminary report on antenatal care, birth and postnatal care of refugees in Greece, collated by the legal group Hellenic Action for Human Rights, shows that every single one of the women reported having medical procedures carried out on them without consent or the chance to question the decision

Lack of access to abortion, especially second trimester abortion also came up as a pressing reproductive injustice. As my co-panelists eloquently explained, some European countries forbid abortion entirely, either in law or in practice by erecting impassable barriers to access. Poland and Ireland stand out in this respect. But another issue is that only six countries in the whole of Europe offer abortion on demand after 12 weeks: Brussels, Romania and Spain (14 weeks), Sweden (18 weeks), Holland (22 weeks), and the UK (excluding Northern Ireland) (24 weeks). This is a major problem for women seeking second trimester terminations. In addition, even in those countries where abortion is relatively easily accessible, it nevertheless often remains criminalised. The UK is a case in point. Abortion is still criminalised in the UK as a result of the 1861 Offences Against Person Act. This is not only paternalistic and outdated, but it denies women reproductive autonomy. #wetrustwomen is campaigning for the decriminalisation of abortion prior to 24 weeks, and on 13th March 2017, MPs will vote on a bill to change the law to decriminalise abortion. In line with the call from #wetrustwomen, I asked attendees to ask their MP to vote to protect women who are currently at risk of criminal prosecution and to vote in favour of Diana Johnson MP’s Reproductive Health (Access to Terminations) Bill.

Birth injustice also stood out as a Europe-wide problem: Theoretically, women in Europe have the right to choose where, how and with whom they give birth. Yet certain legislative and other regulatory moves have called that abstract right into question. In Dubska v Czech Republic, the European Court of Human Rights found that the Czech government was not obliged to regulate midwives to enable them to attend women at home births, despite the significant negative impact this may have on the safety and wellbeing of childbearing women. Five of the judges dissented, arguing that the Czech system effectively forces women to give birth in hospital and could not be justified by any public health argument. According to the UK-based Birthrights organisation: “For women in eastern Europe this will create a significant bend in the road that activists, mothers and health care professionals will need to navigate with clarity and purpose to minimise the damage.” Meanwhile in the UK, independent midwives' indemnity coverage was withdrawn in January 2017 in a decision by the Nursing and Midwifery Council (NMC) that prevents many independent midwives from caring for women in labour. The decision has resulted in the regulator instructing pregnant women to make immediate alternative arrangements for their birth care. Birthrights is actively challenging this decision, given its negative impact on women's birthing choices. Finally, a worrying study released in January 2017, and conducted by the National Childbirth Trust and the National Federation of Women's Institutes (NFWI), found that 50 per cent of new mothers had experienced “red flag” events during labour. These include women in labour being left without a midwife, waiting more than half an hour for pain relief, or more than an hour to be washed or receive stitches after labour. Women described “humiliating and degrading” experiences, being left to feel like they were on a “conveyor belt” and feeling like “cattle.” These findings suggest there is a chronic midwife shortage, with estimates that 3,500 more are needed in England alone. As I explained to attendees last night, these findings reflect my own experience of giving birth in an NHS London hospital in 2015: During labour, I waited for two hours for pain relief after I initially requested it (due to the only two anaesthetists being in emergency surgery). Recovering in the postnatal ward, I pressed the call bell once, to ask for help on my second night. I explained that I was in agony and hadn’t slept in 48 hours. The response from the head midwife: “Welcome to motherhood.” 

***

During the Q&A, a number of interesting issues were raised: What kind of language is necessary and productive to use when challenging these injustices? Direct, blunt and radical language or less confrontational, perhaps watered-down terms? Does context matter when deciding what language and which arguments to use? Could better sex education reduce abortion? 

This final question led to a particularly animated conversation. My co-panelists pointed out that sex education could entail an abstinence-based approach that has proven to be unsuccessful at preventing both sex and pregnancy. More broadly, the content of education and the provider of said education could skew how effective it could be at preventing pregnancy. I agree, but would add that there is also the issue of contraceptive failure: Since no method of contraception is 100% effective, unplanned pregnancy is inevitable. In addition, unforeseen pregnancy occurrences, such as the discovery of a foetal anomaly or the woman developing a medical condition as a result of pregnancy, often arise that necessitate terminations. All of this undermines the idea that 'education' could prevent pregnancy or eliminate the need for abortion. It's also worth noting vis the UK Secretary of State for Education's recent decision to make offering sex education in schools compulsory that (a) parents remain entitled to remove their children from these classes, so children do not have a right to receive sex education, and (b) faith schools (of which there are many) are allowed to teach the subject in accordance with their beliefs, meaning that certain pertinent or even essential information may be absent or misrepresented. Evidently, 'education' is not a silver bullet in relation to a range of reproductive injustices.