Most forms of FGC are decidedly harmful, and pediatricians should decline to perform them, even in the absence of any legal constraints. However, the ritual nick suggested by some pediatricians is not physically harmful and is much less extensive than routine newborn male genital cutting. There is reason to believe that offering such a compromise may 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. It might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick as a possible compromise to avoid greater harm.

This is a really slippery slope, though.  On the one hand, you want to be able to keep a dialog open with members of these cultures, and you want to be able to offer them alternatives to the actual practice of cutting, which is often done by non-medically trained practitioners in unsterile environments, and can be dangerous and deadly, besides the actual sexual and future child-bearing limitations that these practices entail.  On the other hand, it seems a hard thing to condone, and I’m not sure how positive change could be affected through this practice, coming as it does from an outsider/ western institution like the AAP.  The New York Times ran an article on this after the AAP’s announcement, and they did a good job up summing up both sides of the story, but in particular the response to this announcement by advocacy groups like Intact America:

“There are countries in the world that allow wife beating, slavery and child abuse, but we don’t allow people to practice those customs in this country. We don’t let people have slavery a little bit because they’re going to do it anyway, or beat their wives a little bit because they’re going to do it anyway.”–Georganne Chapin, executive director of Intact America.

And she is right about that.  Is allowing American physicians to perform a “ritual prick” the same thing as condoning the practice?  And even if a ritual prick is less damaging to a little girl than male circumcision is to a little boy, what it’s standing in place of is still a debilitating and often times misogynistic practice that in many cultures  is designed to limit a woman’s sexual enjoyment (and therefore her promiscuity), enhance male sexual pleasure, and preserve her status/ virginity/ honor/ marriageability and group identity, and has with it a host of medical conditions

Female Genital Cutting is a difficult subject to broach, even at the best of times.  This something I have struggled with for years.   My first initial response to seeing it was one of shock and outrage at the brutality of it, and ended with me declaring that it is and always will be mutilation, and that I must speak out against it whenever and wherever I saw it.  Further thought on the subject has made me come to realize that as an outsider to these cultures, I can’t approach a woman by telling her that she’s been mutilated as the starting point for any future conversations–that will immediately close her off to me and only serves to project my own cultural bias over her own.  The important thing to remember is that to women brought up in cultures which practice FGC, it is no more strange to them than piercing bellybuttons or lips or eyebrows is to us, even if the implications, the actual act itself and the repercussions of it can be much more damaging to them than a bellybutton piercing.  When viewed within their culture, it’s a mark of belonging and identity, a way of fitting in, a symbol of their womanhood, a manifestation of their virtue and honor, and on its most basic level, the way that they think vaginas are supposed to look–beautiful, even, to their eyes.  When a woman who has been cut sees a picture of an uncut vagina for the first time in her life, the reaction is usually one of shock and horror at how ugly and deformed it is, lacking the symmetry and neatness of infibulation. As members of the western/ dominant/ imperial culture, we are not in a prime position to be doing the actual hard work of change.  Our position of privilege and dominance allows us to advocate for change, but the actual change itself needs to come from within, from programs like Tostan’s, which spends 30 months teaching and empowering community leaders and members of the community, giving them the tools they need to choose to stop FGC for themselves.  Compared to that kind of impetus, the AAP advocating for a western doctor to perform a “ritual nick” seems like trying to put out a fire with a squirt-gun.

But then, on the flip side, I do hear the AAP’s argument for trying to limit the prevalence and severity of FGC by offering a cleaner, safer, less invasive option, and it does seem like they have some research to back this up (but very limited research…and it seems there is also a fair amount of research arguing against adopting this practice. To quote again from their policy: “In some countries in which FGC is common, some progress toward eradication or amelioration has been made by substituting ritual “nicks” for more severe forms.² In contrast, there is also evidence that medicalizing FGC can prolong the custom among middle-class families (eg, in Egypt).³⁵ Many anti-FGC activists in the West, including women from African countries, strongly oppose any compromise that would legitimize even the most minimal procedure.⁴ There is also some evidence (eg, in Scandinavia) that a criminalization of the practice, with the attendant risk of losing custody of one’s children, is one of the factors that led to abandonment of this tradition among Somali immigrants.³⁶“)  My question is: does the AAP really think that women and families from cultures which practice FGC would be approaching their pediatricians about this in the first place?  And in the AAP’s defense, they are by no means recommending this routinely, only offering the option of a ritual nick as a potential last ditch effort when other attempts at education and dissuasion have failed.   The actual recommendations at the end of the policy are as follows:

