A detailed story about pregnant African refugees in Minnesota who were genitally mutilated before arriving in the U.S. has raised possible legal implications for obstetricians and mid-wives who first “deinfibulate” or cut open the seal created by the genital mutilation, but then resew the opening closed, or “reinfibulate” the woman after a baby is born.
The question confronting these healthcare providers, is whether they are complicit in violating laws prohibiting all forms of female genital mutilation (FGM) when, for non-medical reasons, they “reinfibulate” in order to accommodate religious or cultural practices or even personal preferences.
FGM or FGM/C the more culturally sensitive term “female genital cutting or circumcision,” is a practice that “comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.” Critics of the term “female circumcision” say this is an effort by multicultural feminists to normalize immigrant cultural practices that are banned in the U.S.
Infibulation typically refers to Type III FGM in women who have had most of the external female genitalia removed and what is left is sewn closed leaving only a small opening.
The American College of Nurse-Midwives considers reinfibulation to be a form of medicalized FGM/C:
Reinfibulation is considered a form of medicalized FGM/C and a violation of medical ethics. The risks of the procedure outweigh any perceived benefits.
The American Academy of Family Physicians while less direct in advising practitioners, nonetheless cautions against performing reinfibulation:
Reinfibulation itself is not considered FGM, but if performed by a physician, it may appear to condone the practice. Therefore, the AAFP strongly cautions its members against performing reinfibulation.
According to the World Health Organization, medicalization of FGM “includes the procedure of reinfibulation at any point in time in a woman’s life.” Because FGM has been addressed as a health issue, WHO has embarked on a global strategy to stop health care providers from performing FGM:
A recent analysis of existing data shows that more than 18% of all girls and women who have been subjected to FGM in the countries from which data are available have had the procedure performed on them by a health-care provider. There are large variations between countries, from less than 1% in several countries, to between 9% and 74% in six countries. More research is needed to estimate whether this phenomenon is also observed among migrants, refugees and asylum seekers from FGM practising communities. Available data suggest that in countries with these immigrant populations the involvement of health-care providers in FGM mainly concerns the act of reinfibulation.
While WHO is working to eradicated FGM, two U.S. OBGYNs in 2016, published a paper in the Journal of Medical Ethics by seeking to destigmatize FGM by calling it “female genital alteration.” They offer a “compromise solution” that would medicalize FGM if states would “legally permit de minimis FGA in recognition of its fulfillment of cultural and religious obligations…”
The “de minimis” types of FGA for which the doctors advocate, include “a small nick in the vulvar skin” and procedures that create structural change without negatively impacting reproduction or sexual satisfaction likening it to “procedures resembling elective labiaplasty as performed in Western nations.”
The “compromise” offered by these doctors echoes an earlier recommendation by the American Academy of Pediatrics’ (AAP) to a softened approach to FGM. In 2010, the AAP Committee on Bioethics suggested that legally allowing pediatricians to offer a “ritual [clitoral] nick” as a compromise to accommodate imported FGM adherents might avoid potentially more extensive mutilation to young girls. After significant pushback and criticism the AAP was forced to retract the idea of the “ritual nick.”
In 1996, Tennessee criminalized FGM of all types including infibulation. While the law does not explicitly address reinfibulation, the statute suggests that resealing and restoring the genitalia to its prior mutilated state after a woman gives birth if performed for a non-medical reason, would violate state law.
The 2013 data collated in a Population Reference Bureau (PRB) report, shows that the Nashville-Davidson-Murfreesboro-Franklin Metropolitan Statistical Area is ranked 20th in the country for the potential risk of FGM being performed on women and girls. Tennessee is number 18 in overall state rankings for risk to women and girls from FGM.
UNICEF’s statistical overview of FGM shows that “girls and women who have been cut are more likely to favour maintaining the practice” and that for reasons including social acceptance and religious compliance, girls are mutilated even when their mothers oppose FGM. Anywhere from fifty to sixty-five percent of girls and women in Egypt, Gambia, Sierra Leone and Somalia, support continuing the practice of FGM. Refugees from all of these countries have been resettled in Tennessee by federal contractors.