FEMALE GENITAL MUTILATION IN THE UNITED STATES
Protecting Girls and Women in the U.S. from FGM and Vacation Cutting

ACKNOWLEDGMENTS Sanctuary for Families would like to recognize and thank the many women whose stories and voices inspired and informed this report. Their identities have been withheld for their safety and privacy. The primary authors of this report are Archana Pyati and Claudia De Palma. Mariama Diallo, Laura-Lee Atkinson-Hope, and Sayoni Maitra contributed significant research, writing, and editing, and Kaitlin Juleus designed the report. The law firm Cleary Gottlieb Steen & Hamilton LLP contributed considerable legal research and analysis. ABOUT SANCTUARY FOR FAMILIES Sanctuary for Families is dedicated to the safety, healing and self-determination of victims of domestic violence and related forms of gender violence. Through comprehensive services for our clients and their children, and through outreach, education and advocacy, we strive to create a world in which freedom from gender violence is a basic human right. Based in New York City, Sanctuary offers clinical, legal, shelter and economic empowerment services to more than 10,500 adults and children each year. We also seek to address the systemic barriers that perpetuate the cycle of violence by engaging in public outreach and education, and advocating for legislative and policy change. Sanctuary’s Center for Battered Women’s Legal Services is the largest provider in the United States of legal services exclusively for victims of gender violence. Website | www.sanctuaryforfamilies.org Facebook | www.facebook.com/sanctuaryforfamilies Twitter | www.twitter.com/sffny

PO Box 1406 Wall Street Station New York, NY 10268 212.349.6009 © 2013 Sanctuary for Families

EXECUTIVE SUMMARY

This report documents the rising prevalence of female genital mutilation (“FGM”) in the United States. It examines the current legal framework in place to address female genital mutilation when it is performed within our borders and through “vacation cutting,” in which young women in the U.S. are sent abroad to undergo the procedure. It then recommends steps needed to develop a more coordinated, effective response to protect girls and women in the U.S. affected by the threat of FGM.
Each year, three million girls and women around the world are at risk of undergoing FGM.

Female genital mutilation is a centuries-old practice that the World Health Organization defines as “the partial or total removal of the female external genitalia or other injury to the female genital organs for non-medical reasons.” FGM, which is ingrained in a diverse variety of cultural customs, is internationally recognized as a violation of women and girls’ fundamental human rights. • The World Health Organization estimates that about 140 million women and girls worldwide are living with the consequences of FGM, and according to new estimates from United Nations Population Fund and UNICEF, at least 30 million girls under the age of 15 are at risk of being cut. • Women who have survived FGM frequently describe significant physical, sexual, and psychological complications, some of which persist throughout their lives. • The motivations most commonly articulated for FGM—such as enforcement of traditional notions of femininity, control of female sexuality, preservation of family honor, and preparation for marriage— tend to perpetuate discriminatory views about the status and role of women.
Female genital mutilation is increasingly threatening girls and women in the United States.

Although FGM is most prevalent in twenty-eight countries in Africa and the Middle East, it is no longer confined to distant shores. Every year, women in the United States discover that they, their daughters, and their loved ones face a very real and imminent danger of FGM in the U.S. • Estimates from the Centers for Disease Control and Prevention indicate that at least 150,000 to 200,000 girls in the United States are at risk of being forced to undergo FGM. • According to an analysis of data from the 2000 U.S. census, the number of girls and women in the United States at risk for female genital mutilation increased by 35 percent between 1990 and 2000. • While this is a national problem, the greater New York City metropolitan area is home to more girls and women at risk of FGM than any other region in the United States. • Each year, girls are exposed to FGM through a growing phenomenon called “vacation cutting,” in which families send their daughters abroad to undergo the procedure, typically during their school vacations. • Girls and young women are also subjected to FGM on U.S. soil in covert and illegal ceremonies performed by traditional practitioners, or by health care providers who support FGM or do not want to question families’ cultural practices. ii | SANCTUARY FOR FAMILIES

For many years, the United States has lagged behind international efforts to end female genital mutilation.

Female genital mutilation is prohibited in the U.S. by an evolving framework of international, federal, and state laws, but many of these laws have suffered from crippling loopholes or lacked the implementation mechanisms and political resolve necessary to defend those at risk of the practice. • Despite the fact that FGM in all forms has been explicitly illegal in the United States since 1996, legislation criminalizing the practice has not been comprehensively implemented or enforced, and community members, social service providers and law enforcement officials often fail to identify, report or investigate incidents of FGM. • Until 2013, the federal ban on FGM did not penalize the transport of minors overseas for the purpose of FGM, a glaring loophole that placed a significant number of girls in the U.S. outside the reach of any legislative protection.
Recent developments present an important opportunity to more effectively protect women and girls in the fight to end female genital mutilation.