The American Academy of Pediatrics:

1. Opposes all forms of FGC that pose risks of physical or psychological harm.
2. Encourages its members to become informed about FGC and its complications and to be able to recognize physical signs of FGC.
3. Recommends that its members actively seek to dissuade families from carrying out harmful forms of FGC.
4. Recommends that its members provide patients and their parents with compassionate education about the physical harms and psychological risks of FGC while remaining sensitive to the cultural and religious reasons that motivate parents to seek this procedure for their daughters.

I don’t anticipate any actual change to legislation any time soon which would non-criminalize acts of FGC, despite what the AAP may suggest.  In fact, it seems like ths US is cracking down on FGC even more at this time, especially in the form of the new proposed legislation (The Girls Protection Act H.R. 5137) which would criminalize not only acts of FGC in the US, but also sending women and girls abroad to have the procedure done (which  is already law in most of the countries of Europe).  It will be interesting to see how this plays out in the months to come.  Any other thoughts on this?

I can only imagine how birth, which can be so traumatic in its own right, can bring up so many terrifying memories and associations with trauma and rape. Birth is another situation where she can potentially feel vulnerable and exposed, in a situation that she can’t really control, experiencing pain, perhaps feeling helpless and angry and powerless (and keep in mind that this will be a hospital birth and not a woman-on-her-own-turf-at-home-birth). So here’s my question to all you midwives and doctors and nurses who’ve been doing this a lot longer than I have, and who have probably been present at births with women who have a history of trauma or rape (or women who have survived rape or trauma and gone on to birth yourself). Do you have any suggestions? When it comes closer to the time of the birth, what should we focus on? I have many thoughts about where to start: avoiding vaginal exams during the birth, offering early pain relief if desired (maybe a prophylactic epidural before the strong contractions even begin), letting her dictate when and how to push, making her environment as calm and serene as possible…what else am I missing? Any good books on this topic? Any posts that you’ve written which I should read? Anything at all would be helpful, because I still have another 8 months of prenatal care with this woman prior to her birth, and I want to try to make it as healing and empowering as possible (or, at the very least, not compound the trauma with more trauma).

Anyway, I sent Dark Daughta a few posts. One on the Keeper (still one of my proudest feminist and environmentalist statements), one on the UK’s new birth agenda (Maternity Matters), and two on female circumcision (Circumcision or Mutiliation? and Further Thoughts on FGM).

I was curious to see what Dark Daughta would think of them. Leave it to Dark Daughta to not only think about them, but to write an explosive 1000 word treatise as well. She picked my posts on female circumcision, of course, and then ran with them. Ran is a polite word for what she did. More like smacked the posts upside down, flipped them inside out, and then shook all of the loose change out of their pockets. She took everything I had thought after my first encounter with a circumcised woman, and all of the conclusions I had come to at that time (and this had involved a lot of thinking back then, trust me), and managed to turn all of those thoughts, all of those culminations of thought, absolutely, irrevocably, upside down. In the space of just one post. Leave it to Dark Daughta to challenge the hell out of you.

Just a few highlights, here:

Dear Student Midwife:I’m glad that you’re asking yourself questions about how best to proceed. …Maybe examining the culturally based and biased and ofttimes downright racist, response of many privileged feminists who were not born into cultures where genital circumcision is practiced might offer some much needed space inside which there might be less emotionally and politically charged room for a true examination of the issues.There is a power relation here. Are parents in western societies hunted down and denied access to safe male circumcision? Why is the WHO advocating for this procedure when there is a fast growing segment of the male population that is crying out against it?

When male circumcision of babies who can’t make the choice for themselves is enshrined as a part of at least major world religion, are health care practitioners strategizing about how best to stigmatize grown men who present penises that are mutilated? Are feminists of conscience refusing to sleep with men who are circumcized? Are we looking on them with pity and defining them as mutilated? Are we strategizing about how best to divest them of custodianship of their sons so that we can keep them safe from circumcision? Is anyone noticing that the actual side effects of male circumcision…besides those that go horribly wrong…are minimal because these surgeries are done by skilled practitioners in sterile settings?

