Amina Ahmed had always been afraid of needles.
Now, as an 8 year old, she thought someone was going to use one in a place nobody was supposed to touch.
The quivering girl stood next to her younger sister and cousin. The oldest of the three, Ahmed was up first.
Just then — she ran.
An hour and a half later, her uncle and brother found her hiding in a nearby marketplace and brought her back to the small clinic in Mogadishu, Somalia.
Her clitoris was pricked and blood dripped out.
"All kids will cry, especially the little kids," Ahmed, now a 24-year-old University of Minnesota graduate, said. "But afterward, it was something to be proud of."
Much about the young woman, whose family fled the Somali civil war for a life in the United States when she was 13, speaks to her adherence to traditional Somali culture. She’s loyal to her Islamic faith, never goes outside without her headscarf and is dedicated to her vow of celibacy until marriage.
But to Ahmed’s dismay, she won’t be able to pass onto her future daughters a practice she considers sacred, as U.S. law has banned all forms of female circumcision since 1996, and Minnesota law has banned it since 1994.
The World Health Organization estimates that between 100 million and 140 million girls and women have undergone various forms of the procedure and another 3 million girls, most of them under the age of 15, undergo it each year.
Members of the Somali community in the Twin Cities disagree on whether to support the mild form of circumcision some refer to as a "clitoral nick," where a woman’s clitoris is poked and allowed to bleed, a practice that’s believed to render her "clean."
While some, like Ahmed, believe they should be able to practice the long-standing tradition, others are equally passionate about leaving it behind.
On par with ear piercing
Widespread discussion around the topic resurfaced in May of this year when the American Academy of Pediatrics Bioethics Committee reviewed a 1998 policy which banned any female circumcision. The committee recommended that the AAP approve what it called a "ritual nick," arguing it’s on par with ear piercing and "much less extensive than routine newborn male genital cutting," or circumcision.
Douglas Diekema, chairman of the AAP’s Bioethics Committee at the time, has long believed that pediatricians should be able to perform a nick as an alternative to a more dangerous procedure performed in a nonmedical setting.
This wasn’t the first time he’s sat on a committee that agreed to condone the practice. A pediatrician at the Seattle Children’s Hospital, Diekema looked at the issue back in 1996 when a number of Somali women across town at Harborview Medical Center were requesting that doctors circumcise their female babies. Diekema’s committee was tasked with deciding whether Harborview would allow its physicians to perform a nick.
The committee approved the procedure in the summer of 1996, but following a period of angry letters and Congress’ passage of a federal law banning all forms of female circumcision, the hospital overruled the committee in December of that year.
Now, 14 years later, Diekema’s had his second statement denied.
The AAP’s Board of Directors rescinded the Bioethics Committee’s statement in July, although "the committee stood behind it," Diekema said. In the statement, Diekema’s committee referred to nicking the hood of the clitoris, but it didn’t provide a clear description of the procedure, Diekema said, adding, "that probably would have been helpful for some people."
There are major differences between nicking the clitoral hood and the actual clitoris. The clitoris, like the head of the penis, is filled with nerve endings that, if damaged, would impact a woman’s ability to feel sexual pleasure, Jamie Feldman, a physician at the University Center for Sexual Health, said.
The hood, on the other hand, is a layer of skin comparable to the foreskin of a penis. It’s unlikely that there would be any side effects to nicking the hood, Diekema said. He admitted that clarifying that in the statement would likely have saved the committee from a lot of flack.
Shortly following its release, the statement drew furious feedback from doctors, advocacy groups and others who argued it promoted a useless practice that impeded on the child’s right to autonomy.
"To offer up some baby’s clitoral hood because you want a hospital to strengthen a relationship with a community is child abuse; for what, market-share?" wrote Benjamin Aubey, a Columbia University professor and pediatrician at the Harlem Hospital Center.
