AMERICAN MEDICAL NEWS, Vol 39 No 40 (October 28, 1996) Published by the American Medical Association, Chicago, Illinois. `Dangerous, Deadly, Scarring' AMA efforts advance ban on female circumcision; culturally sensitive public education urged `We as humanitarians and particularly as gynecologists, cannot allow females or any group of patients to be mutilated. I'm afraid that this is even more basic than religion. This is humanitarian.' John C. Nelson, MD, AMA Trustee by Christina Kent AMNEWS STAFF WASHINGTON -- Maserak (Mimi) Ramsey remembers when two elderly women came to her home in Ethiopia to "circumcise" her at age 7. They held her down and using two new but unsterilized razor blades, sliced out her clitoris and labia majora. Thirty six years later, Ramsey, now a licensed practical nurse in San Jose, Calif., said, "I still suffer. I was incontinent for a long time. When they cut you sometimes they cut the urethra accidentally so bladder control is gone." Practiced on more than 110 million women worldwide each year, the excision of the clitoris and labia - dubbed female genital mutilation or FGM by critics - is imbedded in the culture of many African and Middle Eastern countries and in Muslim communities in Indonesia an Malaysia. FGM also occurs in the United States among the more than 100,000 people who immigrate here each year from countries in which it is practiced. The procedure is outlawed in France and Great Britain, which has documented four deaths from FGM since 1978. Now, thanks in part to lobbying by the AMA, FGM is illegal in the United States. The 1997 omnibus appropriations bull recently included a rider that: * outlaws the procedure for anyone under 18. The penalty may be fines and jail for up to five years. * directs the Immigration and Naturalization Service to educate immigrants from those countries in which FGM is practiced about the potential health and legal consequences of the procedure. * urges U.S. directors of international financial institutions to oppose loans and grants to any nation that practices FGM. Since 1994, the AMA has supported legislation to eliminate FGM in the United States, and has called for culturally sensitive counseling for immigrant patients and their families. But while physicians must be sensitive to other cultures' traditions, they also must recognize FGM as "a dangerous, deadly, physically and psychologically scarring procedure, said AMA Trustee John C. Nelson, MD, a Utah obstetrician-gynecologist. The issue of whether it should be legally banned goes beyond cultural sensitivity, he said. "I'm sure that we as humanitarians and particularly as gynecologists, cannot allow females or any group of patients to be mutilated. I'm afraid that is even more basic than religion. This is humanitarian." No one else knows how many young girls, including American citizens born here to immigrant parents, are subjected to the procedure. That's one reason AMA policy calls for making FGM a reportable condition to state health departments and the Centers for Disease Control and Prevention. But the new law does not address the issue of reporting, and the Dept. of Health and Human Services said it has not considered making FGM reportable because existing criteria are geared to conditions such as infectious diseases. "We're fairly early in the stage of determining how to be responsive," said Linda Vogel, director of HHS' Office of International and Refugee Health. And getting good data on the prevalence of FGM won't be easy. Already hidden from view, "criminalization is likely to push FGM further underground." Vogel said. Ramsey, who has formed a nonprofit organization called FORWARD USA to try to eliminate the practice through education, said FGM is common among immigrant communities throughout the country, including Somali enclaves in Los Angeles, Texas, Arizona, Minnesota, Tennessee, Virginia, and New York. "This mother admitted to me that she went to all the hospitals and clinics" to ask them to circumcise her daughter, Ramsey said. "And they all said no. She went to one doctor and offered him $1,000, and he said, `Even if you offered me $10,000, I would not do this. We don't mutilate children.' " So the mother went home and circumcised her daughter herself. "She said, `There's no way I'm going to have her acting loose like American girls,'" Ramsey said. Typically performed on girls at the age of 7, FGM is revered in its home cultures as a rite of passage and a crucial way to ensure that women are chaste and desirable marriage partners. But the medically unnecessary modification of female genitalia can lead to shock, infection, keloid scar formation, demoid cysts, tetanus and septicemia from unsterilized instruments, hemorrhage and exsanguination. In addition, there is psychological scarring: Women who have mutilated genitals often are unable to enjoy sexual intercourse. The least extreme form is removal of the clitoral prepuce, followed by excision of the clitoris and the removal of parts or all of the labia minora. But the most extreme form - "infibulation" - involves removal of the clitoris, the labia minora and at least two-thirds of the labia majora. The two sides of the the vulva are stitched together, with a small opening left for passage of menstrual blood and urine. The girl's legs are bound from hip to ankle for up to 40 days so that scar tissue will form. The scar tissue can make urination, menstruation and sexual intercourse difficult and painful, and vaginal delivery dangerous for the infant and mother. Ramsey said she recently talked to several young Somali girls when she came to the Washington, D. C. area to attend an (sic) government on FGM. The girls all admitted they had been infibulated and said they get into trouble at school because they must spend 45 minutes in the bathroom simply to urinate. Critics of the new law say that if parents can't find health care professionals to do FGM, they will hire local untrained "circumcisers," do it themselves, or even send the children back to their native countries for the procedure. But Ramsey insists that outlawing the procedure while educating the public is the best strategy. She said it also gives immigrants who are uncomfortable with the tradition a valid excuse to end it. For example, a Nigerian immigrant father in California told her he reluctantly had planned to take his three daughters back home to have them circumcised - until he learned about the law. Now he's trying to convince his mother, who would be shamed if der granddaughters remain uncircumcised, that he cannot do so because he might get into trouble here.