-Caveat Lector- The Philadelphia Inquirer, May 27, 1999 Manual addresses circumcised females' problems By Marie McCullough INQUIRER STAFF WRITER After years of unprecedented African immigration, North American health professionals are seeing growing numbers of women who have undergone the controversial practice of female genital mutilation. Doctors have been confronting difficult births, unusual gynecologic problems and ethical quandaries, complicated by their own emotions, as they try to relate to patients who consider ritual mutilation normal and proper. Now there is some guidance. Next month, the American College of Obstetricians and Gynecologists will send its first-ever clinical guidelines on genital mutilation - or "circumcision," the less judgmental term physicians are urged to use with patients - to all OB-GYN training programs in Canada and the United States. The guidelines will be complemented by a pioneering technical manual, "Caring for Women with Circumcision," that the U.S. Department of Health and Human Services is distributing to medical, nursing and public-health schools. Written by Nahid Toubia, the first female surgeon in Sudan and an expert on female genital mutilation who now teaches at Columbia University, it covers medical, cultural and legal considerations. These are part of an educational campaign Congress ordered under a 1997 federal law criminalizing the practice of female genital mutiliation. "Because we're seeing more and more of these patients, and it's such a sensitive issue, physicians need to get with it," said Nawal Nour, an OB-GYN at Boston's Brigham and Women's Hospital who gave a seminar on the practice at the American College group's national meeting in Philadelphia last week. About 168,000 circumcised women or girls at risk of the rite were in this country in 1990, according to a federal estimate based on the last census. Experts say that estimate is now far too low. Nearly 80 percent of the women lived in New Jersey, Pennsylvania and 10 other states. Several thousand live in the Philadelphia area. Female genital circumcision, a 3,000-year-old tradition that crosses religious and ethnic lines, is practiced primarily in 28 African and Middle Eastern countries, even though most of them have laws against it. The practice ranges from slicing off the tip of the clitoris, to cutting the clitoris and labia minora (inner lips), to the most shocking form: removing the clitoris and genital tissue and then stitching the genital area shut, except for a small opening through which urine and menstrual blood escape. Women with this severest type, called infibulation, are cut open, or "defibulated," for childbirth, then sewn closed again. The opening also may be widened for the wedding night. Infibulation is the norm in Sudan and Somalia. Circumcision is usually done on preadolescent girls by traditional circumcisers without anesthesia, using razors, knives or glass. Urban families may use a physician - a trend condemned by the World Health Organization as giving medical legitimacy to genital mutilation. The procedure can cause immediate and occasionally deadly complications, including hemorrhage, shock, blood poisoning and tetanus. In the long term, there can be abcesses, cysts, keloid scars, incontinence, chronic pelvic or urinary-tract infections, menstrual difficulties, sexual dysfunction, infertility and childbirth complications, as well as psychological problems. When they come to this country, circumcised women typically do not seek medical attention until they are pregnant. "Many health practitioners . . . will have never encountered female circumcision. . . . Most often they will see a woman who is pregnant or in labor, and will confront medical decisions that must be made quickly and which they have never before considered," U.S. Health and Human Services Secretary Donna E. Shalala wrote in the new manual. In emergencies, doctors unfamiliar with the simple procedure of defibulating pregnant women may instead perform a cesarean section, which experts say is normally unnecessary. Beyond pregnancy, the women can pose unusual medical challenges. University of Pennsylvania Health Systems OB-GYN Ann Honebrink said she consulted colleagues about treating a woman with a difficult cyst. Rosa Hyatt, an OB-GYN who has seen more than 100 circumcised women at Mercy Hospital, has been asked about reconstructive surgery. For many doctors, the hardest part is learning not to show shock, pity or other emotions that may alienate patients. "I'm a white, middle-class female, born and raised in New Jersey," said Jamie Reedy, a physician who works at a New Brunswick clinic that serves African refugees. 'My initial response was, 'Oh my, God! These women are being tortured and mutilated.' Part of medical education needs to be how to approach these women nonjudgmentally." During the seminar, Nour warned about common pitfalls: "It is important to recognize that most women who have undergone this practice do not consider themselves mutilated. They would be offended if you used that word with them." Nour's family defied tradition, but growing up in Sudan and Egypt, she came to understand that circumcized women consider genital cutting an essential part of their womanhood. They believe it tames their sexuality and preserves their virginity until they are married, a status crucial to economic and social survival in poor societies. "The question I'm often asked is 'Why? Why do parents do this to their daughters?' " Nour said."What I try to explain is that parents don't do it to their daughters. They do it for their daughters. It is done out of love and protection, not out of cruelty or torture." Physicians should also understand that patients, constrained by modesty and perhaps language barriers, may not want to discuss the subject. "These are issues these women are taught not to talk about," Reedy said. The dilemma for health-care providers, experts say, is how to be respectful, while still taking every opportunity to teach about the harmfulness of genital mutilation. Some doctors miss opportunities for fear of imposing their values. An example involves reinfibulation - reclosing a woman after she is opened for childbirth. Though it is not illegal in this country, as it is in Britain, it is clearly unhealthy. Experts say every effort should be made to counsel against it. Yet at one major Philadelphia hospital, an OB-GYN said she had been taught to offer such women a choice: "If they want it repaired the exact same way they were before, they just have to tell us." Even more sensitive is the issue of counseling patients against circumcising their daughters. Though most immigrants abandon the ritual, some perform it here in secret or travel to Africa for it. A few naively request it in North American hospitals, confused when they hear that circumcision is offered for male babies. Toubia, who heads a woman's health and human rights organization called RAINBO, offers guidance in the new manual about whether to involve social service or child-abuse authorities when a family plans, or carries out, circumcision. Hyatt, at Mercy Hospital, said she once spent nine frustrating months trying to dissuade a woman from taking her baby daughter to Africa. "Finally she said to me, 'You're right.' She had a lot of pain and nightmares after her own circumcision was done," Hyatt said. Meserak "Mimi" Ramsey, 46, a nurse in San Jose, Calif., who was circumcised as a child in Ethiopia, has intervened on behalf of immigrant teenagers, torn between their heritage and Western culture. Helping teens can be legally tricky, because they may need parental consent for treatment. "Every two weeks, I get a call from a girl who wants to be opened [defibulated]," Ramsey said. "Often, they're going to college, and they call me and say 'Help me.' . . . Recently I took a 19-year-old girl to a hospital. The girl was almost completely closed, and she had a terrible infection. She said she tried to open it with her finger. She was in such pain." Ramsey founded Forward USA in 1996 to conduct outreach and education among immigrants. She welcomes the national initiatives. "This year I was in a San Diego high school, where there are many, many Somali students," she said. "And I was educating the school nurses. They don't know why all these girls are complaining about their menstrual problems. The nurses would give the girls a Tylenol and think they were just trying to get out of school. So here I came with a picture [of infibulation] and explained the problem to the nurses. "One of the nurses just cried nonstop. She said, 'I didn't have a clue.' " © 1998 Philadelphia Newspapers Inc. ================================= Robert F. Tatman [EMAIL PROTECTED] [EMAIL PROTECTED] Remove "nospam" from the address to reply. NOTICE: In accordance with Title 17 U.S.C. Section 107, this material is distributed without profit to those who have expressed a prior interest in receiving the included information for research and educational purposes. For more information go to: http://www.law.cornell.edu/uscode/17/107.shtml POSTING THIS MESSAGE TO THE INTERNET DOES NOT IMPLY PERMISSION TO SEND UNSOLICITED COMMERCIAL E-MAIL (SPAM) TO THIS OR ANY OTHER INTERNET ADDRESS. 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