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USA: Rites and wrongs: Is outlawing female genital mutilation enough to stop it from happening here?

 

Nawal Nour, a Sudanese-American doctor who runs the African Women's Health Center at Brigham & Women's Hospital, which tracks the practice of FGM in the United States. (Globe Staff Photo / Wendy Maeda)

By Rebecca Tuhus-Dubrow  |  February 11, 2007

Last November, Khalid Adem, an Ethiopian immigrant living in Atlanta, received a 10-year prison sentence for cutting off the clitoris of his 2-year-old daughter. (He pleaded innocent, accusing the girl's mother, his ex-wife, of orchestrating the cutting.) The case, hailed as the first conviction for female genital mutilation (FGM) in the United States, has renewed attention to the practice a decade after federal legislation was passed to ban it.

FGM -- also known as female circumcision and female genital cutting -- refers to several rituals, common in parts of Africa and, to a lesser extent, Asia and the Middle East. In practicing societies, circumcision is seen variously as a religious obligation, a rite of passage, a hygienic measure, a means of controlling sexuality, and a prerequisite for marriageability.

Former Democratic congresswoman Pat Schroeder, a longtime champion of women's rights, sponsored the bill to outlaw FGM. Having opposed the custom for years, she was spurred to act by rising rates of African immigration to the United States. She recalls that her bill, first introduced in 1993, initially met with resistance. Some members of Congress were skeptical that FGM was occurring here. Other members argued that "you can't be a cultural Nazi and tell people they can't bring their culture here," according to Schroeder. Still others feared the law could be construed to apply to male circumcision.

Ultimately, however, the bill passed as part of President Clinton's 1996 immigration legislation. In addition to the law criminalizing FGM, other legislative measures were passed mandating data collection and education. And since 1994, 17 states, most recently Georgia, have passed their own relevant statutes.

The argument for the laws is obvious: They are meant to deter a practice abhorred by Westerners and indeed by some members of practicing communities. The forms of FGM range from excision of the clitoral hood (a fold of skin analogous to the male foreskin) to a procedure called infibulation, in which the entire external genitalia are removed, and the vagina is stitched almost completely closed. At the time it is performed, FGM often causes severe pain and bleeding, and, occasionally, death. Long-term consequences can include chronic pain and infections, inability to experience sexual pleasure, and psychological trauma.

Nawal Nour, a Sudanese-American doctor who runs the African Women's Health Center at Brigham and Women's Hospital, said recently, "There are certain families who feel incredibly relieved that the law exists, because they can say, 'We can't circumcise our daughter -- it's against the law.'"

But other families aren't as willing to give up this millennia-old tradition. In journal articles at the time of the federal law's passage, health professionals and legal scholars worried that criminalization could drive the practice further underground, discourage girls and women with FGM from seeking healthcare, and tear families apart if parents were jailed.

This last fear has not generally materialized; with the exception of the recent Georgia case, no immigrants have been incarcerated. Whether the other fears are warranted is harder to establish. But to whatever extent FGM has taken root in the United States, some experts are asking whether prosecutions like the one in Georgia, which may be viewed as discriminatory and alienating to the immigrant communities in question, are really the best way to end the practice.

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As part of the federal law, the Centers for Disease Control and Prevention attempted to gauge the prevalence of FGM in the United States. Based on some simple math -- the number of immigrants from practicing countries in the 1990 Census, and the prevalence in those countries -- it estimated that 168,000 women and girls in the United States had undergone FGM or were at risk. Recently, Nour's center updated this calculation based on the 2000 Census, arriving at the number 228,000.

But these studies have a crucial limitation: They don't address whether immigrants are practicing the custom here. Some experts who work in the communities, including Nour and the staff at Sauti Yetu Center for African Women in New York, say they have not seen evidence of a flourishing underground practice. They do believe, however, that some immigrants might send their daughters back to their native countries for the procedure.

The dearth of FGM cases may seem to confirm the practice's rarity in the United States -- but such logic could be misleading. "The fact that there are so few cases reveals the challenges of enforcing these types of laws," says Laura Katzive, deputy director of the International Legal Program at the Center for Reproductive Rights. "Children are not seeking to speak out against their parents."