Today, there is reason to believe that the tireless work of human rights groups, community-based activists, and legislative advocates has carried us to the threshold of a breakthrough in the campaign against female genital mutilation. • In December 2012, the United Nations passed a landmark resolution, “Intensifying Global Efforts for the Elimination of Female Genital Mutilations,” calling on all countries to enact legislation banning FGM. • In January 2013, President Barack Obama signed the “Transport for Female Genital Mutilation” Act, criminalizing the transportation of girls abroad to undergo FGM, and finally bringing the United States in line with long-standing international efforts to end the practice.
Now, advocates, survivors and community service providers must come together to translate policy into action.

As the prevalence of domestic and vacation cutting rises in the U.S., a small number of advocates, survivors, counselors, lawyers, and doctors across the country are examining ways to not only support and serve those who have experienced FGM, but to also protect girls and women at risk. International experience suggests that successful prevention of female genital mutilation in the U.S. requires a proactive and coordinated approach that includes: • Community and survivor-led outreach and education about the consequences of FGM that engages religious and community leaders, parents, survivors, and at-risk women and girls; • Internationally informed guidelines and training to assist front-line professionals to identify and protect girls at risk, and to provide education and resources on FGM and the legislation banning its practice; • Robust laws that prohibit FGM locally and extraterritorially and implementation measures that provide clear guidance on culturally sensitive, prevention-centered enforcement; and • Reporting and data collection on the incidence of FGM and vacation cutting in the U.S. to inform efforts to serve the needs of survivors, target and develop outreach and education, and ultimately ensure the safety and health of at-risk women and girls.

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TABLE OF CONTENTS
INTRODUCTION p. x PART I: WHAT IS FEMALE GENITAL MUTILATION? p. 1 How female genital mutilation is performed p. 1 Effects of female genital mutilation p. 2 Motivations underlying the practice p. 5 The role of religion in perpetuating FGM p. 6 PART II: FGM IN THE UNITED STATES p. 7 Vacation cutting p. 8 FGM as a result of constructive deportation p. 9 FGM on U.S. soil p. 10 . PART III: THE LEGAL FRAMEWORK FOR ADDRESSING FGM p. 11 International laws prohibiting FGM p. 11 U.S. laws protecting women and girls from FGM p. 12 The enforcement gap p. 13 PART IV: RECOMMENDATIONS FOR BUILDING A MOVEMENT TO END FGM IN THE U.S. p. 15 Objective 1: Community and survivor-led outreach and education p. 15 Objective 2: Guidelines and training to assist in the identification and protection of girls at risk p. 16 Objective 3: Robust, consistently enforced laws that prohibit FGM locally and extraterritorially p. 18 Objective 4: Reporting and data collection p. 19 CONCLUSION p. 20 APPENDIX A p. 21 APPENDIX B p. 22 ENDNOTES p. 24

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INTRODUCTION

Around the world, activists are rising up to end the centuries-old practice of female genital mutilation (also called FGM, female genital cutting, or female circumcision). Women and men in Senegal, The Gambia, Mali, Egypt, Iraq, Indonesia, and many other countries where FGM is practiced are using advocacy, art, drama, music, and literature to educate communities about FGM and to try to stop families from putting girls and women through this medically unnecessary procedure. They collaborate with international nongovernmental organizations and agencies of the United Nations, which have long declared FGM a violation of human rights and a risk to the safety, equality, and dignity of girls and women.1 Recognizing that each year three million girls and women continue to be at risk of being mutilated around the world, on December 20, 2012, the United Nations General Assembly passed a landmark resolution, “Intensifying Global Efforts for the Elimination of Female Genital Mutilations,” calling on all states to enact legislation banning FGM. Female genital mutilation is most prevalent in communities based in Africa and the Middle East, but it is not confined to distant shores.2 Despite the fact that female genital mutilation has been explicitly illegal in the United States since 1996, every year girls and women living here face a very real and imminent danger of mutilation when the procedure is carried out in covert and illegal ceremonies within U.S. borders, or through a practice known as “vacation cutting” in which girls are sent abroad to their ancestral homes during school vacations and forced to undergo the practice. Estimates from the Centers for Disease Control and Prevention (CDC) indicate that at least 150,000 to 200,000 girls in the United States are at risk of being cut here or through vacation cutting.3 According to an analysis of data from the 2000 U.S. census, this population is growing; between 1990 and 2000, the number of girls and women in the United States at risk for female genital mutilation increased by 35 percent.4
“People in the United States think that FGM only happens to people outside of the United States, but in all actuality, people here all over the country have been through FGM. Kids that were born in this country are taken back home every summer and undergo this procedure, and it’s nice to know that someone else heard our voices, and someone else took this stand with us.” -Jaha, 23, The Gambia

