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Female Genital Mutilation is a Problem in the US

And no one knows how to track it—or solve it.

This summer Egypt enhanced a 2008 law against female genital mutilation (FGM). 

Under the 2008 law, those practicing FGM in the country faced only three months to three years in prison, and few cases were prosecuted, leading to only modest reductions in the national FGM rate in recent years at best. This summer also saw revelations that Raslan Fadl, the first doctor convicted under the old regime after he killed 13-year-old Sohair al-Bata'a during the process, had actually avoided his two-year-three-month sentence and was still performing FGM procedures, a strong representation of the impunity reigning over the nation. 

FGM is relatively common in at least 30 nations, mostly in Africa, and documented in ethnic enclaves worldwide. But it's especially prevalent in Egypt, where about 87 percent of women between the ages of 15 and 49 having undergone it. The new law, which drastically increased sentencing guidelines to five to seven years with harsher punishments for those who kill or maim a girl in the process, ostensibly signaled a commitment to address this impunity. Many in the wider world hoped it would lead to a more serious crackdown on the practice in a major offender nation. So many cheered its successful passage and enactment—especially in America, where NGOs and the government proper have long worked to reduce FGM. 

All this focus on FGM in Egypt and other African nations makes it seem, to many Americans, like this is a foreign issue. But advocacy groups and legal agencies have long recognized that FGM is a problem in the US as well—nowhere near as prevalent as in Egypt, but not insignificant either, with stories not infrequently cropping up of girls being flown out of the nation to undergo the practice, or facing it at the hands of traditional cutters and doctors within insular communities on US soil. Health bodies and anti-FGM groups have long tried to combat and raise awareness of domestic FGM. But they face a major roadblock: We don't have any solid data on the scale or contours of of the problem. 

The practice ranges from a "nick" on the clitoris that can cause scarring and pain to the full removal of the clitoris and sewing up of the labia, which not only guarantees painful sex but risks immediate death and potentially deadly complications urinating, menstruating, or giving birth. It affects at least 200 million women worldwide, with up to three million more at risk each year. 

As the global anti-FGM organization Equality Now put it in a report on the practice in the US: "Other countries are far ahead of the US in their data collection, prevention and training programs, health services to survivors, prosecution of perpetrators, and public awareness of women and girls affected by or at risk of FGM." 

Following the prompting of anti-FGM groups, health and statistical bodies in the US have tried to measure the number of girls and women who've either already undergone or are at risk of FGM in the nation. In 1997, the Centers for Disease Control and Prevention (CDC) estimated that figure at 168,000 people. More recently, a 2015 estimate by the Population Research Bureau and a 2016 CDC follow-up on its 1997 estimate put the number at 513,000—an apparent spike that triggered a flurry of outraged newspaper headlines.

But these figures likely don't present a particularly accurate picture of FGM in America. They were all compiled by taking recent reliable census data, looking at the number of immigrants or children of immigrants in the US from countries with a national prevalence of FGM of at least two percent, then multiplying immigrant numbers by the rates of FGM in their homelands. 

As the CDC itself points out in its most recent study, this methodology doesn't reflect the fact that national prevalence rates, aside from sometimes being outdated or generally unreliable, fail to show regional, ethnic, or economic differences in each country, which ought to be mapped onto the US. It also fails to account for the self-selection among populations that migrates to America, which often won't act like the nationwide norm of their homelands to begin with, or for assimilation of those who do act like the nationwide norm under new American cultural and legal influences—both factors that don't show up in census data.

The result is less an accurate map of FGM victims and risk cases in the nation and more a rough map of west, central, and east African migration into America, which flags high concentrations of Ethiopian, Egyptian, and Somali migrants as especially high-risk zones given the prevalence of FGM in their homelands as a whole. (None of the migrant organizations Tonic reached out to for this story responded to questions about whether this at-risk labeling in government studies has affected first and second-generation communities regardless of actual FGM rates or stances.) 

"National data have never been collected in a scientifically acceptable manner," says Holger Postulart, executive director of the Swiss-based Global Alliance against FGM, which is not yet active in America, "on how frequently FGM occurs among women and girls living in the US."  

America's tried, even without a full picture, to fight against domestic FGM through belated legislation. In 1997, congress criminalized FGM—and technically cosmetic labial surgeries, although that's never been enforced—with a penalty of up to five years in prison. (That ban came 12 years after an equivalent law passed in the United Kingdom.) In 2012, the legislature expanded that law to include penalizations for "vacation cutting"—flying girls back to their or their parents' home countries for FGM. In 2015 legislators introduced a new bill to increase public education on and specialists' ability to detect, report, and provide services to those at risk of FGM—but that bill stalled out in congress

Many groups, especially those well-acquainted with migration patterns, do their best to directly engage with new arrivals and established communities they believe are most at-risk, says Amanda Parker, executive director of the US-based Aha Foundation, which fights for anti-FGM legislation. Especially when advocates within those communities initiate those conversations, they can avoid alienating insular groups who are—as seen by the failure of outside groups to reliably identify them—hard to detect. 

Campaigners argue that even flawed data can and do help to bolster the sense of urgency behind new legislation and intra-community interventions. Parker points out that what we do know still gives them a decent starting place to look for those at risk and that any legislation sends a broad and strong signal to dissuade would-be practitioners. 

But, "there's not enough funding… there's not enough targeted community work," points out Adwoa Kwateng-Kluvitse, the head of global advocacy of the British anti-FGM group Forward. And without solid information on the shape FGM takes in America, it's hard for outsiders and funders to know which communities to target with limited resources. It's also hard for law enforcement to know where to focus their efforts to police the nation's extant laws, which have only yielded a handful of convictions. And it's hard to know in any systematic and definitive way which interventions work the best—which is a real concern, given how anti-FGM programs have at times backfired abroad, shifting the practice into weedier, more entrenched, or more dangerous and opaque forms. 

"There is no question: further exploration is greatly needed as is well-targeted activity," says Postulart of the modern American anti-FGM landscape. "Besides the lack of data there is the lack of action," which he and others believe is tied directly to this sense of uncertainty. 

Unfortunately, according to Howard Goldberg, the lead author of the CDC's most recent study on FGM prevalence and risk in America, no one's totally sure how to gather better data. "Ideally, it would be a population-based survey carried out in communities with large populations from [FGM]-practicing countries that specifically asks about experiences and plans related to [FGM]," he says. 

Others have suggested that we ought to look to the UK, which in 2015 initiated compulsory reporting from medical personnel and counselors about FGM amongst their patients to a health body. This summer, they published their first report, identifying 5,700 new cases of FGM, 18 of which were performed in the UK, helping to feed outrage in a parliamentary commission which noted that despite these figures no one has ever been convicted under their anti-FGM laws. 

Neither approach would be easy. A massive study, Goldberg points out, would depend on the willingness of communities to open up to researchers, not to mention a good deal of manpower and funding. And automated reporting would run into all manner of domestic privacy concerns

But for America to fully comprehend and best act upon its own FGM problem—and by so doing avoid a massive irony in its concentration on FGM abroad—the nation will need to invest in deep trust-building in broad at-risk communities. Once we know which sub-groups truly see high levels of risk and establish how common the practice is here, dedicated organizations can efficiently mobilize public sentiment and support and accurately measure the effect of interventions.