The Adem case in Georgia was anomalous in that the mother brought the mutilation to the attention of the authorities. According to Taina Bien-Aime, executive director of Equality Now, an organization that works on the issue, "In the great majority of cases, the mother would support it," making the law more difficult to enforce.

A few Western countries have not only outlawed FGM but also actively stepped up enforcement. In Sweden, for example, some girls have undergone genital examinations -- in a few cases forcibly, by the police, but more often by social workers with the consent of parents. Ayaan Hirsi Ali, the former Dutch parliamentarian, has advocated compulsory annual examinations of girls from high-risk countries.

In the United States, however, even anti-FGM activists are reluctant to call for similar measures. In part, that's because FGM is at once a matter of women's rights and of cultural self-determination -- many who are disturbed by the practice are also troubled by the idea of passing judgment on another culture's customs.

In place of aggressive enforcement, authorities on FGM stress the indispensability of outreach. They emphasize that in many instances, combating the custom is a long-term process of persuasion that must be conducted within communities, not by outsiders. "In a context where there's only a punitive approach and no accompanying outreach, it's at best ineffective and at worst harmful," says Katzive.

Outreach was mandated by the federal FGM law, and in 1996, the Department of Health and Human Services held a series of workshops in cities throughout the country, in collaboration with community representatives. The workshops provided information about the legal, physical, and psychological consequences of FGM. These events generated a positive response, but funding was limited to that single round.

"If we really want to make sure that [FGM] is past history, we need to fund community-based initiatives," says Asmaa Donahue, program officer at Sauti Yetu. "And right now, there is no money for it."

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Schroeder expresses confidence in her law's efficacy. "I think it's been a very strong statement," she says. "If you want to live here -- we don't do this."

Making that statement is arguably the central function of the laws. As Duke law professor Doriane Coleman points out, "There are physical and sex abuse laws that amply cover" FGM. Customized laws are "an educational device," says Coleman. "It ought to send a message that this is impermissible behavior." Such laws also preemptively close potential loopholes by stating that beliefs and tradition are no excuse.

But these expressly tailored laws have a downside: They can be perceived as discriminatory for targeting particular communities. Indeed, some analysts point out, other kinds of genital alteration are common in the United States.

In Seattle in 1996, Somali mothers giving birth at the Harborview Medical Center requested that their daughters be circumcised as well as their sons. The hospital devised a compromise: the girls would be "nicked" on the clitoral hood, in a symbolic gesture meant to deter the families from performing the traditional practice. The plan, which the immigrants supported, was to perform the procedure under local anesthetic when the girls were old enough to give informed consent.

When news of the proposal broke, outrage from the anti-FGM community, including Schroeder, forced the hospital to back down from its compromise. As Coleman has asserted in an article in the Duke Law Journal, the proposed procedure was less severe than circumcision of boys. She argues that under the Equal Protection Clause, hospitals must either perform such a procedure on girls, if requested, or stop circumcising boys.

In fact, some opponents of male circumcision draw parallels to the female kind, describing it as nonconsensual removal of healthy tissue that diminishes sexual pleasure. Still, male circumcision is widely acknowledged to be less damaging than the most common forms of FGM, and recent studies confirm its health benefits.

A more obscure procedure performed in America involves cosmetic surgery on children born with ambiguous genitalia. "Intersex" activists liken these operations to FGM, condemning them as physically and psychologically harmful.

Scrutinizing these accepted cultural practices might help Americans understand the perspective of immigrants who balk at relinquishing their own. "Cultural change is not something that happens overnight," says Layla Guled, who immigrated from Somalia in 1995 and works as an interpreter for Nour. She has discussed the FGM law with patients at the African Women's Health Center. "They felt like it's not right, and I don't blame them." The custom is "something they've known all their lives. Sometimes they say, 'Layla, I'm so worried. Who's gonna marry my daughter?'"

Nonetheless, she says, "I support the law 100 percent. This happened to me, and I don't want it to happen to anyone else."

Rebecca Tuhus-Dubrow is a journalist based in Brooklyn. 

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