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

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

   * 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

   * 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.