Friday, February 28, 2014

Are American doctors still performing clitoridectomies (FGM) on girls?

The website "Atlas of Pelvic Surgery" has an article on "excision of the hypertrophied clitoris". I first thought it was a historic note about how clitoridectomies used to be performed 60 years ago, but no, what I found was that the"Atlas of Pelvic Surgery was originally developed as a practical guide to the performance of gynecologic procedures which reflected Dr. Wheeless' broad experience in surgery and his skill as a teacher."

The "Atlas of Pelvic Surgery" started as a book published by Dr. Wheeless, with its third edition printed in 1997 (coincidentally the year that the federal law against FGM was enacted in the United States). The website itself constitutes the 4th edition of the Atlas. In fact the index of recent updates includes the article on excision of the hypertrophied clitoris, so this article must be relatively recent (but no date is given)

Graphic taken from the Atlas of Pelvic Surgery website

I was in shock. Yes I know that the treatment for intersex girls with enlarged clitoris used to be the removal of the clitoris... long time ago! Today, they use "nerve sparing surgeries" to reduce but not to remove the clitoris (clitoroplasty), and yet this procedure when performed on a minor constitutes a violation of a child's physical integrity (according to the PACE), may damage orgasmic function, and is rejected by the intersex community as a violation of human rights.

But... clitoridectomy (excision of the clitoris)... TODAY?

Excised hypertrophied clitoris... from a 1925 book

The website is the work of Clifford R. Wheeless, Jr., MD, and Marcella L. Roenneburg, MD. both of them servicing Baltimore, Maryland, Dr. Wheeless here, and Dr. Roenneburg here.

I verified the ownership of the website. The domain is registered to Dr. Roenneburg.

According to Jewish Woman International, Dr. Roenneburg is a Jewish woman providing service to African women.

These are the indications and purpose of the excision of the hypertrophied clitoris described in the Atlas of Pelvic Surgery (I underlined key words):

Clitoral hypertrophy, regardless of etiology, is a source of psychological stress, especially in young females. Most pediatric gynecologists stress the importance of normal external genitalia in young children. It is important to weigh the role of the clitoris in sexual climax against the psychological stress incurred when the genitalia of a young child are different from her peers.
The purpose of the operation is to excise the hypertrophied clitoris and create normal-appearing external genitalia.

Female patient before and after clitoroplasty (not full excision - but nevertheless removal of a large portion of the clitoris). While the authors of this 2006 article considered the "cosmetic results" good, some loss of sensation and sexual damage is inevitable when altering the clitoris.

I decided to review the U.S. federal law against FGM:

(a) Except as provided in subsection (b), whoever knowingly circumcises, excises, or infibulates the whole or any part of the labia majora or labia minora or clitoris of another person who has not attained the age of 18 years shall be fined under this title or imprisoned not more than 5 years, or both. 
(b) A surgical operation is not a violation of this section if the operation is— 
(1) necessary to the health of the person on whom it is performed, and is performed by a person licensed in the place of its performance as a medical practitioner; or 
(2) performed on a person in labor or who has just given birth and is performed for medical purposes connected with that labor or birth by a person licensed in the place it is performed as a medical practitioner, midwife, or person in training to become such a practitioner or midwife.
Notice that the FGM law provides an exception when it is "necessary to the health of the person". However the excision of hypertrophic clitoris is not medically necessary. It is only done to "normalize" the aspect of the genitalia, adducing "psychological stress" of the child - but in reality this refers to the "psychological stress" of parents who perceive their daughter as abnormal.

I also checked if Maryland has a law against FGM, and found that the punishment for FGM includes "imprisonment for up to five years and/or a fine of up to $5,000".

According to the World Health Organization, there are four types of female genital mutilation, the first one being:

  • Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).
 The recent resolution of the Parliamentary Assembly of the Council of Europe names several procedures that violate the physical integrity of children, among them Female Genital Mutilation and early childhood interventions of intersex children. The procedure described by the Atlas of Pelvic surgery is both, a childhood intervention of intersex children and female genital mutilation.

Given that the Atlas of Pelvic Surgery "reflect[s] Dr. Wheeless' broad experience in surgery", we have to ask: has Dr. Wheeles performed the excision of hypertrophied clitoris? Has he performed this surgery after 1997?

Since the site also reflects "his skill as a teacher", does he teach how to perform this procedure? (the existence of this article on the website would be evidence for this).

