A pregnant woman, an immigrant to the United States from Somalia, is answering routine hospital inquiries about her plans for labor and delivery, including this: "If it's a boy, do you want him circumcised?"
"Yes," the woman replies. "And also if it's a girl."
How might a doctor respond? Female genital mutilation (as a matter of health policy, "circumcision" is considered a misnomer) has been a federal crime since 1996, but we know it happens here, with an estimated 228,000 American girls having undergone or being at risk of the procedure. If the doctor doesn't do it -- or do something -- someone else probably will, either here or in Somalia, as untold numbers of girls are also sent to their home countries for the procedure. (This, too, may soon become a federal crime).
So what if a U.S. doctor -- while refusing to perform any other or more invasive sort of genital cutting -- were authorized to offer one option: a tiny, symbolic, non-disfiguring pinprick or "nick" on a girl's clitoral hood, under sanitary conditions and local anesthesia? What if her parents, resolved to do some form of ritual cutting, accepted this offer as an alternative? What if the doctor -- though arguably perpetuating, in principle, a cruel and misogynist tradition -- would therefore save this girl from an almost incomparably worse fate, whether on U.S. soil or abroad: perhaps a brutally invasive excision with rough tools and nothing to numb the pain, plus the possibility of serious lifelong health complications -- or death?
Would that, then, be the right thing for this doctor to do?
For a few weeks in May, that question took a small -- though immensely controversial -- step out of the realm of "What if?" The trigger: The American Academy of Pediatrics (AAP) released a provocative update to its 1998 policy on FGM, which unambiguously condemned all forms of the procedure. In a revision published on April 26, the AAP -- primarily out of stated "respect" for the "experience of the many women who have had their genitals altered and who do not perceive themselves as 'mutilated'" -- replaced the term "mutilation" with the more "neutral," less "inflammatory" and, they suggest, dialogue-stifling term "cutting" (or FGC). Without explanation, the AAP removed a reference to FGM's "cultural implications for the status of women." And they advanced what proved to be an incendiary proposition: Let doctors offer the "nick." Not to accommodate, endorse or encourage FGM, but to preclude it: to offer a lesser-evil strategy of "harm reduction" (analogous in some ways to, say, syringe exchange for drug users). "Such a compromise," the policy suggested, could offer a physically harmless way to "build trust between hospitals and immigrant communities, save some girls from undergoing disfiguring and life-threatening procedures in their native countries, and play a role in the eventual eradication of FGC."
The revised policy sent shock waves through the anti-FGM community worldwide -- which is committed to eradicating FGM in all its forms, even when "medicalized" in the interest of harm reduction -- and the sisterhood of anti-FGM advocates in the United States. Marianne Sarkis, founder and director of the Female Genital Mutilation Education and Networking Project and visiting faculty in the Clark University (Worcester, Mass.) international development department, called the statement "an insult to all the women who have put their lives on the line fighting these practices." Her allies from FGM-practicing countries were "outraged" by it, she said. "Many of those who have decided not to force this practice on their daughters felt betrayed by the system that's meant to protect them."
Demands for a retraction came fast, including a joint response (PDF) from the World Health Organization and three United Nations agencies urging the AAP to re-revise its new policy so as to "be aligned with internationally agreed positions which are the result of in-depth analysis of FGM and of the approach that successfully leads to the abandonment of the practice." And so, in a rare -- though widely welcomed, and clearly wise -- move, the AAP retracted the policy last Thursday.
"I cried and told them how grateful I am," Soraya Mire, a Somali filmmaker and survivor of FGM, told CNN. "Thank you for understanding us survivors and hearing our voices."
The new-new version of the policy retains the term "FGC," but replaces the rest with a few blunt paragraphs reaffirming the group's "strong opposition" to FGM in general and making clear that the AAP "does not endorse the practice of offering a 'clitoral nick.'" Said AAP president Judith S. Palfrey, M.D.: "Our intention is not to endorse any form of female genital cutting or mutilation. We retracted the policy because it is important that the world health community understands the AAP is totally opposed to all forms of female genital cutting, both here in the U.S. and anywhere else in the world."