The purpose behind the policy, Diekema said, was to prevent the harm that could come from families sending their children overseas to have a circumcision performed in a nonmedical setting. It recommended that federal and state laws be changed to allow pediatricians to perform the nick.
"I think allowing pediatricians to perform the nick under the right circumstances would be better for some girls," Diekema, also a bioethics professor at the University of Washington in Seattle, said. "There’s no question, based on conversations I’ve had with people who take care of women from these communities, that in the absence of offering something that would not be psychologically or physically harmful, some will have a procedure done that will result in great harm."
A loophole in the current federal law doesn’t punish those who take their girls out of the country to have the procedure performed. A bill floating in committee seeks to fix that. Authored by Reps. Joseph Crowely, D-N.Y., and Mary Bono Mack, R-Calif., the Girls Protection Act would mimic those of European countries that have already made it a crime.
Neither could offer solid numbers on how many children might be affected, although a statement from Crowley used "very rough data based on census estimates" to guess that "it could be in the hundreds of thousands."
A number of local Somali women and medical professionals who work closely with Somali patients said that if children are being sent out of the country, it’s extremely rare.
Rights vs. protection
In a country that supposedly allows religious freedom, it makes Ahmed angry that she can’t pass on to her children what she says is a harmless practice.
"Why someone who does not know anything about my religion tell me I can’t do it?" Ahmed, who works as a respiratory nurse at Owatonna Hospital, said. "You don’t have the right to say that."
While some draw a definite distinction between female circumcision and Islam — defining the practice as a cultural one — several people said that the hadith, the traditional sayings and customs of the Prophet Muhammad, offers the nick as an option.
Although female circumcision has been practiced among other religions, it’s most commonly associated with Islam.
Many point to a line in the hadith in which the Prophet Muhammad says to a circumciser on the way to perform the procedure "do not overdo it, because it [the clitoris] is a good fortune for the spouse and a delight to her." In this statement, some claim that the prophet is advocating the mild form of circumcision. Still others believe the prophet is condemning the tradition altogether.
The practice is unknown in 80 percent of the Islamic world, and it originated in regions of Arabia and Africa before Christianity and Islam held a stake in those societies, according to a 2003 article in the Journal of Muslim Minority Affairs.
It could certainly be seen as a violation of religious freedom, said Lora Harding Dundek, manager of the Birth and Family Education and Support Services department at the University of Minnesota Medical Center, Fairview Riverside.
"It’s that balance between the law as protecting people and law as violating people’s rights," she said. "It’s certainly not inconsistent with other debates we’ve had around religious freedom and private practice."
The U.S. would never consider a law that would ban male circumcision, a practice of Judeo-Christian origin, although there’s evidence that, as an invasive procedure, it carries certain risks, Harding Dundek said.
Compared to male circumcision, the ritual nick is "far less invasive," Diekema said. To make the two procedures equal, you’d have to remove the clitoral hood, he said.
"This would be more like taking a needle and poking the male foreskin so that you saw a drop of blood," he said.
It’d be difficult to say whether condoning the nick would reduce harm until the medical community knows how often circumcision still happens in the U.S., said Elizabeth Boyle, a sociology professor at the University. Boyle, who spent years studying female circumcision and wrote a book on the subject, said the laws against the practice discourage people to be forthcoming about their behaviors, she said.
"A really fundamental point is that we just don’t know whether it’s being perpetuated."
An ancient tradition
Although there’s some disagreement over the location, historians believe female circumcision originated as many as 2,000 years ago in Egypt.
For cultures obsessed with preserving a woman’s virginity, female circumcision has been viewed as the only way to truly achieve that goal.
While still practiced heavily in more than 28 countries in Africa, the Middle East and Asia, female circumcision has more or less ceased in the U.S. and other countries outside of Africa that have implemented laws against it.
While the World Health Organization defines four types, two forms of the practice are the most well-known.
The mild form, which some refer to as a "clitoral nick," or "sunnah," can consist of cutting, poking or removing part or all of either the clitoris or the clitoral hood.
