Genital Cutting Cases Seen More as Immigration Rises

DENVER — One immigrant woman told of visiting five gynecologists in recent months, each of whom gasped audibly at her anatomy.

Another went to see a doctor, only to become the subject of a gawking crew of medical residents.

And a third said she had never visited a gynecologist, despite experiencing abdominal pain since age 10, when her genitals were cut in her native Gambia. “I feel ashamed,” said the woman, Mariama Bojang, 25. “The doctor has probably never seen anything like this. How am I supposed to explain it?”

As the number of African immigrants in the United States has grown, so has the number of women living in this country who have undergone genital cutting. About half a million women in the United States have experienced the procedure or are likely to be subjected to it by their families, according to a preliminary report from the Centers for Disease Control and Prevention. That figure is about three times the last government estimate, made in 1997.

A study to be released Friday by the Population Reference Bureau is expected to show similar numbers.

Public health officials, however, are warning that some doctors and nurses are not prepared to deal with the physical and emotional complications associated with the procedure — sometimes called female genital mutilation or F.G.M./C — and in some cases may unintentionally traumatize the women they are trying to help.

“More and more health providers are going to be taking care of women who’ve undergone F.G.M./C,” said Dr. Nawal Nour, the director of the African Women’s Health Center in Boston, considered by many to be the leading clinic in the United States for women who have undergone genital cutting. Many of her patients, she said, describe “a humiliating time with health providers.”

Female genital cutting is an ancient tradition concentrated in 29 countries in Africa and the Middle East. It is on the decline in some communities but still the norm in others, with more than 90 percent of women cut in Somalia and Guinea. The cutting can be as limited as a small incision or as extensive as an infibulation, which can involve removing the clitoris and repositioning the labia to form a seal with a small opening.

The practice remains a respected tradition in some cultures, linked to purity and community acceptance, though it has no medical benefits and is commonly described as excruciatingly painful, as it is usually conducted without anesthesia.

It is outlawed in United States, and it is also illegal to send a girl abroad to undergo the process. But the country has had a surge of African immigrants in the last two decades, at least some of whom experienced it before they arrived. And some families flout the law and send their daughters abroad to be cut.

Here in Denver, a refugee hub, Dr. Gretchen Heinrichs, a gynecologist, has treated many women who have had their genitals altered. Her patients come from Ethiopia, Sudan, Burkina Faso, Mali and elsewhere. “We’re seeing a lot more F.G.M.,” she said.

Patients’ needs are many. For women who complain of painful sex, Dr. Heinrichs has opened fused closures, using anesthesia. She once removed a large cyst that a woman had developed as a result of the procedure.

Dr. Heinrichs treats wound-related infections and sends unsatisfied couples to sex therapists. She also works to balance foreign tradition and American medical ethics. Sometimes, a pregnant woman asks that the doctor reseal her labia after birth, returning her body to its previous, traditional appearance. Federal law and the American Congress of Obstetricians and Gynecologists allow for this, and some doctors, including Dr. Heinrichs, comply.

But it is a difficult point for Dr. Heinrichs and her colleagues at Denver Health Medical Center.

In one case, a patient gave birth, and her husband, a physician in his home country, turned to the doctor. “He said, ‘Make sure you repair her circumcision,’ ” recalled Dr. Heinrichs. “I said to her, ‘Is that what you want?’ And she said, ‘Yes,’ but you’re never going to know if that’s truly her wish.”

The procedure has caused some controversy, particularly in London, where one doctor was recently charged with violating the United Kingdom’s 2003 Female Genital Mutilation Act after he stitched a woman’s labia in the minutes after she gave birth. The doctor, who was performing an emergency delivery, was found not guilty. In a statement, he called genital cutting “an abhorrent practice.”

The American Congress of Obstetricians and Gynecologists has had a guide on the issue of female genital cutting since 1995, and in immigrant hubs like Denver, New York and Seattle, physicians have been treating women with genital alterations for years.

In medical schools, however, education on the issue is “rare and random,” Dr. Nour said. “It’s treated as a haphazard topic of interest.” Most health care providers have no experience discussing the issue with women or their partners, and do not know how to treat complications, she said.

Dr. Nour said she received calls from flummoxed health professionals treating immigrant women whose jobs have brought them to places like Hawaii, North Dakota and Florida. She points them to a DVD about genital cutting. “The worst thing a health care provider can do is wince or cringe or ask an inappropriate question,” Dr. Nour said. “It deters a patient from returning.”

Ms. Bojang, the Gambian woman with abdominal pain, now lives in Tyler, Tex., about 100 miles east of Dallas. She came to the United States in 2010 to study political science and said she was now considering visiting a gynecologist, spurred by the support of people who oppose the tradition. “When I start talking about this topic, I get really emotional,” she said. “Everything comes back. Going to the doctor — I don’t want to have to explain everything from the beginning.”

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