Brussels Collaboration on Bodily Integrity. Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed?

When is it ethically permissible for clinicians to surgically intervene into the genitals of a legal minor? We distinguish between voluntary and non-voluntary procedures and focus on non- voluntary procedures, specifically in prepubescent minors (“children”). We do not address procedures in adolescence or adulthood. With respect to children categorized as female at birth who have no apparent differences of sex development (i.e., non-intersex or “endosex” females) there is a near-universal ethical consensus in the Global North. This consensus holds that clinicians may not perform any non-voluntary genital cutting or surgery, from “cosmetic” labiaplasty to medicalized ritual “pricking” of the vulva, insofar as the procedure is not strictly necessary to protect the child’s physical health. All other motivations, including possible psychosocial, cultural, subjective-aesthetic, or prophylactic benefits as judged by doctors or parents, are seen as categorically inappropriate grounds for a clinician to proceed with a non- voluntary genital procedure in this population. We argue that the main ethical reasons capable of supporting this consensus turn not on empirically contestable benefit-risk calculations, but on a fundamental concern to respect the child’s privacy, bodily integrity, developing sexual boundaries, and (future) genital autonomy. We show that these ethical reasons are sound. However, as we argue, they do not only apply to endosex female children, but rather to all children regardless of sex characteristics including those with intersex traits and endosex males. We conclude, therefore, that as a matter of justice, inclusivity, and gender equality in medical- ethical policy (we do not take a position as to criminal law), clinicians should not be permitted to perform any non-voluntary genital cutting or surgery in prepubescent minors, irrespective of the latter’s sex traits or gender assignment, unless urgently necessary to protect their physical health. By contrast, we suggest that voluntary surgeries in older individuals might, under certain conditions, permissibly be performed for a wider range of reasons, including reasons of self- identity or psychosocial well-being, in keeping with the circumstances, values, and explicit needs and preferences of the persons so concerned. Note: because our position is tied to clinicians’ widely accepted role-specific duties as medical practitioners within regulated healthcare systems, we do not consider genital procedures performed outside of a healthcare context (e.g., for religious reasons) or by persons other than licenced healthcare providers working in their professional capacity.