We are proud to introduce this special collection of papers on child genital alteration practices spanning the Global North and South and transcending conventional boundaries of sex and gender. It is increasingly recognized that there is an urgent need to evaluate all forms of genital cutting or surgery, especially those carried out on presumptively pre-autonomous persons, in a systematic way [1,2,3,4,5,6,7]. It is necessary both to clarify what is known about these practices medically and scientifically, but also to work through the cultural, legal, and ethical implications of performing such significant operations on persons who are generally presumed to be incapable of providing morally valid consent to them on their own behalf.
This edited collection includes nuanced discussions of female, male, and intersex forms of genital cutting or surgery performed on young people in countries and cultures around the world. Although the focus is on genital operations that are widely argued to be both medically unnecessary and non-consensual, an important lesson that emerges from this collection, as discussed below, is that both the concept of medical necessity and the criteria for giving ethically valid consent to certain body modifications are not a matter of universal consensus. Rather, they are politicized, moralized, and contested . This is nowhere more apparent than in the case of permanent alterations to the sexual or reproductive anatomy of legal minors. When are young people capable of consenting to genital modifications of various kinds, and when should they be protected from choices to modify their sexual anatomy that they may later come to regret?
Similar questions apply to parents or guardians. Should they be allowed to provide “proxy” consent for genital modifications they believe or judge to be in the child’s overall best interests—that is, not only their physical best interests, but also their mental, social, and perhaps even spiritual best interests [9,10,11]? What if the child is too young to meaningfully participate in the decision? Alternatively, should there be categorical restrictions on genital modifications that are not necessary for the child’s physical health until they are mature enough to give their own consent [12,13,14,15]? Or does the answer depend on (inevitably disputable, value-laden) [16, 17] judgments about the expected level of net benefit or harm in each particular case?
Most scholarly projects on this topic concentrate on practices affecting children of one sex or gender (typically female) in “non-Western” (typically African) cultures, thereby reinforcing the common Anglo-European assumption that what “others” do is uniquely problematic and therefore in need of special investigation [18,19,20,21,22,23,24]. This collection, by contrast, critically evaluates practices affecting children of all sex characteristics and gendered embodiments, without exempting from scrutiny the customs of Western cultures or powerful nations such as the United States [25,26,27,28,29,30].
Thus, in addition to boundary-pushing work on ritual or religious cutting of girls’ vulvas (most common in parts of Africa, South and Southeast Asia, and the Middle East, where it is done in conjunction with ritual circumcision of boys in nearly all practicing communities) [31,32,33,34], this collection features critiques of anatomically comparable [35,36,37] vulvar modifications that are more closely associated with Western culture and which are described in that context as being “cosmetic” in nature [38,39,40,41]. These include such modifications as clitoral “unhooding” or other forms of reshaping, vaginal “rejuvenation” procedures, and the more familiar labiaplasty—the last of which is increasingly performed on adolescent girls in parts of Europe, Australasia, and the Americas [42, 43].
The issue also covers surgical operations carried out in similar contexts on infants who are judged to have intersex traits (whether designated female or male) [44,45,46,47], as well as medicalized penile alterations including non-therapeutic infant circumcision and surgery for hypospadias [48,49,50]. The collection is highly interdisciplinary with academics and practitioners from diverse fields contributing their expertise: medicine, law, philosophy, bioethics, anthropology, sociology, psychology, gender and sexuality studies, and history are all represented.
The collection will be published over two consecutive issues of the journal. This editorial is an introduction to the first part, which begins by examining tensions and contradictions surrounding current ethicolegal treatment of diverse forms of genital cutting or surgery [4, 9, 13, 14, 51]. In particular, authors question why different standards of protection are applied to equally non-consenting children based, in practice, on their sex-typed anatomy. In many countries, it is a criminal offense to engage in medically unnecessary genital cutting or surgery on a minor, no matter how superficial or severe the intended modification and irrespective of motivation, only if the child is categorized as female at birth and has no apparent intersex traits.
Such interventions into female-normative genitalia are illegal even if the child’s parents request a relatively minor procedure to be undertaken by a skilled practitioner for religious reasons, such as the so-called “ritual nick” that is customary in some Muslim communities (e.g., the Dawoodi Bohra) [52,53,54,55]. Following the World Health Organization (WHO), such cutting or nicking is defined in Western law as an instance of “female genital mutilation” (FGM Type 4 on the WHO classification) independently of any measurable outcomes for health or sexuality, whether on average or at the extremes .
In most of the same countries, however, it is not a criminal offense to engage in equally or more substantial modifications of the healthy genitalia of an otherwise identical child if she is deemed to have certain intersex traits: for example, a larger-than-average clitoris that is perceived to be insufficiently “feminine” according to dominant gender norms [6, 57,58,59]. Likewise, is it not illegal to engage in genital cutting or surgery on physically healthy children categorized as male at birth, whether or not they are regarded as having an intersex trait or (other) sex feature variation [60,61,62].
