BY WREN MACCAGER
Somewhere in the United States, a girl will soon be held down and a stranger will cut out her clitoris - if it has not happened already. The stranger will do so at her parents' request, but it is unlikely that the parents will be prosecuted. Indeed, their friends will probably respect them for having arranged the procedure. Female circumcision is coming to America with African immigrants every day.
According to the female circumcision Web page on the Internet (http://www.hollyfeld.org/~xastur/), an estimated two million girls undergo the procedure (mostly in Africa) every year. The girls are typically between four and twelve years old, although in some areas females are circumcised in infancy while in others the ritual is not performed until shortly before the birth of a woman's first child. The procedure is often performed by the girl's relatives, using a razor blade, a kitchen knife or a pair of scissors - and sometimes no form of anesthesia whatsoever.
Now female circumcision is becoming an American legal and medical problem. According to an Linda Burstyn's article in the October  issue of the Atlantic Monthly, approximately 7,000 females immigrate to the U.S. every year from countries where female circumcision is a common practice. Some African families already living here send their daughters home to undergo the rite; sometimes several families will pay to bring a professional circumciser here.
Educators, health-care providers, and lawyers in the areas with significant populations of African immigrants - California, New York, and Washington, D.C - are increasingly confronted with the effects of this procedure. A small but vocal contingent of professional African women living in the United Suites has called for the ritual's eradication and is working to break down the social forces that perpetuate it.
Meanwhile, in February , Representative Pat Schroeder of Colorado introduced pending legislation that would make circumcising young women illegal and compel the Department of Health and Human Services to gather data to define the scope of the problem in the U.S.
The term "female circumcision", used somewhat in deference to the custom's cultural and religious aspects, is misleading - the procedure involves far more than the removal of the fold of skin which covers the clitoris. In a 1994 issue of the New England Journal of Medicine (NEJM), N. Toubia described the various forms the ritual can take.
In the mildest commonly performed, clitoridectomy, the clitoris itself is removed - a procedure analogous to amputation of the penis - wrote E.J. Schoen in a letter published in the January 19 issue of the NEJM. Sometimes the labia minora are removed as welL In the most radical form of female circumcision, known as infibulation, the labia majora are also cut away to leave raw surfaces that are then stitched together to cover the urethra and the vaginal opening with a hood of skin. A pencil-sized opening is constructed close to the anus to allow emission of urine and menstrual flow. The girl's legs are bound together for a few weeks to allow the incision to heal, thereby effectively closing off the vagina completely. According to Toubia, the extent of tissue removal varies widely, up to the whim of the "surgeon" and local custom.
Unsurprisingly, female circumcision can precipitate a variety of physical problems. Performed on an area endowed with a rich network of nerves and blood vessels, the extremely painful procedure often results in massive losses of blood; shock is common, and many girls have bled to death as a result. Even minor bleeding, if prolonged, can result in severe anemia and stunt growth in children who may also be poorly nourished.
Infection of the area is a very common immediate complication; Toubia reported that abscesses, ulcers, tetanus, systemic infections, and even gangrene have resulted from the procedure. Infibulation, especially, involves a host of long-term complications. Urine flow is inhibited, which can result in chronic urinary-tract infections followed by kidney stones or kidney damage; menstrual flow is also inhibited, resulting in chronic pelvic infections.
A very common complication is cysts in the line of the scar. Incisions can heal badly, causing the victim to suffer recurrent abscesses for years, or episodes in which the scar just splits apart.
Intercourse for an infibulated woman is an undertaking in and of itself. Surgical deinfibulation (cutting open the hood of skin covering the vaginal opening) is sometimes performed before the woman's wedding day. But in a study of 290 Somali women published in a 1992 issue of the East African Medical Journal, M.A. Dike found that most of the subjects had been deinfibulated "naturally" by their husbands.
In a 1992 issue of the International Journal of Gynecology and Obstetrics, B.C. Ozumba reported seeing so many cases of vaginal stenosis (a closing off of the vaginal entrance severe enough to make intercourse intensely painful, if not outright impossible) in Nigerian women as to define the problem, in his words, as one "of public health dimensions." Neuromas, very painful nodules that can develop when nerve endings become embedded in scar tissue, can also cause severe pain whenever intercourse is attempted.
Childbirth is, obviously, another problem. Women are often further deinfibulated while in labor and reinfibulated after delivery. If deinfibulation is not performed, the delivery can be impeded or even prevented completely, resulting in extensive perineal tears and the death of child and mother. (In a 1993 issue of Social Science and Medicine, B.K. Paul showed that the extremely huge rate of maternal mortality in sub-Saharan Africa is associated with the practice of female circumcision.)
Tissue damage caused by problems with infibulated deliveries can also result in almost total urinary incontinence. If a woman has many children, with repeated deinfibulations and reinfibulations, excessive scatting can cause problems as well. Some women never have a child, since chronic pelvic infections can produce sterility.
With such a multitude of horrifying medical problems resulting from female circumcision (as Toubia points out in her paper, its psychological and sexual effects have not really been studied yet), why does the practice continue? It is not really a religious issue, according to Toubia - though commonly believed by African peoples to be a tenet of their faith, the practice is never prescribed in Islamic, Christian, or Judaic holy writings.
Rather, it is a culturally dictated custom based on the premise that women, if left with sexual organs intact, would incline to promiscuity. Some African women believe that the clitoris, if not removed, will eventually dangle between their legs; that if a baby's head touches the clitoris during birth, the child will be retarded; and that removal of the clitoris helps a woman control her emotions.
Among some, uncircumcised women are not considered suitable for marriage, and both men and women believe that circumcision makes a women more attractive and, somehow, more completely feminine. It is thus a ritual deeply embedded in the social fabric, wrapped in a cloak of religious and moral tradition, and girded by long-held beliefs regarding the proper place and behavior of women.
Faced with having to decide whether to circumcise their daughters, African women living here balance precariously between two worlds. Their parents and husbands often pressure them to maintain tradition, and the apparent promiscuity of American culture often leaves them afraid for their daughters' purity. On the other hand, a greater understanding of their own anatomy and the medical effects of circumcision, plus an exposure to Western concepts of female sexuality, may cause them to question the ritual.
African women who have dedicated themselves to intervention meet with the mothers and attempt to convince them to protect their daughters, but often the decision is taken out of the mother's hands. A husband or a grandmother, sensing a mother's ambivalence, will seize the first opportunity to do the job themselves.
Unsurprisingly, its growing number of opponents consider the term "female circumcision" a detestable euphemism. They have successfully lobbied for use of the term "female genital mutilation" (FGM) instead. Five African countries have recently joined many European nations, as well as Canada, in making FGM if not illegal, then against official policy. With American media attention and the recent publicity afforded Alice Walker's book Possessing the Secret of joy, it is only a matter of time in the U.S. before similar legislation is passed.
In addition, the World Health Organization, in conjunction with the International Federation of Gynecology and Obstetrics, has recently issued statements condemning the practice and calling for cooperative efforts to abolish it.
In a 1993 column in the New Yank Times, however, two victims of the procedure - Seble Dawit and Salem Mekuria - pointed out that pronouncements from the West are unlikely to have any real impact. Westerners must be sensitive to the social and religious foundations of the practice and work with women in Africa who are attempting to change cultural perceptions of women and the proper, healthy state of their genitalia. In the meantime, American physicians and nurses must prepare to deal with circumcised women in a culturally sensitive manner, but without condoning or contributing to a practice which has proven so detrimental to women's health.
December 1, 1995
The Los Angeles View