Each year, Sanctuary for Families works hand-in-hand with community members, advocacy groups, and legal and social service providers to assist hundreds of girls and women affected by female genital mutilation. Sanctuary has also been working to find ways to better protect girls and women at risk of FGM, looking for guidance to France, the United Kingdom, Ireland, and other countries where legislation and public outreach efforts have been developed and implemented with varying success.5 These efforts led in part to the federal Transport for Female Genital Mutilation Act, signed into law on January 3, 2013, which criminalizes the transportation of girls abroad to undergo FGM, and finally brings the United States in line with longstanding international efforts to end the practice.6 x | SANCTUARY FOR FAMILIES

With the momentum of the U.N. resolution calling for a total ban against FGM here and abroad, and the passage of the Transport for Female Genital Mutilation Act offering more robust federal protection for at-risk girls in the U.S., we now find ourselves at a critical turning point in the fight to stop female genital mutilation. It is vital that together we seize this opportunity to better protect girls and women facing mutilation, developing a collaborative, coordinated movement that prioritizes education and outreach about FGM, and engages faith leaders, survivors, community members, teachers, service providers and law enforcement in affected communities in efforts to more effectively defend the rights of girls and women at risk of the practice. Sanctuary for Families offers this report as a tool to raise awareness about the impact and risks of female genital mutilation on girls and women in the United States, and to explore next steps in ending FGM once and for all.

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PART I: WHAT IS FEMALE GENITAL MUTILATION?

The centuries-old practice of female genital mutilation is deeply ingrained in cultural norms and beliefs about the role of girls and women in society. Its context and consequences are often shrouded in secrecy, and misinformation about what the procedure entails and why it is performed is pervasive. An accurate, indepth understanding of the practice in the communities where it remains widespread is necessary to begin to protect those in the United States who are at risk of FGM or now live with its consequences.
HOW FEMALE GENITAL MUTILATION IS PERFORMED

Female genital mutilation is most prevalent in twenty-eight countries in Africa and the Middle East, with the highest rates of cutting in Djibouti, Guinea, Mali, Egypt, Somalia, and Sudan.7 (See Appendix A.) In addition, there have been some reports of female genital mutilation among certain populations in India, Indonesia, Iraq, Israel and the Occupied Palestinian Territories, Jordan, Oman, Malaysia, Thailand, and the United Arab Emirates.8 The World Health Organization (WHO) defines female genital mutilation as “the partial or total removal of the female external genitalia or other injury to the female genital organs for non-medical reasons.”9 WHO outlines four types of female genital mutilation: 10 Type I Type II Type III Clitoridectomy, or the partial or total removal of the clitoris and/or the clitoral hood. The partial or total removal of the clitoris and the inner labia, with or without the removal of the outer labia. Infibulation, or the removal of the external female genitalia and the sealing or narrowing of the vaginal opening using stitches or glue. The clitoris may or may not be removed. A small hole is left for urination and menstruation and women subjected to this procedure are later cut open for intercourse and childbirth. All other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping, and cauterization.

Type IV

Some types of female genital mutilation may be more prevalent in certain countries.11 However, the type of female genital mutilation performed on a girl or woman depends on a number of factors, including the reason for the mutilation, the family’s historic practice, or the demands of her birth or marital community.12 As such, several types of female genital mutilation may be prevalent in any one country, community, or even within a single family.13

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The manner in which female genital mutilation is performed varies widely around the globe. Although it is commonly performed on girls before they turn 15, the specific age varies by region, local custom, and ethnic group,14 and in many countries, the average age is reported to be falling.15 The procedure may also be carried out on adult women, particularly around the time of marriage, and in some communities women face the risk of additional FGM later in life.16