After exploring the legal, ethical, anthropological, and historical dimensions of this wider controversy, the journal issue transitions to a focus on intersex operations specifically (i.e., surgeries to “normalize” the bodies of persons with genitalia regarded as anatomically non-normative for members of their assigned sex, due to a difference of sex development). Advances in genetics, diagnosis, surgery , terminology, parental and public attitudes [64, 65], patient advocacy, and human rights reforms  are all explored, with a particularly detailed discussion of recent changes in law, focused on the case of Germany .
The second part of the collection will be accompanied by a separate editorial and will focus on “endosex” operations, that is, genital cutting or surgery on persons who are not considered to have intersex traits . As we shall see, even healthy genital features that are deemed anatomically typical for a child’s sex, whether female or male, may nevertheless be considered by parents, family, or community members to be socioculturally or aesthetically unacceptable for the child’s assumed/anticipated gender (i.e., identity or role). In such cases, non-intersex children may likewise be subjected to socially driven—e.g., gender-conforming—genital cutting rituals or surgical modification . The implications of this are debated by several authors.
A word about the scope of the collection. Although we have adopted a broad division between intersex (Part 1) and endosex (Part 2) procedures in allocating articles to separate issues, both parts include papers that examine, or at least touch on, practices that are more centrally discussed in the other part. Indeed, a major goal of this project is to question dominant sex- or gender-based categories that may artificially obscure important commonalities among the various forms of genital cutting or surgery to which children are subjected on a cross-cultural basis . To our knowledge, this is the first collection of papers to offer in-depth, comparative analysis of such interventions on both intersex and endosex minors, in such a way as to encompass the most common practices involving infants and children of all gender assignments and sex characteristics.
What about genital surgeries for transgender persons? In the current political climate, any mention of gender and genital modification is bound to raise this association . Although such surgeries are briefly discussed in some of the commissioned pieces or associated commentaries, they are not a major focus of this collection for three main reasons. First, such surgeries are rare in the population of interest, namely minors, especially younger minors,Footnote 1 with at least some prominent gender medicine clinics categorically refusing to perform them on persons under the age of 18 . To that extent, they fall outside the scope of our remit. Indeed, our collection was conceived as an exploration of relatively common practices affecting mostly pre-pubertal or peri-pubertal children—often, but not always, the majority of such children who have the relevant sex characteristics in a given culture or subculture (e.g., ritual female genital cutting; penile circumcision; surgery for pronounced hypospadias).
Second, in the exceptional cases in which gender identity-related genital surgeries are performed in trans minors (i.e., between the ages of 15 and 18), the minor in question must meet strict eligibility criteria, including having lived for “several years” with persistent gender dysphoria . They must also show a firm understanding of what is at stake in the intervention, including long-term implications; and they must demonstrate sufficient cognitive and emotional maturity to provide their own informed consent or assent (i.e., affirmative agreement in conjunction with parent or guardian permission) .
The conditions under which a young person can realistically meet these conditions is a matter of considerable debate, especially given the gaps and limitations in existing evidence regarding long-term outcomes, as these bear on the ability to be adequately informed [77,78,79,80,81,82]. Nevertheless, with a few key exceptions (e.g., teenage labiaplasties and adult clitoral reconstruction surgeries following childhood genital cutting, both addressed in Part 2), our collection is focused on genital modifications that are not actively requested by the affected individual. Instead, they are, by most accounts, either relatively non-voluntary (e.g., genital cutting as an adolescent rite of passage where non-participation is highly stigmatized) [83, 84] or completely non-voluntary (e.g., infant intersex surgeries).
Finally, if and when genital surgeries are performed in trans minors as described above, the surgeries will, as a matter of fact, have been deemed medically necessary by their healthcare team: i.e., as a means of alleviating otherwise unresolvable dysphoria [85, 86]. This, too, is a matter of controversy, as there is no consensus about what makes a surgery medically necessary in the first place. So, it may be helpful to reflect on a paradigmatical example of a medically necessary surgery to get a sense of the normative force or pragmatic purpose of the underlying concept in typical contexts.
Consider an open-heart surgery to save the life of a person who has fallen unconscious in the emergency room and so cannot provide their own consent. Unless the person has a verifiable “do not resuscitate” order—reflecting their autonomous preferences for how they would like to be treated in such a circumstance—it is clearly permissible, and in fact obligatory, to perform the surgery even without their consent. Now consider a surgery that is paradigmatically not medically necessary, say, a rhinoplasty for purely cosmetic purposes (i.e., to conform to a subjective, culturally or individually variable aesthetic norm or preference). Under no circumstances would it be permissible to perform such a surgery without the fully informed, active consent of the affected individual. What distinguishes these two examples?
