Sierra Washington was stunned when, as a reproductive specialist in Sub-Saharan Africa, she first saw a patient who had undergone female genital cutting. Washington worked in Zambia, Cameroon, Kenya, Rwanda and Tanzania, countries where about one quarter of women had undergone female genital cutting.
Cutting ranges from clipping off the clitoris to what’s called infibulation – slashing the outer labia and stitching them together so that they heal across the vaginal entry, often closing the path for urinating and simply leaving a small opening to the entire region. The procedure, a cultural practice intended to prevent women from having extramarital sex, is most often performed on girls sometime between infancy and adolescence.
Today, as medical director for Planned Parenthood of the Pacific Southwest,* Washington works with the Family Health Centers of San Diego treating refugees as part of the Duyna Women’s Health Collaborative. That’s where she recently treated a woman whose labia had been sewn together years before. After childbirth, the patient was faced with a choice – did she want her labia sewn together again? “I asked her what she wanted to do,” Washington recalled, “and she turned to her husband for the answer.”
Such patients are why the Family Health Centers, led by Kristin Brownell, sought and recently won a grant of nearly $1 million from the U.S. Department of Health and Human Services in July 2016. They plan to develop a program to turn San Diego’s large African community away from female genital cutting (FGC) while developing culturally competent medical care for women who have been cut.
San Diego and particularly the City Heights neighborhood are home to as many as 30,000 Somalis – though reliable numbers are hard to come by – and thousands more people from Eritrea and the Sudan, where cutting is also practiced.
A United Nations Children’s Fund report released in 2013 estimates that, worldwide, more than 125 million girls and women have experienced some form of cutting. In Somalia, Eritrea and the Sudan, 95 percent or more of the women and girls have been cut.
FGC appears to have migrated with those families, many of whom came to the U.S. as refugees fleeing from terrible, violent conflicts. Just two weeks ago, a doctor in Michigan became the first U.S. FGC practitioner to be arrested, allegedly for cutting girls as young as seven. A second Michigan doctor was arrested and charged Friday.
The Centers for Disease Control and Prevention says that 513,000 girls and women are at risk of being cut nationally, including about 8,000 girls under 18 in San Diego.
FGC is recognized by U.S. immigration officials as a valid reason to seek asylum in the U.S., according to immigration attorney Elizabeth Lopez. It is also recognized as violence against women and as torture.
Cutting results in lifelong health problems. “We see frequent urinary tract infections, a range of problems with menstruation and difficulty getting pregnant. Natural childbirth is extremely difficult and can result in tremendous damage,” Brownell explains. Scarring from primitive procedures brings additional problems, including the necessity for Caesarian section delivery of infants or extremely difficult post-birth episiotomies, both triggered by keloid scars that bring a lifetime of pain and discomfort.
Yet, Brownell says, “Our doctors weren’t trained to deal with this – either medically or culturally.”
So Brownell sought out partners in the community, including the Nile Sisters, a nonprofit well-known in the community for its economic empowerment and self-sufficiency efforts with African women in City Heights. Many of its staff are refugees or the first generation of U.S.-born children of African refugees
“Our goal is to create a pipeline of support, outreach and education,” explains Rebecca Paida, a program manager for the Nile Sisters. “We know it is very difficult for a woman to go up against social norms.”
To begin the conversation with the communities where girls are at risk, both doctors and social service providers must first find a neutral way of describing the practice.
Khalwa Suleiman-Qafiti, a primary care doctor who practices in Family Health Clinics, says that describing the culturally sanctioned procedure in terms of mutilation and violence makes it harder for patients to trust their medical providers.
“I like to call this female circumcision because it is respectful to the culture,” Suleiman-Qafiti says. “It is done as a rite of passage; it’s done out of love. It was not done with the idea of hurting these girls – as difficult as that is to understand. When you describe it in such negative terms, the result is shame.”
Most refugees already know that FGC is illegal because the agencies helping them settle into life here tell them as part of the acculturation process. Condemning the practice simply drives the at-risk girls and their families into secrecy, advocates say, which is why changing minds about FGC is a much more effective method of ending the practice, particularly when it is possible to simply circumvent the illegality of the procedure in the United States.
There is, for instance, a widely-recognized practice of ‘vacation cutting’ – where girls sent to visit family in the old country are being cut with or without their parents’ blessing. “We have seen the results of vacation cutting,” says Paida. “The girls’ teachers notice changes in their behavior and their health when they come back from visiting family.”
The grant collaborative is developing strategies to make it safe for women to talk about the practice, so they don’t look for other methods of obtaining FGC for their daughters, Brownell says. One approach, she says, is “talking about male circumcision and how there aren’t valid medical reasons to have it done. Then people started opening up and sharing their experiences.”
At first, the Dunya women talked to immigrant women and girls alone, but they found that women won’t make decisions about their daughters’ health without their husbands, so they now find ways to include men in the conversation, Paida said. Often, men don’t know how profoundly FGC affects their wives’ health and how it could affect their daughters.
To help those who have already had the procedure, the health centers currently refer patients to surgeons – including Washington – for reconstructions. They rely on Washington and sometimes on a San Francisco surgeon whose expertise comes from gender transition surgery.
“When the labia were sewn together, you can reconstruct them,” Washington said. “When the clitoris has been removed, we haven’t yet figured out a way to replace the clitoris.”
*an earlier version of this story did not specify Washington’s position or employer.