All told, this was a painful episode that everyone involved would probably like to forget. (Advocates privately called it "embarrassing," the newly amended policy "lame.") But to pretend it never happened -- or dismiss the AAP's intentions -- would be to ignore the problems that the nearly stillborn policy revealed and legitimately, if maladroitly, sought to address.
As a nation of immigrants, we (in some ways like France, with its tensions over the burqa) continue to see tested the limits of liberties we hold dear; we continue to negotiate the tricky territory of embracing peoples while -- in this case, rightly -- rejecting their practices. And our doctors, evidently, are being asked to do exactly that in their own examining rooms. How can doctors address FGM in a way that makes sense to patients (why boys but not girls?) and educates without alienating, thus possibly helping protect that daughter from future harm? The above scenario with the Somali mother was a real one: It led to a comparable, and also rejected, "nicking" proposal in Seattle in 1996. So here we are again, revisiting the question at a national level, with doctors apparently still trying to figure out the most effective way to help protect the girls they encounter. What can we learn, this time around, about how to help them?
FGM refers to a variety of traditional rite-of-passage practices, widespread in parts of Africa, Asia and the Middle East, that involve the nicking, cutting or removal of parts of female genitals for reasons both non-medical and mythical (e.g., to make a woman "clean" and "reduce" her libido). Health consequences include severe pain and bleeding, hemorrhaging, chronic infection, infertility, painful intercourse, post-traumatic stress, pregnancy complications possibly fatal to the baby, and death of the victim herself. While remarkable steps have been taken toward abandonment of the practice -- lawmakers from 27 African nations recently joined together to call for the U.N. to ban the practice as a human rights abuse -- FGM, along with the misogynist belief and social systems it represents, remains deeply entrenched in numerous villages, regions and nations worldwide. "Uncut" girls may be shamed and considered unmarriageable, raising the prospect of severe economic consequences for her and her family. Coming to America does not mean abandoning the practice; in fact, according to some reports, some families here see FGM as an essential bulwark against the girls-gone-wildness of our culture. "Think of it as a genital burqa, designed to control female sexuality," said Somali FGM survivor and opponent Ayaan Hirsi Ali, writing in the Daily Beast.
The revised AAP policy ignored the fundamentally anti-woman underpinnings of FGM, critics said. "Perpetuating any form of FGM, however seemingly innocuous, is denying girls their fundamental right to bodily integrity -- and failing to recognize FGM as part of a system of violence and discrimination against them. One can't violate just a little less or discriminate a little less. The AAP's suggestions are the equivalent of advising doctors to agree to bind three toes instead of a girl's whole foot, or supporting child marriage at age 13 instead of 8," said Taina Bien-Aimé, executive director of Equality Now, a leading voice in the anti-FGM field.
The WHO/U.N. agency joint statement addressed to the AAP also outlined several concrete reasons why global anti-FGM consensus does not support "nicking" as a harm reduction approach. Among the concerns: The performance of any type of FGM by medical personnel confers a dangerous legitimacy on the practice; the lack of data confirming that a "nick" really would prevent worse; general lack of clarity about what a "nick" means in practice; and the concern that a "nick," if ever established as an alternative, would be even harder to eradicate than harsher forms and would "thus result in greater overall harm."
To be clear, the AAP was not about to start sending doctors out with nicking kits. Nor (as was erroneously implied and reported) was the group trying to be "culturally sensitive" for its own sake. The retracted statement urged doctors to "use all available educational and counseling resources to dissuade parents from seeking a ritual genital procedure for their daughter"; it acknowledged not only FGM's harmful effects but also its status as a violation of human rights and a form of child abuse. Its intention was specifically, and only, to suggest that federal and state laws banning FGM in the U.S. should be tweaked to allow for the "nicking" possibility as a last resort. (Actually, and also contrary to reports, legal experts do not agree on whether federal law precludes a "nick" in the first place).