According to one view , medically necessary surgeries are the ones that are instrumentally required to avoid a serious harm to well-being, where (a) there are no other comparably effective but less risky options available, and (b) the harm in question—for example, dying prematurely due to heart failure—is universally or almost-universally recognized as a major setback to a person’s long-term interests (i.e., it is not a matter of subjective opinion; its status as a serious harm does not depend, for example, on norms or standards that tend to vary between cultures or individuals depending on their beliefs or values) .
Plausibly, that is a significant part of why such surgeries are widely agreed to be acceptable even in the case of persons who cannot currently consent to them due to insufficient decision-making capacity. In short, it can safely and justifiably be assumed that the person would consent to the surgery (i.e., at the proposed time and under the given circumstances) if they were sufficiently autonomous to do so .
Medically unnecessary surgeries, by contrast, might be characterized as falling short of either (a) or (b), such that the same proposition cannot be (as) safely or justifiably assumed. Of course, even accepting this distinction, it may be a matter of disagreement where any particular surgery falls on the spectrum from clearly medically necessary to clearly medically unnecessary. According to the view under consideration, however, the more disagreement or uncertainty there is about this fact (i.e., whether a surgery is indeed medically necessary in the above sense), the more important it is to allow the affected individual to decide for themselves whether to undergo the surgery in question when they (re)gain the capacity to do so autonomously. In that way, the thinking goes, they can decide on the basis of their own informed beliefs, preferences, values, and sense of acceptable trade-offs, given the specifics of their known—rather than merely predicted, future—circumstances and any available treatment alternatives, including non-surgical options .
How does this reasoning apply to minors? As one ethicist has stated: “Children are generally unable to provide autonomous, independent informed consent for medical treatments. This long-standing tenet of pediatric care protects children who often do not possess fully developed cognitive decision-making capacity by preventing rash, permanent, and potentially regrettable medical decisions. As pediatric patients become adolescents and approach adulthood, their involvement in medical decision-making often increases to take into account their values and preferences. But until a youth reaches the age of majority, the medical decision-making process generally includes permission from parents or guardians and informed assent from the patient to the degree appropriate” [88, p. S23].
Going forward, we expect that debates in this area will center on questions about the kind or degree of maturity, self-knowledge, understanding, and so on, required for a minor’s active agreement or assent to genital modification to count as an ethically valid basis for proceeding, assuming that there is (also) parent or guardian permission. Some might be tempted to give a categorical answer in the negative (i.e., no minor can validly assent to a permanent modification of their sexual or reproductive anatomy that is not necessary to save their life or avoid long-term physical impairment) , whereas others are likely to argue that the decision must be made on a case-by-case basis, taking into account the physical and mental healthcare needs of each individual as well as specific information and evidence regarding the procedure being proposed .
We cannot settle such debates with a brief editorial. Instead, we invite interested parties to read and reflect carefully on the papers collected in this issue (Part 1) as well as in the second issue (Part 2) and strive to reach their own conclusions, taking into consideration the complex stakes involved and the diverse viewpoints offered.
Phalloplasty, for example, is almost never performed on minors. In its current guidelines, the World Professional Association for Transgender Health (WPATH) recommends against considering the procedure prior to adulthood: “Given the complexity of phalloplasty, and current high rates of complications in comparison to other gender-affirming surgical treatments, it is not recommended this surgery be considered in youth under 18 at this time” [72, p.S66]. Vaginoplasty, though still uncommon before age 18, is less rare and is increasingly performed in older adolescents. According to a 2017 survey of 20 WPATH-affiliated surgeons based in the United States, more than half reported that they had performed vaginoplasty in legal minors (contrary to WPATH guidance at the time), with 1–20 cases per surgeon and an age range of 15 to 17 years for the affected individuals . The survey authors state that the specialist surgeons who perform vaginoplasty on transgender minors “have, without exception, refrained from publishing any peer-reviewed outcome data or technical articles on this small but increasingly important population” [73, p. 225]. Thus, the available data on physical and mental health outcomes for minors who have undergone vaginoplasty “are limited” [72, p. S66]. It has also been reported that “masculinizing” mastectomies are increasingly performed in younger populations, including adolescents , to relieve significant dysphoria associated with pubertal breast growth . As our edited collection concerns specifically genital cutting or surgery, which has a different risk profile and raises distinct ethical questions, it does not cover modifications of secondary sex characteristics.
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Earp, B.D., Abdulcadir, J. & Liao, LM. Child genital cutting and surgery across cultures, sex, and gender. Part 1: female, male, intersex—and trans? The difficulty of drawing distinctions. Int J Impot Res (2022). https://doi.org/10.1038/s41443-022-00639-4