Ancient ritual, modern suffering: Drexel program aids survivors of female genital cutting

Salimatou Sy, an immigrant from Mali who underwent Female Genital Mutiliation (FGM) as an infant, is shown here speaking with an unidentified victim of FGM during an interview at African Family Health Org (AFHO), in West Philadelphia. Sy is a health educator at AFHO, an organization which helps African immigrants access health services.

She is an undocumented immigrant from Burkina Faso, one of the poorest countries on earth.

She fled her West African homeland a year ago with her daughter, then 11 years old, to protect the girl from a cultural rite that goes beyond class, religion, and ethnic groups.

Much of the girl's external genitals were to be cut off -- the same ritual the mother had endured 34 years earlier.

Last month, the mother sat in an office at the African Family Health Organization (AFAHO), a small nonprofit in West Philadelphia. She agreed to be interviewed through a translator, provided that her name be kept confidential. Dabbing her eyes with a tissue, she talked about her discouraging quest for work and permanent housing.

But she also described a bit of good fortune. AFAHO connected her with Drexel University's Women's Care Center in Center City, where a new health clinic is devoted to women who have undergone genital cutting, also known as female circumcision or female genital mutilation.

Like any patient at the center, she received routine preventive care, including a blood pressure check, breast exam, and Pap smear. The clinic also treated her for yeast and urinary infections aggravated by her abnormal anatomy  and assembled medical documentation for the asylum claim she will submit to U.S. immigration authorities. Fear of genital cutting has been grounds for seeking asylum since 1996.

"They were excellent," the woman said of the Drexel clinicians.

She is a beneficiary of a novel federally funded initiative unfolding in Philadelphia and 12 other American cities.  The government is giving $6 million over the next three years to try to improve health services for some of the estimated 513,000 females in the U.S. affected by the ancient practice of genital cutting.

In metropolitan Philadelphia, home to 16,500 such women, AFAHO and Drexel are collaborating with the Nationalities Service Center, a refugee resettlement agency. The partners will spend $300,000 a year for three years on a two-pronged strategy: Educate Drexel medical professionals about genital cutting, and reach out to women to offer free, nonjudgmental care at the new clinic.

The goal, said Karen B. DeSalvo, a top official with the U.S. Department of Health and Human Services, is "to identify those at risk while providing support and specialized care for survivors. These awards represent an important step forward in our fight to end female genital cutting."

An overdue step, activists say. Almost two decades ago, Congress criminalized female genital cutting and ordered an educational campaign. Health officials developed a pioneering technical manual, Caring for Women with Circumcision, and gave it to medical, nursing, and public health schools.

But with no mandates or money, the strategy has had little impact. When unprepared clinicians encounter a circumcised woman -- usually, not until she is pregnant — they have a typical reaction.

"They gasp," said Oni Richards, executive director of AFAHO.

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Genital cutting remains widespread in 29 African and Middle Eastern countries, even though most, including Burkina Faso, have laws against it.

The types of cutting, classified by the World Health Organization, range from slicing off the tip of the clitoris, to removing the clitoris and labia, to the most shocking form, called infibulation. It involves removing the clitoris and genital tissue, then stitching the area shut except for a small opening that allows urine and menstrual blood to escape.  Women are cut open, or "defibulated," for childbirth, then sewn closed again. The hole also may be widened for the wedding night.

Cutting is usually done on preadolescent girls without anesthesia, often with unsterilized tools. The immediate, occasionally deadly, consequences can be hemorrhage, shock, tetanus, and blood poisoning. Over time, there can be abscesses, cysts, keloid scars, incontinence, chronic infections, menstrual difficulties, painful intercourse, infertility, childbirth complications, and more.

The basic purpose of cutting, human rights advocates say, is to suppress women's sexuality and make them submissive.

Nonetheless, many affected women consider the practice normal and proper. Teaching Drexel obstetrician-gynecologists to be culturally sensitive — meaning don't react with shock, pity, or disgust — is part of the education initiative.

"There are a range of attitudes," said Emily Finley, community health educator at Drexel's new clinic. "Some women say they feel very traumatized, and it's psychologically difficult to come to terms with it. Others say, 'This is part of my culture, and I'm proud of it.'"

A key leader at the new clinic is obstetrician-gynecologist Sandra Wolf, executive director of Drexel Women's Care Center. For  many years, she has helped cutting survivors seeking asylum.

The new clinic, operating one day a week since October at 1427 Vine St., has seen about 25 women, with a goal of 250 women in its first year. In addition to Wolf and Finley, the clinic is staffed by ob-gyn Jasjit Beausang, and a rotating group of Drexel doctors-in-training and medical students.

Each patient's appointment lasts nearly an hour, with a translator on hand. Generally, Wolf said,  the women welcome the chance to discuss a practice that is cloaked in secrecy in their own culture,  without feeling stigmatized by American culture.

"They ask, 'What part is missing?'" Wolf said. "If they have a vaginal infection, they wonder if it's related [to being cut]. They ask, 'If I get pregnant, do I have to have a cesarean section?' We explain that usually they don't."

A few women seen so far were in crisis. One had a painful vulvar cyst that had grown so large, it was interfering with walking, yet she and her partner were afraid of surgery.

"They required a lot of counseling," Wolf said. "But ultimately, she had a complex surgery that was tremendously successful."

The other case was that of a teenager, raised in the U.S., who had undergone the least severe form of cutting as a baby, losing part of her clitoris. "She didn't know she was different until health class. She fell apart," said Wolf, who reassured her that cutting does not always preclude having a normal life, including sexual intimacy.

In training seminars, some Drexel ob-gyns have asked about their legal and ethical responsibilities if a woman asks to be reinfibulated -- reclosed after childbirth. Although it is not illegal in this country, as it is in Britain, it is clearly harmful.

"We know reinfibulation can lead to medical problems," Finley said. "So we're saying, 'Try to have in-depth discussions with the patient of the potential side effects. It can take a series of discussions."

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AFAHO, situated in a warren of offices over a fitness club at 4415 Chestnut St., used part of its grant money to hire Salimatou Sy — known as Sali — to spread the word about the new clinic. She invites women to information sessions by distributing tactful flyers in businesses that cater to African immigrants, befriending women who come to AFAHO's English language classes, and networking with refugee resettlement workers.

The job requires diplomacy, compassion, fluency in multiple languages, and a foot in two cultural worlds.

Born in Mali, Salimatou, now 41, has no memory of, and no complications from, being cut — the least severe form — as a week-old infant. She came to the U.S. in 1996, married, and earned a degree in health services management while raising five children.

Ironically, one obstacle she faces in recruiting women for the new clinic is their sense that they have healthier lifestyles, and thus less need for doctors, than Americans.

"Some of the women want to go," Salimatou said. "But some say they don't care or see the point. Preventive medical care is not something they're used to. Where we come from, we don't go to doctors unless we're really sick."

She doesn't hesitate to use hard sell techniques.

"I tell them I did it myself: I had a Pap smear and a mammogram," she said. "I tell them, 'You never know. You may have a problem you don't know about.'"