For Angela Montague, it began with a young woman from the West African country of Guinea. In February 2008, Montague, a licensed clinical social worker and the assistant director of social work at the Metropolitan Hospital Center in East Harlem, received a referral from a doctor in the hospital's family planning clinic. A 19-year-old patient had come in complaining of abdominal pain and then broke down crying.
The young woman traced her physical and emotional pain to when she was 8 years old and the women in her community in Guinea had gathered to perform a rite of passage on her - namely, cutting off her clitoris.
"She came to see me the same day as her physical exam," Montague said. "She was clearly experiencing symptoms of post traumatic stress disorder. She had regular nightmares about the day she was cut, and she had difficulty concentrating because the memories would continually resurface. She even feared groups of people because it reminded her of the group of women who held her down while the cutting was performed."
Known alternately as female genital cutting (FGC) or female genital mutilation (FGM), the removal of all or part of the external female genitalia is practiced across cultures and religions in parts of Africa, Asia and the Middle East. It is generally performed by women on girls as part of the transition to adulthood. The World Health Organization estimates that between 100 million and 140 million women and girls worldwide have undergone FGC. In the United States, estimates suggest that the number of women and girls who have undergone FGC or who are at risk grew by about 35 percent between 1990 and 2000 - from 168,000 to 228,000. The New York metropolitan area is estimated to have the highest number of women and girls affected by or at risk of undergoing genital cutting in the United States: just under 41,000, according to estimates based on data from the 2000 census.
Montague saw the young woman regularly for counseling and began to receive referrals of other women in New York experiencing similar problems. When she spoke to her colleagues throughout the city about genital cutting, she discovered that many of them were not aware of the issue and that education on the health consequences of the practice was limited. And while some individual service providers were working to support women and girls who had undergone cutting, a comprehensive structure for addressing the issue remained unrealized at both the state and federal levels.
In fact, neither the city nor the state government has taken concrete steps to address the practice or its effects, which can range from post-traumatic stress disorder to severe infections, painful menstruation and complications during pregnancy and childbirth.
What the Government Is Not Doing
New York is one of 17 states that have passed legislation criminalizing the practice of FGC on minors. The state law, which is modeled on federal legislation that was also enacted in the mid-1990s, identifies both the person who performs the cutting as well as the parent or guardian who consents to it as being "guilty of female genital mutilation."
The law also required the state Departments of Health and Social Services (now the Office of Children and Family Services) to establish "education, preventive and outreach" activities in communities that traditionally practice FGC in order to inform them of the health consequences of the practice and the provisions of the state law.
Very little has been done, however, to implement either part of the law. The last sustained education and outreach activities took place 10 years ago in collaboration with the women's advocacy organization RAINBO, said Mary Applegate, who coordinated the project when she was the medical director in the New York State Department of Health's Bureau of Women's Health. The bureau's current women's health coordinator, Margaret Allen, said that she is not aware of any ongoing activities on FGC at the state level.
The New York City Health Department also reported that they have no information on FGC.
A bill that is currently before the New York Senate Health Committee would require the state Department of Health and the Office of Children and Family Services to produce an annual report to the governor and state legislature on their activities addressing FGC. Versions of the bill have been making their way through the Assembly since 1995 but have repeatedly died in the Senate. The bill was reintroduced in January 2009 by Assemblywoman Barbara Clark of Queens.
"As far as we know, the state is not undertaking activities to address this issue," said Jessica Gormand, Clark's legislative director. "Part of the motivation for putting this bill forward was to bring this to light."
And on the law enforcement side, no criminal case has ever been brought using the New York law, or other state and federal laws, on genital cutting, said Taina Bien-AimĂ©, executive director of the human rights organization Equality Now, which works to end the practice worldwide.
The lack of activity in the state mirrors the situation at the federal level. Federal law also criminalizes the practice of FGC on minors and charges the Department of Health and Human Services with conducting outreach and education to communities and service providers. The department worked with RAINBO to produce and distribute a curriculum for health care providers on FGC in the late 1990s and held a few community workshops, but no regular activities have taken place since 2000, said Wanda Jones, deputy assistant secretary for health and director of the department's Office on Women's Health.
The small amount of funding that was allocated to these activities in the 1990s also has largely disappeared, Jones added.
The lack of government activities on FGC in the United States comes at a time when governments in Africa and Europe are stepping up their efforts to prevent and respond to cases of FGC through legislation and targeted social services, said Bien-AimĂ©.
"The United States has fallen behind many European and African countries in addressing female genital mutilation," she said. "There is a fundamental ignorance on the issue and a limited political will to recognize that girls are at risk here."
A Grassroots Effort
Without leadership or resources from the city, state or federal government, a handful of community-based organizations, like Sauti Yetu Center for African Women in New York, and individual service providers like Montague have taken on much of the work of preventing FGC here and responding to its effects.
In New York, Sauti Yetu is the only community-based nonprofit working specifically on FGC, said Asmaa Donahue, senior program officer at Sauti Yetu.
As part of its response efforts, Sauti Yetu trains health-care professionals, medical students and social service providers working with African communities to give medically appropriate and culturally sensitive care to women who have undergone FGC. In many cases, service providers who come across FGC in their work will also approach Sauti Yetu to develop a partnership. Montague, for example, worked with Sauti Yetu earlier this year to organize a panel on FGC and medical care at Metropolitan Hospital Center, and she is also working with them to organize a session on FGC for the hospital's staff.
At the federal level, Health and Human Services has begun to re-engage with community activists and service providers to see how the federal government might support prevention and response efforts, said Jones. In 2006 and 2007, for example, the department's Region II Office of Women's Health, which includes New York, participated in meetings organized by Sauti Yetu to discuss gaps in addressing FGC in the region. The participants included state department of health officials, nonprofit organizations working on reproductive health and sexual violence, and women from immigrant communities. Sauti Yetu also continues to lobby the federal government for funding to support community-based work on FGC, said Donahue.
There are currently very few organizations spearheading prevention efforts in the United States. Organizations such as Equality Now and the Tahirih Justice Center near Washington, D.C. seek to raise public awareness and support women and girls seeking asylum due to the threat of FGC in their home countries.
At the local level, Sauti Yetu engages communities in discussion about the practice and is cultivating a network of African women working to end FGC in their own communities. The New York area, though, does not yet have many vocal, grassroots advocates on this issue, said Donahue.
Several service providers noted that prevention efforts can be successful only when the communities are involved as leaders.
"Activism in the 1990s focused on criminalizing FGC, and communities [that traditionally practice FGC] were left out of the policy conversation. This led to a backlash," said Donahue. "They saw themselves being portrayed as barbaric in the media and they felt under attack. Women felt stigmatized rather than empowered to address the issue."
Service providers fear that a renewed focus on law enforcement could drive the issue further underground and prevent women and girls from seeking help either to prevent FGC or to address its effects, said Jones.
Still, at both the federal and state levels, little promises to change soon. FGC does not appear to be on the agenda of relevant state or city agencies in New York, and in a city of millions, an issue facing thousands of immigrant and refugee women and girls can easily remain marginalized. Despite the numbers, though, the need to address the practice remains.
"New York is a city of immigrants so service providers have to be prepared to provide culturally sensitive and appropriate services on practices like FGC," said Montague. "These women need a safe place to go."
Alyson Zureick is a freelance writer based in New York.