Harm reduction and female genital alteration: a response to the commentaries.

We thank the commentators for their thoughtful remarks. We have arranged our responses to the commentators thematically; within each section we start first with general comments before discussing particular statements by individual commentators. We also thank the Journal of Medical Ethics for publishing our original manuscript, the accompanying commentaries, an editorial from the Journal staff, and our response together in order to facilitate dialogue surrounding the multifaceted, complex issue being discussed. Our response is confined to issues involving female genital alteration (FGA). Some of the commentators discussed male circumcision. We addressed this in the original manuscript, and again in this response only in passing, given that circumcision is legal throughout the Western world. Further discussion of the ethics of male circumcision is beyond the scope of this discussion. We appreciate the areas of agreement between our position and the viewpoints of the commentators. Particularly, we wish to acknowledge Professor Macklin’s view that sanctioning de minimis FGA would constitute a harm reduction strategy that cannot reasonably be considered a human rights violation. We also recognise that Professor Shahvisi’s hypothesis of a ritual vulvar nick in a clean environment and performed by a trained provider as ethically appropriate indeed is within the scope of our category 1 procedures. Professor Shahvisi mistakenly describes this suggested proposed classification system as one based on ritual, and recommends a system that instead accounts for function. In fact, our classification system (as opposed to the current WHO system that groups various FGA procedures based on ritual) is based on functional impact upon the female. Therefore, we and Professor Shahvisi agree that, for medical, ethical and policy reasons, the classification system should be revised to focus on function, not ritual.