I don’t agree with either kind of circumcision. But I can’t fail to notice that one is filled with shame and stigma heaped on those who experience it, while the other is thought of as a throwback that should be done away with but is still tolerated and executed in hospitals.

Being useful is definitely not going to include making any circumcized wimmin feel uncomfortable and on the spot about the decisions of their parents. So, labeling a woman’s cuts “mutilations” without checking to see what if anything she says about her own genitalia will go a long way to making a practitioner seem like a judge and not as someone a woman can potentially confide in or turn to.

Because really, the shock and the unfamiliarity with the view below is ours, not theirs. If we’re gonna pay lipservice to accepting the anatomy of the vulva, we’re going to need to work at really understanding and respecting that wimmin come in all sorts of configurations for all sorts of reasons.

This “who is civilized” and “who is babaric and uncivilized” binary split that serves the west/the north, giving our cultures a much needed oppressive ego boost needs to GO!

Yowsa. And those are just the highlights. I’d highly reccommend that you go and read the rest of the post, because she writes with so much passion and conviction, and has this incredible way of phrasing things in ways that I would never, ever think of.

Now, how do you respond to a post like that? I didn’t even know where to start. First I had to do a lot more thinking on the subject, which I’ve been doing for the past several days and nights. I wrote an e-mail response to her, which she published in last Sunday’s Reloaded V which started to flesh out some of my thoughts. And now I find myself here again, having done yet another 180 on the subject (my apologies for repeating some parts of my e-mail, but this is pretty much where my thinking is at right now).

I think Dark Daughta is right on a lot of counts. There is indeed an inherent racism/ oppression in a viewpoint which has decided to call one form of ritual cutting “mutilation” while at the same time leting so many other types of cutting fall under the category of “circumcision” or some other word, and therefore under the umbrella of cultural acceptability (male circumcision, labioplasty, clitoral hood piercing, episiotomy etc.). I can see how that is indeed our culture (and by that I mean western culture) taking its own viewpoint on what constitutes a healthy vulva and setting it forth as “right” and “correct” and that anyone else who does anything different to their vulva (especially something brutal or harmful and something we as a culture don’t fully understand) is therefore wrong and backwards and oppressed and brutalized by their own culture…and that this “mutilation” is therefore a form of violence against women. This viewpoint then lays the groundwork for our invasion of their culture; in other words, this viewpoint basically gives us permission to enter their culture and tell them what’s right and wrong, and that they have to stop this cultural practice. And many huge, big name organizations like UNICEF, the World Health Organization, the US Dept. of State, Amnesty International, USAID etc. etc. have all issued policies and statements which call for an end to this practice, and have programs or policies in place which exist to help educate and save these women from their fate.

Calling something “mutilation” implies, by its very nature, that those who are “mutilated” need to be saved. That makes sense, and I see that now, but I had never before thought of it in those terms. So further thinking on this is prompting me to start to refer to this ritual as “circumcision” again rather than “mutilation”. I do appreciate that my view of what constitutes a healthy vulva is certainly not everyone’s view, and who am I (or who are we?) to decide what is or is not the right kind of vulva? Why is labioplasty or clitoral hood piercing okay, while female circumcision is not? And what would happen if circumcision was done well, by medically-trained people using sterile instruments, sharp instruments, making clean, hygienic cuts? So many of the problems inherent in this practice comes from the scarring and infection which is secondary to the cuts themselves. If there was no scarring, if there was no infection, would the damage be less? As Dark Daughta pointed out, female sexuality stems from a lot more than the tiny nub of flesh which is the clitoris. If the clitoris is removed, but in a clean and precise manner, using sharp, sterilized instruments (rather than a rusty tin can or a piece of glass etc.), would women be able to retain a higher level of sexual functioning? I never, ever would have thought that an underground feminist movement to provide clean, hygienic, medically-trained female circumcisions is not that far off from what feminists were doing in the 70s with their underground abortion clinics to provide clean, hygienic, medically-trained abortions, but yeah, I do see the similarity.

