Consent and cultural conflicts: Ethical issues in pediatric anesthesiologists’ participation in female genital cutting

The Case A healthy 5-year-old female patient is scheduled for “surgical correction of clitoral phimosis.” The patient's Somali parents explain their custom of “circumcising” girls; a surgeon has agreed to perform the procedure. The anesthesiologist doubts the medical indications for the procedure. The parents assert the need to circumcise their daughter so she will be accepted in their community. They tell the anesthesiologist that if they cannot find a US physician to perform the procedure, they will go to Somalia where a village elder will do it, without benefit of anesthesia or aseptic conditions. Female genital cutting (FGC) refers to procedures involving partial or total removal of external genitalia or other alteration of female genitals for nonmedical reasons. The World Health Organization (WHO) defines four types of FGC. Type I (clitoridectomy) involves partial or total removal of the clitoris and/or the prepuce. Type II (excision) involves partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type III (infibulation) involves cutting and appositioning the labia minora and/or the labia majora to create a covering seal narrowing the vaginal orifice. Infibulation may or may not involve excision of the clitoris. Type IV involves all other procedures to the female genitalia for nonmedical purposes, including pricking, piercing, incising, scraping, or cauterization. Despite this categorization, significant overlap and ambiguity exist in the practice within and between the cultures that practice it.