In order to make its case, the AAP's revised policy made passing reference to what came to be known to some as "the Seattle Compromise." In 1996, a group of Somali-born mothers approached doctors at Seattle's Harborview Medical Center to open a radical conversation. They made clear that if some form of the procedure did not happen at the Center, they would send their girls to a local Somali "midwife" or even to Somalia, in which cases they'd be subject at least to clitoridectomy, if not complete "Pharaonic" infibulation -- removal of all external genitalia and stitching together of the resulting wound. The Somalis' proposal: allow Harborview doctors to perform only a symbolic "sunna," a tiny nick. "Remember, these women were all infibulated, so it was a big step to not do anything for their daughters," notes Leslie Miller, a Seattle OB/GYN formerly at Harborview who was a key player in the discussions and whose patients were among those who'd raised the question.
Harborview doctors and officials convened and came up with this counteroffer, one substantially more specific than the AAP's proposal: a small cut to the clitoral hood, with no tissue excised, conducted under local anesthetic on children old enough to give consent. "Have you ever seen a male circumcision? Surely if we condone that then a simple nick of the prepuce is a tiny price to pay to prevent something more extreme," says Miller of her colleagues' rationale. (Comparisons between male circumcision and FGM are often disingenuous, ignoring the vast differences between the stated purposes of the practices and the belief systems from which they emerge. That said, the circumstances of the Seattle case, and "nicking" proposals in general, do invite limited areas of comparison, an interesting discussion of which -- along with the full story of the Seattle Compromise -- appears in this 1998 article in the Duke Law Journal.)
Did the "nicking" alternative save any Somali girls in Seattle from something worse? No: It was never put into place. Reaction against the proposed compromise -- from the community, anti-FGM advocates, and Rep. Pat Schroeder, who'd worked for years to enact the federal FGM ban -- was so swift and savage (though, according to the Duke Law Journal, probably based in part on inaccurate reports about Harborview's motives and intentions) that Harborview dropped the idea without further discussion. (A similar proposal, also raised by Somalis, was rejected in Holland as well; it's coming up right now in Australia. UPDATE: The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) has clarified that it has no current plans to change its position against all forms of female genital mutilation.) Could it have made a difference? Would any given community actually accept such an alternative? We don't have that kind of data, say experts, stressing that even "successful" harm reduction in the short term would come at too high a price.
By most accounts, the Seattle episode left such a bad taste that the primary lesson learned seems to have been "Don't do that." Can we do better this time around? Fourteen years later, it appears that many doctors here -- like, metaphorically speaking, traditional FGM practitioners -- are still equipped with only the roughest of tools. Flat-out refusal or condemnation of the procedure can backfire, driving patients away; the full weight of negotiation or education shouldn't be left upon physicians, either. "The AAP should call for the local, state and federal authorities to educate, in a culturally sensitive way, the parents of at-risk girls about the harmful effects of FGM and how it is not necessary to secure a girl's virginity until marriage or guarantee her chastity," said Bien-Aimé of Equality Now.
In fact, that's the law: The 1996 federal FGM ban called for funding for outreach efforts, but nothing ever happened. "The Department of State has dropped the ball on this issue," confirms Marianne Sarkis of Clark University. In response to the AAP retraction, Rep. Joe Crowley, D-N.Y. (co-sponsor, with Rep. Mary Bono Mack, R-Calif., of proposed legislation that would make it a crime to take a girl out of the country for FGM), vowed to "continue pressing Congress to fund strong, comprehensive community-based outreach and education efforts to prevent this human rights abuse."
Pediatricians are hardly the only, or the most influential, point of contact for immigrant groups, but they are potentially powerful allies in the fight against FGM in our country. The very clumsiness and cluelessness of the AAP's retracted proposal -- could the whole thing have been avoided with one call to the WHO? -- makes one wonder why groups committed to the same goal were so out of touch in the first place. Now we see a clear chance for last week's foes to join forces today: perhaps to improve and broaden the linking of doctors' practices with community groups to whom they can refer families; to further educate doctors about the most effective way to respond when a girl seems to be at risk. And yes, to get money for that out of Congress. The real enemy is FGM, not the AAP. This is a chance, on behalf of our nation's newest daughters, to turn outrage into opportunity.
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