The pain of female genital mutilation is felt in the U.S., too

By — October 27, 2014

Her father helped her escape. He knew if she stayed in Ivory Coast, she’d be married against her will as a teenager, her genitals ritualistically cut, raped by her husband, and forced to bear his children. Her life as she knew it would end. She left for New York, where her father thought she would be safe.

Now the U.S. immigration system wants to send her back. She is 16 years old. (Because the outcome of her case is still pending, her attorney asked that she not be named.)

For survivors of female genital cutting, fleeing the country of their injury for a place like the United States can be a victory in and of itself. But it is often the beginning of a much longer struggle, one that entails reliving the very trauma they fled. In an immigration system that is increasingly under fire for its dysfunction, women whose asylum claims hinge on an experience with female genital cutting bear the burden of proof in their scars.

Survivors of the procedure endure a harrowing process in hopes of gaining asylum. The system greets them with cold skepticism, and asks that they overturn every stone on the dangerous path that brought them here to prove that they deserve to stay. As a supervising attorney for African Services Committee, a nonprofit organization that serves refugees, asylum seekers, and immigrants in New York City from across the African diaspora, Kate Webster estimates that 90 percent of her female West African clients have either experienced genital cutting or left their home countries in fear of it. And then there are the cases that happen on U.S. soil.

In the case of the 16-year-old client from Ivory Coast, Webster must convince an immigration judge that the fate her client will inevitably face if sent home is real. Yet, she explained, her client would have a much stronger case for asylum had she arrived on U.S. soil with the physical scars to prove she had already endured female genital cutting. 

“Documenting her case, that future fear, is exceptionally challenging,” said Webster.

The danger right here
Female genital cutting, also referred to as female genital mutilation (FGM) or female circumcision, is defined by the World Health Organization as “the partial or total removal of the female external genitalia or other injury to the female genital organs for non-medical reasons.” The procedure has no health benefits, and typically results in lifelong infections related to the urinary tract and menstruation. Depending on the extent of the cutting, intercourse for survivors is tolerable at best and severely painful at worst. Survivors who become pregnant face a host of other complications. For those without access to medical care, labor can result in death for the baby, mother, or both.  

A sign advises against the practice of female genital cutting in Uganda. (Amnon Shavit)

The practice, centuries old, is most common across 28 countries in the Middle East and Africa. Motivation for it varies by community and country, but its roots lie in cultural beliefs tied to marriage, purity, and a desire to further physically differentiate women from men. It is not particular to a specific religion. 

In the West, it may be easy to dismiss FGM as symptomatic of archaic traditions fostered in far-flung places. But in spite of her clear disdain for the practice, Deborah Ottenheimer, a New York-based OB/GYN, was quick to say that the issue is hardly remote. Ottenheimer volunteers her time to examine women whose asylum claims rely in part on forensic evidence obtained through gynecological exams. “People need to know that it happens here,” she said. “People get paid to do this right here in our backyard.”

In spite of its criminalization in the U.S. in 1996, FGM still takes place underground.

The Centers for Disease Control and Prevention estimate that 150,000, to 200,000 girls in the country are at risk of FGM, either in the United States or through “vacation cutting” in other countries. In “vacation cutting,” an increasingly common practice, girls are sent on trips to their ancestral homes, where they are cut against their will before returning to the U.S. to resume their lives, according to the New York-based domestic violence organization Sanctuary for Families.

Painstaking gathering of evidence for asylum
Obtaining asylum in the U.S. is a cumbersome process constructed to weed out fraud. Applicants who can present evidence of bodily harm and torture, like survivors of FGM, have a higher rate of success than those seeking relief on the basis of psychological trauma or future persecution. For an attorney like Webster, medical evaluations from U.S. practitioners are indispensable both at the asylum office and in immigration court. But the process is not without its own kind of intrinsic harm.

“Unfortunately, the collection of evidence requires the retelling of their story,” said Ottenheimer. “I’ve already read the affidavits when I do the exam. I corroborate them so I don’t have to go through every single detail again. If there are other scars, I always ask what they’re from, and sometimes that brings up a lot of sadness.”

Asylum seekers and their attorneys, if they are fortunate enough to have legal representation, must build these cases on interactions with strangers. From the judge to the doctor to the lawyer, constructing an argument in their favor requires clients to repeatedly share personal and often devastating details about their lives. For women whose claims rely on FGM, these details are all the more intimate.

Mary Malotky, a nurse midwife, has worked with women from Minnesota’s large population of Somali refugees at Hennepin County Medical Center since the mid-1990s. In 98 percent of her patients, she said she observes the most dramatic version of female genital cutting: infibulation. Infibulation entails the removal of external female genitalia, usually in addition to the clitoris, and the sealing or narrowing of the vaginal opening with stitches or glue. Before childbirth, the opening must be cut to safely deliver the baby. Malotky works to convey the benefits of leaving the vagina open after childbirth to her patients, but if a woman requests it, she is legally permitted to re-close the space. In her experience, education about the prospect of not living with chronic infections associated with being “closed” is often enough to change women’s minds.