Among some groups, female genital mutilation may be carried out on a series of young girls, one after the other, as part of a ritual or initiation ceremony.17 Though some communities have medicalized the practice,18 in the majority of cases, traditional would heal closed. Afterward, we were practitioners without medical training perform the told not to cry, but all I could do was cry.” procedure as their vocation, or older women in the family or community may be responsible for - Nafissatou, 53, Guinea the procedure, which usually takes place far from hospitals or clinics.19 As a result, most girls and women undergo female genital mutilation without anesthetics, antiseptics, or antibiotics.20 The way female genital mutilation is performed may impact some of its psychological and physical consequences. However, even when FGM is carried out in medical settings, the impact of the sense of betrayal, the loss of sexual sensation and function, the motivations behind the procedure, and the sense of shame may all still deeply impact the women who have been cut.
EFFECTS OF FEMALE GENITAL MUTILATION

“Early [in the] morning—when it was not yet light out—the old women made us leave the village. We lined up, and they took us one by one. When it was my turn, one woman, very old and heavy-set, grabbed me and blindfolded me. She made me lay down on the mat, and someone grabbed one of my legs, while another person grabbed the other. Then someone cut me. It was the most terrible pain, and I struggled hard, though I could not get away from the grasp of the old women. After cutting me, they used a sticky substance to glue me together so that I

Regardless of the way female genital mutilation is performed, many survivors disclose ongoing physical, sexual, and psychological complications as a result of undergoing the procedure. The sexual and psychological impact of the practice cannot be understated, nor considered secondary to its physical impact; the consequences survivors suffer are typically complex, interlinked, often irreversible, and always very personal.
“The first girl went into a dark room, and I heard her screams. I thought, ‘they are going to kill me.’ Then I saw the girl come out with a very sad face, and I knew that something terrible was happening to us, even if they didn’t kill us. I wanted to run, but there was no way out.” - Aminata, 49, Guinea Physical Consequences

Girls and women who have undergone female genital mutilation report many physical complications, including: Short-term:21 • severe pain from the cutting of nerve ends and sensitive tissue • hemorrhage • shock from pain or hemorrhage • difficulty in urination or defecation due to swelling, edema, or pain • infections, including tetanus and sepsis • death due to hemorrhage or infections

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Long-term:22 “I think FGM is the worst thing that has • severe chronic pain due to trapped or unprotected nerve ends ever happened to me. • dermoid cysts • abscesses I lost the right to my • genital ulcers body and the desire to • excessive scar tissue (keloid) experience what it feels • pelvic infections, urinary tract infections, and sexually transmitted and like to be a woman.” reproductive tract infections, including bacterial vaginosis and genital - Alima, 30, Guinea herpes • slow and painful menstruation and urination, accumulation of menstrual blood in the vagina (hematocolpos), or urinary retention, especially in cases of Type III FGM or infibulation • greater risk of HIV transmission due to increased prevalence of genital herpes and increased likelihood of bleeding during sexual intercourse
Sexual and reproductive health consequences

Women who have undergone female genital mutilation frequently describe severe pain during sexual intercourse.23 Those whose female genital mutilation consists of a partial or total clitoridectomy also report a reduction or elimination of their ability to experience sexual arousal or fulfillment.24 For many women, physical pain during intercourse persists throughout life due to infibulation or re-infibulation, extensive damage to sensitive genital tissue, or scar formation.25 Many women who have undergone female genital mutilation also describe the significant impact that their mutilation has had on their maternal health, as FGM can increase the “I still am afraid of having risk of childbirth complications, such as prolonged or obstructed labor.26 sex at the age of 23. I try Women who have undergone female genital mutilation are more likely to avoid sex as much as to need a Caesarean section or an episiotomy, and they report a number I can because I only get of serious health problems, including perineal tears, obstetric fistula due pain from it.” to prolonged and obstructed labor, postpartum hemorrhage, and even - Kadiatou, 23, maternal death.27 The mother’s mutilation can also increase danger to The Gambia the infant; death rates among infants increase by 15% for mothers with Type I FGM, 32% for Type II FGM, and 55% for Type III FGM.28 “I saw a clitoris for the Some women contract infections resulting from the cutting of the labia first time when my majora that result in infertility.29 daughter was born.” - Salimata, 19, The Gambia

