There are many ways to abuse a child – emotional, physical, sexual. But female genital mutilation is a unique form of abuse in this respect; it is always, supposedly, carried out in the child's best interests.
That is the critical factor that makes dealing with the practice so difficult. The British Medical Association says that the number of doctors having to confront the issue with immigrant groups is growing as asylum-seekers are dispersed round the country. In guidelines issued on Monday it warned doctors that they must explain to parents that the procedure is illegal in this country and perceived as a form of child abuse: "Doctors need to make this clear to parents in a way that is not culturally insensitive."
Just how do you convey, in a way that does not cause offence, to parents who believe they are following centuries of religious and social tradition, that they may be guilty of child abuse? The World Health Organisation estimates 138 million women worldwide have undergone the procedure. Explaining that the cultural rite to which they have submitted themselves is nothing more than butchery is a very delicate task.
In Britain, up to 15,000 girls are said to be "at risk", although there are no figures for the number who have had the operation here. They are mainly refugees from Eritrea, Ethiopia, Somalia and the Yemen. Some families, encountering medical resistance in this country, send their daughters on holiday to Africa, where the procedure is then performed. Although the practice is most common among Muslims, it is also carried out among certain Christian communities in Africa.
There are three types of female genital mutilation ranging from the least invasive – removal of the tip of the clitoris and the only procedure that can be correctly called circumcision – to the most extensive, infibulation, in which all of a girl's external genitalia are removed leaving a matchstick-sized opening for urine and menstrual blood.
The principal object of the operation is to reduce a woman's sexual desire and to ensure her virginity until she is married. From the family's point of view this is essential; an eligible man would not consider marrying a woman who had not had the operation, and it also guarantees a good bride price. But to Western eyes it is an exercise in male supremacy and the oppression of women.
In Britain the practice was outlawed in 1985 after three girls bled to death following the operation. However, after 16 years no one has yet been prosecuted under the Female Circumcision Act. Last year a cross-party parliamentary inquiry called for the law to be tightened by requiring doctors to report any cases of female genital mutilation that they encounter.
In London, Harry Gordon, a consultant gynaecologist, runs a weekly clinic for African women seeking reversal of sterilisation at the Central Middlesex Hospital. He has carried out more than 100 operations but he is depressed by the attitude of most doctors to the problem, which he describes as one of "polite disinterest".
Some doctors feel awkward about interfering with the customs and traditions of a particular ethnic group lest they be regarded as racist. But failing to take proper action on humanitarian grounds for fear of an accusation of racism is itself a perverse form of racism since it amounts to a retreat based on racial considerations to the detriment of the welfare of the child.
There is a different danger, however: that the focus on genital mutilation distracts attention from the many other, often more serious, sexual and reproductive problems that plague women in the developing world. Female genital mutilation tends to arouse voyeuristic interest because it is both gory and titillating. What about the human rights of a teenager who is the third wife of a man who is the age of her grandfather, who is refused permission by him to use contraception but who nearly died during the birth of her last baby? Circumcision is the last thing she will be worried about so she is unlikely to respond to efforts to end it.
Female genital mutilation must be seen as one of the many harmful practices affecting women in traditional societies, and planning its abolition must take account of women's own perception of what affects their wellbeing.
Although the British Medical Association has set doctors a monumental task with its new guidelines, it cannot be avoided. While the position of parents who request the operation is defensible, given their cultural and social background, the position of doctors who aid them or, worse, accede to their request and carry out the operation, is not.
There are understandable reasons why parents would request a procedure that amounts to abuse of a child. They need education, counselling and advice. For doctors the position is different. They must be gentle and sensitive but firm – and they must say no.