COPENHAGEN—On Monday, the World Health Organization released new guidelines for doctors caring for survivors of female genital mutilation at the Women Deliver conference in Copenhagen. Due to increasing migration from countries where the practice is common, WHO representatives said, a rising number of doctors in countries not known for FGM—including the U.S. and countries in Europe—are encountering patients with FGM-related complications.
More than 200 million women and girls worldwide are living with FGM, and a 2015 Population Reference Bureau study estimated that nearly 507,000 women and girls in the U.S. are at risk for FGM. That’s more than double the number of women and girls thought to be at risk in the country in 2000. Many of these women have come to the U.S. from countries such as Ethiopia, Somalia, and Egypt and live in immigration hubs such as California, New York, and Minnesota. Some women come to the U.S. having already been mutilated, some girls born in the U.S. to immigrant parents are sent to their parents’ native countries during school vacations to undergo the practice, and some are mutilated by visiting cutters from other nations. FGM has been illegal in the U.S. since 1996, but federal law has only explicitly prohibited sending a girl to another country for FGM since 2013.
The WHO’s new guidelines include recommendations for health care providers caring for women living with four types of FGM: removal of the clitoris and/or clitoral hood; removal of the labia minora and/or majora; removal of the labia and using it to form a covering over the vagina to narrow its opening; and any nonmedical cutting, scraping, or cauterization of the genitals. Aside from the immediate risks of FGM—including hemorrhage, infections, and death—survivors of FGM are liable to present later in their lives with recurring urinary tract infections, menstrual problems, reproductive tract infections, PTSD and depression, sexual dysfunction and pain, and chronic genital pain. They are also at risk for several adverse complications for both mother and newborn during childbirth.
For women whose vaginal openings have been narrowed or covered, the WHO recommends deinfibulation—reopening the scar tissue—to prevent or treat urinary tract issues and allow for intercourse and safer childbirth. For survivors of FGM who suffer from mental health problems and sexual dysfunction, the WHO advises health care providers to offer cognitive behavioral therapy and sexual counselling, respectively. The new guidelines also cover questions women might have before and after deinfibulation as the look and function of their genitals change. “This is the WHO’s contribution to the fight against a scourge that we feel … we have to eliminate,” said Flavia Bustreo, an assistant director-general at the WHO.
Most doctors know that FGM violates medical ethics and human rights, but outside of the countries where it’s the cultural norm, many are surprised and unsure how to proceed when they meet a woman dealing with its medical consequences. “The one gap has always be: What should the medical profession be doing about this?” said WHO director Ian Askew. “What we’ve seen is a globalization of the phenomenon because of migration, but we’ve also seen a medicalization of the procedure in many countries.”
When FGM researchers talk about medicalization, they mean genital cutting performed by doctors in medical settings. Some doctors around the world believe that, by performing FGM in sanitary conditions with medical tools, they can reduce harm and complications while promoting less invasive techniques that preserve genital function and fulfill symbolic religious demands. Research suggests that 18 percent of all FGM procedures are performed by trained health-care practitioners, even though the practice has no medical purpose. Most leaders in the medical community are extremely resistant to medicalization, which is widely thought to further entrench the practice and violate multiple human rights.
“FGM is everybody’s business,” said Comfort Momoh, a Nigerian English WHO adviser and midwife who practices in London. “People think, ‘It has nothing to do with me. It’s their culture.’ No. It is about child abuse. We’re talking about informed choice. We’re talking about consent.” Momoh performs at least one deinfibulation a week, and not just for women who underwent FGM as girls—she recently met a Nigerian woman who suffered FGM at age 40 as a punishment from her husband for planning to run away from his abuse. This is happening in England, where arranging or performing FGM is punishable by more than a decade in prison.
In the U.S., many immigrant or highly religious parents will ask gynecologists if routine exams could break their adolescent daughter’s hymen, which would impact her future premarital virginity test. Others ask doctors to perform the hymeneal virginity exams themselves, then sign a certificate of purity; some doctors acquiesce, even though there is no physical exam that can prove or disprove someone’s virginity.
Likewise, whether it’s out of ignorance of best practices or a desire to “respect” a form of torture that’s been justified as a cultural or religious practice, some doctors in the Western world still perform FGM and fail to recommend the best course of action for women suffering its consequences. Activists are hopeful that the new WHO guidelines will help make the practice less common and mitigate its effects in developed and developing countries alike. At the Copenhagen event, an audience member from London—a woman who suffered FGM at the age of 11—stepped up to the mic during a Q-and-A session with WHO leaders. “I really commend the WHO, because this will really go a long way with our work,” she said, detailing the complaints of sexual dysfunction that trouble the women in her FGM support group. “FGM does not really finish once you’ve been cut. It goes on forever.”