The most severe form, which advocacy groups refer to as "female genital mutilation" or "infibulation," consists of removing the clitoris, labia minora and inner layers of the labia majora. Both sides of the vaginal opening are then sewn together almost completely, often leaving an opening the size of a pencil head or q-tip for the passage of urine or menstrual blood.
This procedure has taken on a number of forms depending on where it’s performed and by whom. In Somalia, a country with a high prevalence of the extreme procedure, it’s often performed by an elder woman in the clan — usually someone with no formal medical training — using a razorblade and no anesthesia.
The procedure has been the subject of intense, sweeping educational efforts by groups like UNICEF, the U.N. Human Rights Council and the WHO over the past two decades.
In the short term, it’s caused everything from hemorrhage, shock, severe pain, infection and death. Over the years, women who’ve undergone the procedure experience a high number of urinary tract infections. Intercourse tends to be excruciating, and most of the women are unable to achieve orgasm. Furthermore, 25 to 30 percent of women who undergo the procedure are infertile, sometimes because of their inability to have sex, according to a 2003 article in the Journal of Cultural Diversity.
Perceptions are being changed
There are several waves of change working their way through the Somali community as they adjust to life in the U.S., but perhaps none have been as abrupt as the shift away from circumcision.
Back in Somalia, women were circumcised to conform to society, but in the Western world, the practice is a deviation from the norm.
Iman Warsame, a University senior studying psychology and English, estimates that "almost all" of the women in her mother’s generation have had the extreme form of circumcision performed on them. But among her generation, she thinks, almost no one has had the extreme form, and less than half have had the mild form.
A number of medical professionals said they see the severe form of the procedure much less frequently than a decade ago. It’s much more commonly seen in older women than in teenagers and is almost nonexistent in children.
Even in Somalia and other African countries, educational campaigns have begun to chip away at the number of families who carry on the more damaging procedure. Nowadays, it happens predominately in rural areas and less and less in urban areas like Mogadishu.
Ahmed’s five older sisters each had an infibulation done. By the time Ahmed’s turn came, her mother had become more educated about the side effects of the practice and decided on the clitoral nick instead.
"She asked forgiveness for her other daughters," Ahmed said. "She knew it was the wrong thing to do."
Whether most Somali women in the U.S. today have undergone the mild form of circumcision generally depends on when they moved.
The average age at which girls are circumcised in Somalia is between 7 and 9 years old, so those whose families fled the country when they were younger than that weren’t likely to have been subjected to it.
It’s an example of a shift toward Westernization, Ahmed argues — one that shouldn’t be forced.
"It’s frustrating," Ahmed said. "It’s like you have to take American culture. You have to leave your religion behind."
Warsame, the events coordinator of the Somali Student Association, strongly disagreed. She said only "ultra conservative" mothers would want to circumcise their daughters today, and most don’t mind that it’s illegal.
In interviews, several local Somali women estimated that about half of their community believes it should be legalized, and the other half is glad it’s not.
The original goal of the tradition, mostly supported by mothers, was to make their daughters more attractive marriage prospects, and now that not being circumcised is becoming acceptable to Somali males in the U.S., circumcision is unnecessary, Warsame said.
"Your daughter’s not going to marry a guy from your generation, she’s going to marry a guy from her generation," Warsame said, "and it’s not very popular now."
Fatuma Farah, a junior at the University majoring in child psychology, agreed.
"Guys today are saying, ‘Hey, if you’re not circumcised, that’s OK,’ " she said. "Perceptions are being changed."
But even the way it’s fading away irritates Warsame.
"The only thing that’s stopping parents is that they know it’s not as fashionable as it used to be," she said. "Can you imagine that? My body would be under the whims of a guy my age, what he might think."
Just one more kind of trauma
Although it was rare in the U.S. to begin with, the practice of circumcision seems to have ceased by and large among those who’ve immigrated to the U.S. But Somali women of all ages still bear the effects of the practice.