Webster catalogs her client’s stories as thoroughly as possible. “My role is to try and learn and honor their story, but I have to ask them very detailed questions about some of their darkest times,” she said. “It is a very challenging thing to do, and I have no doubt that they are re-traumatized even by just discussing this.”

In south Texas, a former asylee from Eritrea named Yohannes finds himself searching for health care providers like Ottenheimer willing to examine women primarily from Ethiopia on a pro bono basis. (Yohannes gained asylum in the United States in 2009, but does not publicly use a last name because he has not yet gained citizenship.) Working with immigrant and refugee center RAICES as a legal assistant, Yohannes says he gains the trust of the women he serves by explaining that gynecological exams could very well save their lives. Because they are detained in remote facilities, he must negotiate not only with health care providers, but with Homeland Security and immigration officers to convince them to transport the women to a medical facility. Both Webster and Yohannes noted that access to detention facilities for medical practitioners is extremely restricted.

“Unfortunately, because they are undocumented and in detention, it’s very hard for us to find a volunteer [doctor or nurse],” Yohannes said by phone. “At this time, I have four women waiting for an exam.” He often pushes immigration officers to transfer his clients to clinics in advance of their hearings, as without forensic evidence documenting FGM, their asylum cases are likely to fail.

Ottenheimer is part of a large network of volunteer medical practitioners, coordinated by Physicians for Human Rights, who work to fill this gap. It’s the job of Jillian Tuck, the organization’s asylum program manager, to identify and connect with health care professionals across the country who want to use their expertise to protect victims and support the prosecution of human rights violations.

With volunteers in 42 of the 50 states, PHR is able to provide pro bono services to the majority of attorneys who contact them. Tuck explained that PHR volunteers are trained to serve clients, FGM survivors or otherwise, with utmost sensitivity. Their approach is grounded in ensuring the practitioner has the informed consent of their patient, and an open and communicative exam process that aims to put the patient at ease and help them understand why intrusive and painful questions are necessary.

“The hope is that if they can get through this process, having status here and not having the threat of being sent back to their country to face further harm is the first step in the healing process,” said Tuck.

To successfully pursue an asylum claim, an attorney must prove that their client suffers from past persecution, or fears future persecution because of their membership in one of five statutory categories: race, religion, nationality, political opinion, or the ambiguous “membership in a particular social group.” Women who survive FGM fall into that last legal category, and it is the job of advocates to highlight the ways in which FGM is part of ongoing persecution.

“It’s only one event in a long lifetime of living in a culture that’s not friendly to women,” said Ottenheimer. “That’s one of the things you want to emphasize in the affidavit.”

In 2008, the U.S. Court of Appeals for the Second Circuit made great strides in safeguarding FGM survivors by granting asylum to three Guinean women whose applications had been denied. In Bah v. Mukasey, the court rejected the Board of Immigration Appeals’ reasoning that because the women had already been cut there was no future risk of harm. Since then, Webster says the law is very clear that female genital cutting is considered past persecution, which gives applicants a presumptive eligibility for asylum. But they have to prove it first.

The trauma of gaining asylum
When asked what percentage of applicants is revealed to have fabricated their FGM experience once they make it to the exam room, Tuck thought for a moment. Lying to seek asylum is not unheard of; surely in desperation some of these women exaggerated the extent of their condition. She eventually recalled one case in which a woman had lied about being cut. The clinician who evaluated her ultimately diagnosed her with psychosis. In the context of FGM, such cases are few and far between.

“There is this presumption that every migrant, and every person that interacts with the immigration system that they’re up against, is probably not telling the truth,” Webster said. “The immigration system is structured in a way that it requires types of evidence that are just extraordinarily unnatural for people to produce.”

A refugee woman must lay bare her scars, her stories, or the fear of what will come if she is sent home. Her attorney, if she has one, must then translate and adapt this information to fit into the confines of our immigration system.

“I see clients who arrive here and they’re terrified, and have suffered untold horrors,” said Webster. “Our system makes it worse for them.”

Regardless of the sensitivity displayed by the attorneys, doctors, and psychologists who work to construct such asylum claims, the process itself is unavoidably traumatic. These advocates only have control over their clients’ treatment up to a certain point. Eventually, a woman will find herself before an asylum officer or judge whose primary objective is to determine the strength of her case—not to make sure she isn’t re-traumatized in the process. At this point, she must hope she has exposed enough, in the right way, to please the system. Her very life depends on it.