Given that Dr. Roenneburg provides service to African women, has she performed this procedure on daughters of African women? On those from countries and cultures where FGM is prevalent?

According to Jewish Women International, Dr. Roenneburg has operated "on scores of women with these devastating childbearing-related wounds, called vesicovaginal fistulas—holes between the bladder and the vagina" in Niger. It should be safe to assume that she is aware that these vesicovaginal fistulas are sometimes consequence of female genital mutilation, and that FGM is prevalent in Niger (one of the forms of FGM prevalent in Niger is clitoridectomy). So why does a website registered under her name and which includes her bio, and which is meant to be used as a learning resource, explains how to perform clitoridectomies? 

Is FGM at the hands of American surgeons any less of a crime?

Are there American girls and women of any ethnia living their lives without their clitoris, having had it removed at the hands of Dr. Wheeles, Dr. Roenneburg, or the students of Dr. Wheeles or readers of his book or their website?

Related: How parents 'consenting' to intersex genital mutilations (IGM) do so because of biased information given by doctors

Related: Clitoris Amputations & Intersex Genital Mutilation (see PDF files)

Testimonials of American women subjected to clitoridectomy as a way to prevent masturbation, by American doctors, at parents request, during the 20th century.

Please listen to their testimonies. They were traumatized by doctors. Is it fair to perform this procedure on any girl? Even if she has a "hypertrophic" (which simply means "large") clitoris?

To put it in perspective, would you treat a boy with a "large penis" by having the penis removed?


Related: Hida Viloria, intersex activist, on Montel Williams. Hida Viloria was born with what these doctors would consider a "hypertrophied clitoris", but her dad, a Colombian doctor, had the awareness to decline surgery.

Circleaks is willing to listen to Dr. Wheeless and Dr. Roenneburg. We wish they can provide a sworn statement that they have not performed this procedure, and can justify a reason why this procedure should be even included on a teaching website -or proceed to advise AGAINST this procedure on their website, and if they do so, we will make their voice public.  Otherwise, it is our duty to expose to the American public our suspicion that these doctors may have performed this procedure or taught others (either in person, through Dr. Wheeless book or through the website) how to perform it, thus possibly prolonging  the history of forced clitoridectomy (female genital mutilation) in the United States into the 21st century.

And yes we are aware that the article is about excision of the "hypertrophied" clitoris - in other words, a large clitoris that resembles a small penis. It remains true that the clitoris is an integral part of female sexuality, and whether it is small or large, its removal has devastating lifetime consequences for the individual. No parent - and no doctor- should ever make this decision for any girl.

Related: Upcoming book about female circumcision and clitoridectomy in the United States

Resources on the Victorian Era clitoridectomy in UK and US

Isaac Baker Brown and his "harmless operative procedure"

Isaac Baker Brown and the clitoridectomy operation

According to this article on FGM Network, a 1894 doctor was one of the last doctors to perform clitoridectomies. We know this is not the case, with the two video testimonials having had their operation during the middle of the 20th century, and with intersex clitoridectomies occurring up to the 70s... or until now?

 The sexual politics of female circumcision - mostly about FGM in Africa, it includes a first person account of a victim of African clitoridectomy and also some information about the origin and motivation of clitoridectomies in the US and UK.

An obsolete residual of the Victorian era, much like routine infant circumcision:
In females, the author has found the application of pure carbolic acid (phenol) to the clitoris an excellent means of allaying the abnormal excitement. John Harvey Kellogg, Plain Facts for Old and Young, 1888 
Cool sitz baths; the cool enema; a spare diet; the application of blisters and other irritants to the sensitive parts of the sexual organs, the removal of the clitoris and nymphae... John Harvey Kellogg, Ladies' guide in health and disease, 1893

More on Dr. Wheeless and Dr. Roenneburg's background:

Dr. Wheeless is certified by the American Board of Obstetrics and Gynecology, is a fellow of the American College of Obstetrics and Gynecology, the American College of Surgeons and the Southern Surgical Association. He received his degree from the University of North Carolina and has been a member of The Johns Hopkins Medical Institution. He was a Professor of Gynecology and Obstetrics at Emory University and at Sinai Hospital, and later at the Hopkins School of Medicine.

Dr. Roennesburg received her medical degree from the Medical College of Wisconsin and completed her internship and residency at Union Memorial Hospital in Baltimore, under the direction of Dr. Wheeless. She received a Distinguished Alumni Award for Community Service by the University of Winsconsin.