I wrote in a comment on my first post that “I undrstand that there are a lot of cultural and personal reasons involved in choosing [male] circumcision, and I don’t feel like it’s my place to say.” So if I can so graciously back out of the debate when it comes to males, why can’t I do the same with females? To say that these girls aren’t educated about the pros and cons of the procedure, that they’re forced into it by their parents and their culture at a young and vulnerable age (usually at puberty), and that they therefore aren’t making informed consent doesn’t hold up, either, because the same can be said of male circumcision. Baby boys are absolutely, positively NOT making an informed decision when it comes to having their penises cut or not. It’s a decision that their parents are making for them for many different reasons, just as it’s a decision that the culture/ parents are making for the girls who are receiving female circumcision. And I ask again: what right do I have to step in to this decision-making process and tell someone that they’re wrong, or that this decision is wrong? I have no right whatsoever.

Now, before someone comes along and rips into me, let me just make this very very clear: I am not advocating female circumcision, nor am I advocating male circumcision. I am not condoning either practice, nor am I saying that they’re both fine and acceptable, and that they should continue unhindered. All I am saying is that it’s not my place to judge these practices, and it’s not my place to make these decisions. Since I’m not a member of a culture that practices female circumcision, the rich cultural context with which this practice resides is lost on me. The shame or humiliation someone of that culture might feel by not being circumcized and therefore not being a full participant of their culture is something I’m never going to be able to empathize with. And I am questioning whether it is right for our culture (Western culture) to go on huge “Stop Violence Against Women” campaigns in cultures which are not ours, in contexts which we don’t fully understand (and probably can never fully understand).

I do think that these practices need to stop. But I don’t think that the impetus for changing this is going to come from us (from the West), and I don’t think it should. If it’s going to change, it needs to come from within; from women and advocates who are of these cultures, who understand the context, who can see the patriarchy at work in such acts, and who want to rise up against it. And when they do, we as Westerners can and should support them with all of the resources our rich, privileged cultures afford us.

I guess the only sticking point I still have at this point is the following: if you’re a member of a culture, and if it’s all you know, and if you’re never exposed to anything else, you will never have the objectivity necessary to ever question or rise up against these practices that you have seen and been a part of since birth? And maybe that is where an organization can step in and offer education to members of these cultures; ideally, the education should come from members of the culture themselves. I think the folks over at RAINBO are on the right track, and if we as Westerners want to support the education of women (and therefore indirectly the hope that eventually these practices might stop), we can do this by supporting organizations like this.

As far as being a practitioner, the take-home lesson here is once again very simple, and very difficult to fully learn: LISTEN TO WOMEN, and DON’T JUDGE. How is it that I can see this so clearly on issues like abortion, where I absolutely, 100% feel that it is not my place to say, and that since I’m not carrying her baby or walking in her shoes, I have no right to judge at all….and yet issues like female circumcision still bring about huge, heaping amounts of judgement? As a white woman from a privileged background, I’ve been trying for awhile to own my privilege, and see the way that this affects my point of view on everything. This is a difficult, never-ending task, and while I feel that I’ve managed to own this on several more obvious issues, this is an issue I hadn’t even picked up on. I guess the ultimate, life-long goal for every evolving human soul is to continue to move towards a state of less and less judgement. To become as close to non-judgemental as you can possibly be. I say possibly, and “close to” because I think being non-judgemental is an impossible goal. Our psyche, our sense of self, our identities, our culture, our experiences and background and upbringing, everything we use to know ourselves as who we are–all of this is based on judgements which we have formed through living, judgements which we have consciously or unconsciously absorbed, and I think it’s impossible to seperate yourself from them. I am not using this as an excuse. Moving towards a more non-judgemental state requires very close and painful examination of those life experiences and background and upbringing and culture. It requires seeing the ways that your life experiences and culture has potentially prejudiced you, seeing the ways you are privileged, seeing the ways that power affects your identity–power you have, or don’t have, or have in some areas but not others. It requires seeing where you come from, seeing the way that this has formed your world view, and then seeing the way that this outlook affects how you see others. That’s a huge part of becoming less judgemental.

The LISTEN TO WOMEN and DON’T JUDGE take-home message means that all future encounters with women who have been circumcized will involve calling it circumcision, following her cues, and letting her talk or not talk about it, as she desires.

