Tuesday, May 14, 2019

Female Genital Mutilation in the United States: Estimating the Number of Girls at Risk

Female Genital Mutilation in the United States: Estimating the Number of Girls at Risk

by Phyllis Chesler
Dignity: A Journal on Sexual Exploitation and Violence
May 2019

Female genital mutilation (FGM) is not at all like male circumcision. Despite the politically correct preference for calling it "genital cutting," FGM is usually far more than a mere cut.

It is a procedure that involves removing part or all of the external female genitalia (or any other injury to the female genitals) for non-medical reasons.

There are four types of FGM that have been identified. Type 1 is a clitoridectomy, which removes part or all of the clitoris. Type 2, excision, removes part or all of the clitoris and inner labia, with or without removal of the labia majora. Type 3, infibulation, is a narrowing of the vaginal opening by creating a seal, which is formed by cutting and repositioning the labia, and type 4 involves any other non-medical procedures to the genitals, such as pricking, piercing, incising, scraping, stretching, and cauterizing the genital areas (National Health Service, 2016).

Due to immigration, FGM now poses a potential health crisis in North America.

Not only is the capacity for sexual pleasure destroyed, serious medical complications are routine and include bleeding, painful urination, cysts, dangerous and recurrent bladder and urinary tract infections, the growth of scar tissue that make marital intercourse a nightmare and that turns childbirth into an experience of danger and torture (World Health Organization, 2018). It increases the likelihood of newborn deaths. In addition, some girls and women develop fistulas and become incontinent. They are doomed to defecate and urinate without control. Absent effective surgery, this is a lifelong condition which leads to the woman being shunned by her family.

In addition, a lifelong post-traumatic stress disorder routinely accompanies the experience of having been subjected to such pain and long-term suffering—by your own mother or grandmother, and traditionally, at the hands of a female butcher, or today, perhaps, at the hands of someone more expert.

The World Health Organization confirmed that this hellish procedure renders absolutely no health benefit and, on the contrary, harms its victims beyond measure and violates their human rights (World Health Organization, 2018). This practice is common in Africa, the Muslim Middle East, and increasingly in the Muslim Far East (Asian Pacific Resource and Research Centre for Women, 2019; Kine, 2016).

Despite the cultural reasons given to justify this atrocity, in my view, FGM is a crime against humanity. We may not be able to prevent or prosecute such a crime if it takes place in Somalia, Sudan, Kenya, Eritrea, or Egypt. But we can and must stop this crime if it takes place in the West, especially in the United States.

Due to immigration, FGM now poses a potential health crisis in the West, both in Europe and in North America.

What steps might we take to abolish this practice? First, we must understand the size and scope of the problem both here and abroad. To do so, we need a plausible way to estimate ongoing and potential incidence rates. What do we really know?

Imam Shaker Elsayed of Dar al-Hijrah Islamic Center in Falls Church, VA, sparked controversy in 2017 by recommending female genital mutilation to avoid "hypersexuality."

In the 21st century, numerous surveys, studies, reports, memoirs, resolutions, declarations, and statements were published about FGM, and by the World Health Organization (Ali, 2007; World Health Organization, 2016). Non-enforceable resolutions have been repeatedly passed by UNICEF, the UN Population Fund (UN-FPA), and by the UN General Assembly (Ki-Moon, 2012; OHCRH, 2008; UN Children's Fund, 2013; UNFPA-UNICEF, 2017; UN General Assembly, 2016; UN General Assembly, 2018; UN Population Fund, 2018; World Health Organization, 2004).

The guesstimates of FGM prevalence vary greatly and range from 3 million to 70 million girls at risk for FGM worldwide (at any given moment in time), and between 125 million to 200 million girls and women who have already been genitally mutilated (Ali, 2019; UN General Assembly, 2016; UNICEF, 2018; World Health Organization, 2016). Most researchers agree that this atrocity is underreported and that their guesstimates are possibly only the tip of the proverbial iceberg.

None of the studies or surveys employ the same methodology (UNFPA-UNICEF, 2017). Also, researchers and advocates have done surveys or interviews in different countries and in different years.