Additional Exhibits

Types of Female Genital Mutilation per the World Health Organization. Notice that type I is shown removing not only the external portion of the clitoris, but also the clitoral hood (the prepuce, the equivalent of the male foreskin)

Lawson, Wilkins et al, removal of hypertrophic clitoris. Published in 1958 and again in 1971, pretty much the same procedure explained by Dr. Wheeless and Dr. Roenneburg.

"Nerve sparing" clitoroplasty, still a mutilating surgery which intends to spare the nerve bundle. Adult patients who had this procedure during childhood still report pain and sexual dysfunction. 

Image source: Article by John M. Hutson at Pediatric Urology Book. Text added by an activist opposing these kinds of surgeries.

Related topic: Dr. Dix Poppas caused strong commotion in 2010 when people learned that he was following up on "nerve sparing clitoroplasties" by testing sensitivity with a q-tip and a vibrating device... on minor patients. This scandal allowed many people to learn about clitoromegaly ("hypertrophied" clitoris) and congenital adrenal hyperplasia. However, as far as we know, nobody has apologized for reducing the clitoris of these girls.

From Hasting Reports, Bad Vibrations

From Secular Parent, The not so good touches of Dr. Dix Poppas

Dr. Dix Poppas, Description of technique

OII Intersex network: A conspiracy of deceit

In "Aesthetic surgery of the Female Genitalia" (2011), Dobbeleir et al indicate that four ethical principles mark the difference with genital cutting practices. The first principle is "Autonomy of the patient" (Patients should be over 18 years old, psychologically stable, and fully informed on the risks and expected results, so that the decision in full knowledge of the issue is theirs only. An informed consent should always be obtained). The text indicates that if any of the preconditions are not fulfilled, aesthetic genital surgery should not take place.

Clitoral surgery on "young girls" does not fulfill this requirement, thus making it Female Genital Mutilation.

The World Health Organization

While far from condemning intersex genital surgeries, the World Health Organization casts such surgeries in negative light (underlined by us):

Many intersex children have undergone medical intervention for health reasons as well as for sociological and ideological reasons. An important consideration with respect to sex assignment is the ethics of surgically altering the genitalia of intersex children to “normalize” them.

Clitoral surgery for intersex conditions was promoted by Hugh Hampton Young in the United States in the late 1930s. Subsequently, a standardized intersex management strategy was developed by psychologists at Johns Hopkins University (USA) based on the idea that infants are gender neutral at birth. (38) Minto et al. note that “the theory of psychosexual neutrality at birth has now been replaced by a model of complex interaction between prenatal and postnatal factors that lead to the development of gender and, later, sexual identity”. (39) However, currently in the United States and many Western European countries, the most likely clinical recommendation to the parents of intersex infants is to raise them as females, often involving surgery to feminize the appearance of the genitalia. (40)

Minto et al. conducted a study aiming to assess the effects of feminizing intersex surgery on adult sexual function in individuals with ambiguous genitalia. As part of this study, they noted a number of ethical issues in relation to this surgery, including that:

  • there is no evidence that feminizing genital surgery leads to improved psychosocial outcomes;
  • feminizing genital surgery cannot guarantee that adult gender identity will develop as female; and that
  • adult sexual function might be altered by removal of clitoral or phallic tissue. (41)

World Health Organization - Gender and Genetics 

The mentioned idea that infants are gender neutral at birth comes from John Money and Johns Hopkins University, who first tested this on David Reimer, when, as a baby (born Bruce, 1965), lost his penis as the result of a botched circumcision. John Money oversaw his raising as a female (Brenda) including follow ups. David's later testimony tells of John Money forcing him and his twin brother Brian to "play sex" with the hope that "Brenda" would accept the passive role. According to David, Money photographed these sessions; David was however unable to obtain copy of the records, which were donated to the Kinsey Institute to remain sealed in perpetuity. During adolescence, the test was deemed a failure, and "Brenda" took a new male identity, David, undergoing breast removal and penile reconstruction. For many years, Money continued presenting the "John/Joan" case (fictitious names) as a success until David went public in 1997. David committed suicide in 2004, at the age of 38.

Many medical institutions still cite the work of John Money when dealing with intersex patients and genital surgeries.

I find it ironic that when dealing with medical excision of clitoral tissue, the WHO says that "adult sexual function might be altered", but when described in the context of female genital mutilation, it "interferes with the natural functions of girls' and women's bodies".

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