Anyway, those are my thoughts on this subject at this moment in time. Granted, I will continue to think, and I’m sure my thoughts will continue to evolve. I’d be really interested to hear what others think about this as well. It is a very sticky subject, and it’s not about to get any more clear any time soon.

We live in a scary, scary world right now. I was looking over some of the articles Lynn Paltrow has written or commented on, such as Blaming Pregnant Women, The Pregnancy Police Are Watching You, The Rights of “Unborn Children” and the Value of Pregnant Women and Do Pregnant Women Have Rights? , and I was shocked, not to mention frightened, by how far current and proposed laws have gone at eroding the civil liberties of women. While the Unborn Victims of Violence Act was blinking somewhere on my radar, it was mostly framed in terms of what this meant for abortion rights, without taking in the larger picture. I had no idea things had gotten so bad (guess I need to be reading The Mommy Blawg more often, huh?). These articles talk about cases where women have been forced to undergo surgery against their will; where women have been jailed as criminals for “murdering” their children through drug use; where fetal rights have been found to trump the rights of the living, breathing women who are “housing” them…women who used to be entitled to their own personal freedom and life, liberty and the pursuit of happiness…until they got pregnant, that is. Granted, these cases are rare, and seem like aberrations rather than the norm, but in a legal system that is built on precedent, even a single case can yield terrifying future implications.

As Melissa from A Womb of Her Own rightly pointed out, though, this goes beyond the abortion debate. This isn’t even remotely about abortion any more. This is about women losing their voice, their rights, their power. And this is about a system that seeks to punish individual women, isntead of asking: why do so many women turn to drugs? How can we help them with that? Why do so many women live in fear for their lives? Surely it’s not just because abuse is a pattern, and some women “just keep dating the wrong guys”, like it’s her fault for choosing such a poor partner, instead of his fault for beating her in the first place? Why do so many women live in poverty? Why do so many of these women happen to be brown or black? Why is the health of a fetus more important than the health of the mother? And if we’re so concerned with the pain of the fetus that we’re now requiring doctors to counsel women about it before performing abortions after 22 weeks, why are we so unconcerned about invasive procedures during pregnancy that hurt the fetus, or circumcision, or children living in poverty and neglect?

Hummm. I bet some of these questions were addressed in the conference call that I missed. *sniff* However, the good news is: NAPW is hosting a summit in January, and we’re in the process of putting together another conference call or interactive chat with Lynn Paltrow and NAPW for midwives, student midwives and doulas. Because, let’s face it: this is something we should be more than just up-to-date on. This is something we should be razor-sharp-cutting-edge on, because as midwives, these aren’t just abstract questions to us, but the lives and choices and challenges of the women we’re taking care of every day.

And for those of you who are in town this weekend, come to Friends of the Birth Center’s 3rd Annual “Celebrate Birth” Picnic, which will be in Central Park this Sunday (June 18th). It should be a great afternoon, including birthday cake and lots of entertainment for the kiddies, and the $10 suggested donation goes towards (re-) opening a free-standing birth center in Manhattan after the tragic close of the Elizabeth Seton Childbearing Center. For more information, visit the link above. (Unfortunately, I’m going to be out of the city camping this weekend, but we get back on Sunday, and if we get back in time…I’ll be there).

And with that, I’m off to cook dinner, and then work on my neverending modules.

And breathe.

“Oh,” I said, as calmly and casually as I could, “I see you’ve been circumsized.”

“Yes,” she said, “back in my country.”

And then I sat there for another few seconds, on my stool with her legs in stirrups on either side of me, wondering if I should say anything else. What should I say? Should I ask her how she feels about it? Should I ask her if it bothers her? Should I ask her if she’s planning on having her daughter circumsized? Was there anything I could do for her? Was there anything I should do for her? We’d learned about female genital mutilation (FGM) in school—the different types and degrees of mutilation, the different surgical procedures that can be done to de-infibulate women—but actually seeing it was like a slap of cold water to the face. And yet, at the same time, I was very hesitant to impose my judgements on her. Asking her if it bothered her implies that it should bother her; asking how she feels about it is a more neutral question, but she was definintely giving me signals which seemed to indicate that she didn’t really want to talk about it.