Psychological consequences

For many girls and women, female genital mutilation is a psychologically traumatic event due to “pain, shock, and the use of physical force by those performing the procedure.”30 Because family members frequently do not tell a girl or woman that they are taking her to undergo FGM, or refuse to listen to any objections, survivors often feel betrayed or socially isolated in the aftermath of the procedure, and come to mistrust or fear some of their closest family members, including their parents.31 Survivors may also harbor deep feelings of shame for being chastised for resisting or crying out during the procedure, or for being blamed
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and told that they are “bad luck” because someone in their group did not survive the mutilation. As a result of these experiences, many FGM survivors frequently suffer from depression, anxiety, multiple phobias, memory loss, and post-traumatic stress disorder (PTSD).32 Symptoms of PTSD can be acute or chronic, persist over many years, and may be triggered by certain memories, particularly during sexual intercourse, gynecological exams, and childbirth.33 Survivors also commonly describe feeling incomplete and inferior to other women, low self-esteem, and poor body image. Victims who were subjected to FGM at an older age and have memories of the trauma are often the most severely affected, but even those who are cut as babies or young girls and therefore have no memory of the event itself suffer psychologically throughout their lifetimes, commonly reporting symptoms such as sadness, hopelessness and powerlessness.

“FGM has affected me emotionally throughout my entire life . . . Those terrible moments stay with me, and I just cannot forget them. When I went to the hospital to give birth to my children, my experience with FGM was what I remembered most. Every time I shower, I think about it. There is a sadness and emptiness I feel every day because of what FGM took from me.” - Nafissatou, 53, Guinea “It is difficult to put into words just how terrifying and painful the whole experience was. For many months afterwards, I suffered recurring flashbacks, nightmares, and insomnia. I still suffer some to this day. Every time I would try to sleep I would see the women coming towards me with a knife.”

Female genital mutilation may also impact the psychological aspects of sexual health. Traumatic - Fanta, 37, Guinea memories of the procedure, painful menstruation, and painful intercourse can lead to fear of sexual intercourse.34 Continuing lack of sexual enjoyment can also result in decreased sexual desire or cause other psychosexual health problems.35 This in turn can lead to physical violence and domestic abuse by family or partners who expect women to perform sexually despite their history of gynecological trauma.

Karima, 39, Senegal Karima has endured countless forms of violence throughout her life. She was only 9 years old when her mother’s brother brutally raped her, after years of sexual abuse, and left her bleeding profusely in their house in Kenya. Karima recalls her mother’s harsh reaction: “[S]he blamed me for the abuse” and forced her to undergo female genital mutilation. Even though her mother took her to a medical doctor, Karima endured a brutal form of FGM. “I started screaming for my mother to help me, but she just told me to shut up. [The doctor] used a scalpel, sliced off almost all of my clitoris and then sewed my vagina essentially shut without providing me with an anesthetic.” Just two years later, Karima was forced into a marriage with a 45 year-old man. She was sent back to the doctor’s office for a painful reversal procedure so that her husband could forcibly have intercourse with her. Karima now says, “I will speak out against FGM as I believe it violates women’s human rights and is designed to subjugate and control women.”

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MOTIVATIONS UNDERLYING THE PRACTICE

It is not known when or why the practice of female genital mutilation began, and some historians believe that its original motivation has long since been forgotten.36 Today, the tradition is commonly understood as a manifestation of cultural beliefs relating to gender, sexuality, marriage and family.37 In many communities, in fact, FGM is thought to be so normal that the concept of a woman who has not undergone mutilation is inconceivable.38 As a result, survivors and their allies routinely report that the motivations articulated for FGM perpetuate discriminatory views about the status and role of women in society Female genital mutilation is often carried out to reinforce “In Mali, I only knew one woman traditional notions of femininity; for example, some practicing who had not undergone excision. communities believe mutilation enhances female “docility When the man she was supposed and obedience,” and mutilation is viewed to be essential to to marry found out that she the initiation of girls into womanhood.39 Female genital was not excised he refused to mutilation is also performed to “cleanse” or “purify” girls and marry her, claiming that it was women of past actions that are socially unacceptable to their unacceptable to marry her communities.40 because it would be like he was Some communities also believe that female genital mutilation marrying a man.” physically differentiates women from men. Among these - Fatoumata, 29, Mali families, the clitoris and the labia are considered “male-like” body parts, and their removal is seen as marking a girl’s identity as female.41 If a woman does not go through FGM, her society may not consider her “fully female,”42 and she may be ostracized because others in the community will say “‘she is like a man.’”43 Furthermore, some view women’s unmutilated genitals as “ugly and bulky,”44 whereas FGM brings about “smoothness,” which is considered beautiful, especially in communities that practice infibulation.45 Female genital mutilation is typically a strict requirement for marriage in the communities where it is practiced, in part because FGM is seen as ensuring premarital virginity and marital fidelity,46 both of which are highly prized and carefully policed.47 A clitoridectomy is believed to control a woman’s sexuality by removing her “site of sexual desire,”48 and infibulations are performed in order to prevent sexual intercourse and maintain virginity until marriage.49 In some cultures, FGM is thought to enhance men’s sexual pleasure.50 After marriage, women’s infibulations are frequently cut open for their husbands,51 and after childbirth women may be subjected to re-closure (reinfibulation) to “make them ‘tight’ for their husbands.”52
“In my village, FGM is seen as a way to ‘clean’ a girl of whatever she might have done before, to make her pure for her husband.” - Madeleine, 25, Burkina Faso