For example, in 2004, based on a survey, UNICEF reported that "1,367 communities representing 20% of the practicing population (in Senegal) were contacted or educated" (UNICEF, 2004). However, we do not know what this educational outreach achieved. There is no way to compare this to other communities in Senegal or to any country other than Senegal.

In 2014, the British Health Service released a study that documented "467 newly identified cases" of girls and women who had been genitally mutilated. Half live in London. Previously, 1,279 girls and women were known to be receiving post-mutilation treatment (British Department of Health, 2014). Estimates suggest that up to "170,000 women and girls living in the UK have undergone FGM." Again, there is no way to compare this to any country other than the UK, and only for the years sampled.

In 2016, another UK study released by the National Health Service (NHS) and published by Plan International UK reported that between April 2015 and March 2016, "there were 8,656 times when a girl or woman was assessed at a doctor's surgery or hospital" (British National Health Service, 2016; Plan International UK, 2019). They report that a patient was assessed on average every 61 minutes. Among those, a case of FGM is newly recorded "every 92 minutes on average." This is a promising and plausible way of trying to measure incidence in the West but it may only be true for the UK and for the year sampled.

According to a 2016 report issued by UNFPA, "more than 3,000 communities, involving nearly 8.5 million individuals, made public declarations of abandonment of female genital mutilation and cutting (FGM/C). This brings the total number of public declarations to more than 6,000, and the number of individuals reached to more than 18 million since the start of Phase II in 2014. In addition, more than 1,000 Egyptian families have declared abandonment of FGM" (UNFPA-UNICEF, 2017).

However, it is unclear whether these "public declarations" were actually honored.

In 2018, UNICEF stated that "there has been an overall decline in the prevalence of the practice in 29 African countries and two Middle Eastern countries over the last three decades" (UNICEF, 2018). Countries with the highest prevalence of FGM, according to this report, are Somalia, Guinea, Sudan, Egypt, Sierra Leone, Eritrea, and Mali.

According to the UNFPA (2018), fourteen European countries (UK, France, Spain, Norway, Austria, Italy, etc.) have banned FGM (UNFPA, 2018). Thus far, twenty-eight American states have also done so. Despite all these bans, to date, to the best of my knowledge, there have been very few prosecutions. One was in the UK, one was in Egypt, and one was in the United States (BBC, 2015; Chesler, 2018a; Equality Now, 2018; Friedman, 2018; Ly, 2018; Victor, 2017; Yore, 2019).

In 2001, in Atlanta, Georgia, a father, Khalid Adem from Ethiopia, cut off his 2-year-old girl's clitoris with a pair of scissors. He was arrested and, in 2006, tried and convicted of "aggravated battery and cruelty to children." He was not convicted for FGM because the crime had occurred before Georgia had criminalized FGM. After serving ten years in federal prison, he was deported to Ethiopia in 2017. Please note that he was jailed and deported but not for an FGM violation. While I am in favor of banning FGM in the remaining American states, such bans alone may be necessary but are not be sufficient.

In 2018, a rather sophisticated study was released by bio-statisticians, mathematicians, epidemiologists, and public health experts at six universities in the UK, Norway, and South Africa (Kandala, 2018). They stated that, "Recent estimates show that more than 200 million women and children around the world have undergone female genital mutilation and cutting (FGM/C)" and that there is "... an emerging consensus that more than three million children in Africa are now at risk each year." This is based on their meta-analyses of data originally collected by UNICEF. However, there is no way to mix and match these and similar findings in order to draw a more comprehensive conclusion.

This minimal sampling of reports demonstrates how difficult it is to measure the incidence of FGM in a way that can be generalized to many countries or to other areas in the same country. The reports are more suggestive than conclusive. In part, this is because the subject itself seems to be both a hidden and moving target. There is no sure way of estimating incidence rates in the West based on surveys in non-Western countries. Or is there? A recent and very sensible approach may allow us to do so.

One creative way of measuring incidence rates has been to measure the prevalence of FGM in the non-Western countries where it is practiced and then to calculate how many immigrants from such countries are living in the West.