Jill Sandeen, a midwife at the University of Minnesota Medical Center, Fairview Riverside Campus, said while it used to be very common at the height of Somali immigration, she doesn’t see many extreme circumcisions anymore.
In conversations with her many Somali patients, she’s learned about their terrible experiences with circumcision.
"One woman said she was 7 and was told there was going to be a party for her," Sandeen said. "And then they strapped her down and she couldn’t pee for four days."
And while such an event would be traumatizing for the average American, these women’s lives have been marked by tragedy, so their circumcision doesn’t stick out, she said.
"They come from a horrible, war-torn place where people were murdered before their eyes," she said. "I think on some level this is just one more kind of trauma they’ve incorporated into their existence."
Confusion over anatomy
As a midwife, the topic of circumcision is almost inevitable when Sandeen meets a new Somali patient. But among many of them, there isn’t a strong understanding of their own anatomy, she said.
In the case of one woman, "she didn’t know that she still had a clitoris," she said. "It kind of takes us back to the 1950s. They don’t even know what’s down there or what was down there."
Others in the medical community share similar stories.
Janis Keil Day, another midwife at the Fairview, Riverside clinic, said she’ll always ask new Somali patients whether they’ve been circumcised. Many will answer no, but when she goes under their hospital gown, she’ll discover otherwise.
"I’m not sure if it’s because they don’t necessarily understand the question you’re asking or if there’s a language barrier," she said.
In any case, many women within the Somali community have dramatically different views on the side effects and implications of the various forms of the procedure. While almost everyone agrees that infibulation is extremely damaging, there’s more division on milder forms.
Ahmed said she doesn’t believe she’s experienced side effects like infection or decreased sensitivity from her circumcision.
A valuable organ
Malyun Duale observes the effects of Westernization on her five daughters with frustration.
"Talking back to their mom," she said.
She talks openly about her concern that they’ll abandon their Somali roots, become consumed with American "sass" and disrespect their mother.
But if there’s one thing the 55-year-old Somalia native is not afraid of, it’s of losing the circumcision tradition. Duale, who moved to the U.S. in 2001, is vocal about not having subjected any of her daughters to the procedure.
"If God creates you and you say ‘you missed something’ or ‘you didn’t do this’ and fix it," she said. "No, the religion says to avoid that."
Adjusting her bright headscarf, Duale’s face falls into a smile naturally as she speaks. She’s passionate about ridding the Somali community of all forms of circumcision and believes education is the way to do it.
Before she left Somalia, she saw the dramatic impact of UNICEF and other organization’s campaigns on circumcision’s prevalence.
She recalls her own circumcision, a mild version, when she was 6 years old. It was done in a clinic in Mogadishu with anesthesia, so it didn’t hurt. She compared the procedure to a finger prick to test for hemoglobin in the blood.
Still, she warned, the procedure can have dramatic side effects. Tugging at the healthy skin on the top of her hand as a demonstration, she noted that any time an operation is performed, normally healthy tissue is forever scarred. Since blood collects in the clitoris when a woman is aroused, she said, the scar tissue could hinder the woman’s ability to feel sexual pleasure.
"This is a valuable organ," she said. "We have to respect this organ and know it’s sensitive. It’s not like a leg or a hand. It needs more care."
Duale has worked at the Fairview Riverside clinic as a doula for seven years now, providing emotional and physical support for Somali women as they have children. The Somali Doula Program, a support service for Somali women through the birthing process, was implemented at the Riverside clinic in 2002.
Duale was surprised to learn that college-educated women would still practice the mild form of circumcision if it were legal. She said she thinks those in higher education usually learn to analyze beyond the scope of their own culture.
For years, the idea behind circumcision was to keep a woman celibate, she said. But today, people just need to live according to their morals and don’t need surgery to do that.
"If you’re circumcised or not, you say ‘I’m not going to have sex until I’m married, until I have a good person that I want to share my life with,’ " she said. "The decision depends on how you choose to live."