So what did I do? I didn’t say anything. I proceeded with the rest of the exam. It was a Type II mutilation, her introitus and vagina were perfectly normal, the laceration from her delivery had healed nicely, there wasn’t any infibulation present, and she was obviously able to give birth vaginally without complications from the FGM. I finished the exam, wrote my note, talked about it briefly with my preceptor, and then moved on to the next woman.

Except that now I can’t shake the feeling that I didn’t handle the situation correctly—in fact, the more I think about it, the more certain I am that I handled it very incorrectly. I’m not sure exactly what the correct way of handling it is, but I feel like I didn’t advocate or educate or do my job as well as I potentially could have. And I can’t get the image of her vulva out of my mind, either. It’s not something you ever want to see, and having seen it now, it’s not something I’m ever going to be able to unsee.

What’s the right balance to strike? We try so hard as midwives to be tolerant and respectful and non-judgemental of the cultural practices and beliefs of the women we serve that it’s too easy to look at FGM as a cultural practice, and avoid questioning it or challenging it for fear of stepping on any toes, or making a woman feel that we’re not being respectful of her beliefs and practices. I was scared of saying anything because I didn’t want to impose my own judgements of what’s right and wrong on her (i.e. my culture thinks clitoral hood piercing is cool, sexy and trendy, but I’m going to sit here and tell you that your cultural practice of FGM is actually violence against women?). How can you tell her that FGM is an act of violence when she might firmly believe that it is actually an act of love? When she might be grateful to her parents for insisting that she have it, so that she wouldn’t be unsightly and ugly in the eyes of her culture? Should I be the one to challenge her, or dissuade her of her long-held beliefs? And what if challenging this ends up throwing her entire worldview into chaos, and whereas before she was accepting of the FGM, afterwards she starts to think about it more and it begins to torture her? As if she hasn’t been injured enough. Is it my place to be the one to tell her that it’s wrong?

Was all of this floating around somewhere in my head when the word “circumcision” came out of my mouth? Probably. And that’s probably why I did say “circumcision” instead of “mutilation”. Mutilation is such a loaded word—such a terrible word! How horrible to tell someone that they’ve been mutilated! And yet calling it “circumcision” is like putting a thick veneer of acceptability onto a procedure that is unacceptable. Circumcising men doesn’t cause medical complications such as shock, homorrhage, possible death, long-term urinary incontinence, lifelong reproductive problems, cysts, keloid scars, absesses, not to mention permanently destroying their sexual function or ability to enjoy sex—or sometimes just their ability to walk without difficulty or pain.

Calling female genital mutilation “circumcision” is like calling genocide “ethnic cleansing” or calling rape a “forced sexual encounter”. It’s making something that’s violent and painful and oppressive and horrific into something that’s clinically palateable, something that can be politely discussed in the literature from a safe, removed distance, something you can say in a professional setting as if we were discussing a new haircut: “Oh, I see you’ve been circumsized. Yes, do you like it?” No! If beating women into a bloody pulp every Friday night was a specific cultural practice (and some days, it feels like it is), would we turn our heads and say: well, that’s just their cultural belief, and who are we to question it? If a man had no testicles and no penis, but just a thin white scar exactly where those organs should be, would we call that “circumcision”? I think not. FGM is a prevalent, worldwide form of descrimination and violence against women. Notes to self: it can’t be glossed over with antiseptic terms like “circumcision”, it can’t be tolerated as a cultural belief, and it can’t be ignored in the clinical setting.

So…that’s what happened today. I’ve been trying to wrap my head around it all night. I have no idea what I’ll say next time I’m in this situation, but I know for sure that I will definitely call it what it is: mutilation. And I will definitely say something, instead of just letting it slide. But what to say?????

Here are some great resources on FGM, most of them courtesy of Women’s Health News:

Female Genital Cutting — National Women’s Health Center
Female Genital Mutilation: Legal Prohibitions Worldwide — Center for Reproductive Rights
Female Genital Mutilation: A Human Rights Information Pack — Amnesty International
Female Genital Mutilation — Unicef
STOPFGM
RAINBO — Research, Action and Information Network for the Bodily Integrity of Women
Prevalence of FGM — US Dept. of State
Female Genital Cutting — USAID
Female Genital Mutilation — AAP Bioethics Committee Policy Statement
Possessing The Secret of Joy — a novel by Alice Walker