In the 2018 Kandala study: "Accurate, up-to-date information on prevalence of FGM/C among children is necessary for the development of national and international health policies for prevention of these practice; and would allow international public-health policy-makers to assign sufficient priority and resources to its prevention.

The United States

In 2016, an American Centers for Disease Control-based Public Health Report concluded that as of 2012, "an estimated 1.1 million women and girls living in the United States were born in FGM/C-practicing countries or were born in the United States to women born in such countries. Thirty-six percent were younger than 18 years of age. According to this Report, the total represents an increase of about 863,000 women and girls from the 1990 estimates" (Holdberg, 2012).

According to a 2016 Report issued by the Population Reference Bureau (PRB), "there were up to 507,000 U.S. women and girls in the United States who had undergone FGM/C" or were at risk of the procedure (PRB, 2016). This figure is more than twice the number of women and girls that Brigham and Women's Hospital estimated to be at risk in 2000 (228,000) in the United States (Brigham and Women's Hospital, 2000).

The PRB report states that the "rapid increase" in girls at risk in the United States "reflects an increase in immigration to the United States... The estimated U.S. population at risk of FGM/C is calculated by applying country- and age-specific FGM/C prevalence rates to the number of U.S. women and girls with ties to those countries. A detailed description of PRB's methods to estimate women and girls at risk of FGM/C is available" (PRB, 2013).

PRB found that "55 percent of all girls and women at risk in the United States immigrated from three countries: Egypt, Ethiopia and Somalia." These countries have a high FGM/C "prevalence rate for women and girls." Since "ninety one percent" of girls and women are genitally mutilated in Egypt; 74 percent in Ethiopia, and 98 percent in Somalia," the PRB estimated that about 97 percent of U.S. women and girls at risk were from these African countries, while just 3 percent were at risk from the Arab Middle East (Iraq and Yemen)." (See Table 1.)

Based on their knowledge of which specific countries the girls or women have immigrated from and the prevalence of FGM in that country, the PRB estimated that in 2013, 65,893 girls and women were at risk in New York-New Jersey-and Pennsylvania; 51,411 were at risk in Washington-Arlington-Alexandria, WV; 37,417 were at risk in Minneapolis-St .Paul-Bloomington-Wi; 23,216 were at risk in Los Angeles-Long Beach-Anaheim; 22,923 were at risk in Seattle-Tacoma-Bellevue, WA. They estimate risk in seven other locations and conclude that as of 2013, 506,795 girls and women were at risk of FGM in the United States. Important to note that the largest at-risk populations (216, 370) live in large metropolitan areas in New York, Washington, Minneapolis-St. Paul, Los Angeles, and Seattle. (See Table 2.)

This comparative demographic work is the most promising guesstimate thus far. It helps us understand how many girls may be at risk in a particular state and city and allows us to focus outreach program there. Interestingly, most of the states in which at-risk girls live—have banned FGM.

In terms of Europe, German researchers (2018) took a similar demographic approach and found that the majority of girls and women at risk for FGM (or who had already been genitally mutilated) had immigrated to Germany from Egypt, Ethiopia, Eritrea, Somalia, Indonesia, etc. (Terre Des Femmes).[1]

Based on the UNICEF surveys, which were conducted between 2000 and 2017, and which dealt with 208,195 children (0-14 years old), the six researchers (Kandala, 2018) found a "huge and significant decline" of FGM in 29 countries in Africa and in some countries in the Muslim Middle East." They believe that this "decline" may be due to the "legal ban on FGM/C among children currently in place in most of these countries."

But even Kandala, Ezejimofor, and Uthman (2008) admit that there is a "...possibility of (a) reverse trend in some countries." The "risk factors include lack of, or poor education, poverty, and continued perception of FGM/C as a potential marriage market activity." Further, they concede that their "findings" may be "distorted" due to the fact that "FGM/C may be under-reported. In fact, a recent body of evidence suggests that under-reporting of FGM/C cases could occur."

Banning Female Genital Mutilation

If Kandala et al. are right, banning FGM, state by state, in the United States is important. Even if their conclusion is premature, criminalizing FGM is still a necessary if not sufficient first step.

Recently, a United States' Federal District Judge ruled that the federal ban against FGM was "unconstitutional" (Friedman, 2018). The Department of Justice (DOJ) refused to appeal this to the Supreme Court and instead suggested new legislative guidelines for an anti-FGM federal ban (Department of Homeland Security, 2017; Ryan, 2019). As of this writing, Congressional leaders have "asked the U.S. 6th Circuit Court of Appeals for permission to intervene in the case" (Baldas, 2019).

However, does criminalizing a human rights atrocity truly abolish it? While criminalization is a necessary first step, it is far from sufficient in terms of deterrence, prevention, prosecution, or abolition.

To date, there has been a total absence of political will and funding in terms of combatting violence against women and children in general.

Thus, while bans have existed for 37 1/2 years in parts of the West and in Egypt, as noted above, only two prosecutions have taken place—one in the UK and one in the United States, which failed.

Despite all that we have gained in terms of American women's rights—and we have gained a great deal—we still have not managed to abolish such violence. Prosecutions of incest, rape, and domestic violence are minimal (Fontaine, 2013; Leins, 2015; The National Domestic Violence Hotline). Rescue and refuge for the female and child victims of violence are less than minimal (The National Network to End Domestic Violence, 2016).

Do some judges and police officers still subconsciously believe that family and community dissolution is worse than incest or woman-battering and that society will collapse if the family does not remain intact? Perhaps they do. But the toll on society is already great given the costs in terms of prison, mandated education, lifelong medical care for the victims—as well as the loss of potentially productive citizens due to trauma-caused disabilities.

Political correctness and misplaced "sensitivity" to immigrant customs explain why FGM is so rarely prosecuted.

If Americans lack the will (and, arguably, the means) to prosecute violence against American women and children who live in fully integrated communities, imagine the reticence when it comes to American immigrant communities. A misplaced "sensitivity" to immigrant customs (such as FGM, the Burqa, polygamy, child marriage, honor-based violence, etc.) and a fear of inflaming both the immigrant and politically correct "street," might also explain why FGM has been so rarely prosecuted in America.

That—coupled with a lack of concern for women of color—may also account for this.

Also, no one wants to turn family members or neighbors over to prosecutors.

What conclusions may we draw? First, that guesstimates of FGM are all that we have and that they vary widely both globally and in the West.

Given the rise in immigration from African, Middle Eastern, and South East Asian countries; the rise in Islamic/anti-Islamic/pre-Islamic fundamentalism; and the enduring poverty and illiteracy in the developing world, not only is the suffering of women worldwide beyond belief, the problem we face in the West is huge, possibly magnitudes more than these guesstimates.

But in the West, especially in the United States, if we have the political will, we may be able to a) prevent this child abuse atrocity from happening within our borders; b) educate immigrants about the lifelong harm such a practice causes; c) have the ability to rescue children before they have been genitally mutilated; and d) retain the legal means to prosecute their parents, relatives, and doctors for refusing to obey the law.

We may be able to spare numerous girls such untold suffering. Perhaps we may even be able to abolish the practice within our borders.

We must at least try.

Phyllis Chesler, a Shillman-Ginsburg Fellow at the Middle East Forum, is an emerita professor of psychology and women's studies and the author of sixteen books. The author would like to acknowledge the assistance of Emily G. Feldman. Dignitythanks Eleanor Gaetan for her review and comments on this article.


[1] According to a website titled, in an undated and sadly anonymous report, similar estimates were obtained for six countries in Europe. In France, of 205,683 girls, 12-21% were at risk of FGM; in Italy, of 76,040 girls 15-24% were at risk of FGM; in Belgium, of 22,544 girls, 16-27% were at risk of FGM; in Greece, of 1,787 girls, 25-42% are at risk of FGM; in Cyprus, of 758 girls 12-17% are at risk of FGM; and in Malta, of 486 girls, 39-57% are at risk of being genitally mutilated.


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