In many societies that practice FGM, women are viewed as the “gatekeepers of family honor,”53 and female genital mutilation is thought to bring greater social value, status, respectability, and honor, not only to the girl undergoing the procedure, but also to her family members. For example, the bride price that a family can collect for a daughter who has undergone female genital mutilation may be significantly greater than that of one who has not;54 infibulation can further increase the amount of money a groom will pay for a girl.55 Because FGM is closely linked to gender identity, family honor, social status, and marriageability,

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women who refuse the procedure face isolation, stigmatization, and difficulty finding a husband.56 In some societies, women who have not undergone female genital mutilation are even believed to be “dirty” and consequently be forbidden from handling food and water.57 As a result, many women describe immense social pressure to subject themselves or their daughters to FGM to avoid rejection by potential husbands and the larger community.58
THE ROLE OF RELIGION IN PERPETUATING FGM

A persistent misconception about female genital mutilation is that the practice is required by religion, particularly Islam.59 However, FGM is not particular to any religious group, and is not prescribed by any faith. It is prevalent among communities of different religious backgrounds, including Muslims, Christians, Jews, and followers of traditional animist religions.60 Although in some countries members of one religious community may be more likely to practice female genital mutilation than others, in other countries, there is no significant difference in FGM prevalence “I believe in Islam to this day . . . However, between religious groups.61 A multi-country survey I do not share the Islamic beliefs of my conducted by WHO reveals that the perceived link between female genital mutilation and religion may husband and my family . . . My family’s in fact be only a reformulation of the focus on beliefs that a woman should undergo FGM women’s sexuality, as in many communities, FGM’s and marry who her family chooses are primary connection to religion is that it supports connected to their beliefs in Islam and our the religious expectation of sexual restraint in ethnicity. On the other hand, I believe that women.62 Islam does not command these things about women. I believe that men read the Quran and tell women what they think. Men do not state exactly what is written in the Quran, but transform it into something that is favorable to men and not to women.” - Khadija, 29, Burkina Faso

Moreover, female genital mutilation predates Islam and is not practiced by the majority of Muslims in the world.63 While some local leaders promote the practice, many well-known religious figures, scholars, and theologians have spoken out against FGM.64 Secretary-General of the Organization of Islamic Cooperation, Ekmeleddin Ihsanoglu, has stated that “This practice is a ritual that has survived over centuries and must be stopped as Islam does not support it.”65 The late Sheikh Mohammed Sayed Tantawi, Grand Imam of Al-Azhar Mosque and Grand Sheikh of Al-Azhar University, has also remarked that “there is no text in Shari’a, in the Koran, in the prophetic Sunna addressing FGM.”66 With regard to Christianity and Judaism, Bishop Mousa, Representative of Pope Shenouda III of the Coptic Orthodox Church, has also expressed, “There is not a single verse in the Bible or the Old or New Testaments, nor is there anything in Judaism or Christianity – not one single verse speaks of female circumcision.”67

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PART II: FGM IN THE UNITED STATES

Until quite recently, experts and advocates were unaware of the pervasive risk of female genital mutilation faced by girls and women living within the United States. In 1997, however, the Centers for Disease Control and Prevention (CDC) estimated that as many as 150,000 to 200,000 girls in the United States were at risk of being forced to undergo female genital mutilation.68 Girls and young women were being subjected to the practice by traditional practitioners brought in from overseas to preside over covert ceremonies where an entire group of girls would be cut in the course of an afternoon;69 after the practice on U.S. soil was criminalized in 1996, a rapidly increasing number of families began sending their female children overseas to undergo FGM to avoid the possibility of criminal charges.70 Although updated studies are greatly needed, anecdotal evidence strongly indicates that the number of girls in the U.S. at risk of FGM has increased steadily since the CDC’s original report. Typically, girls in the U.S. are most affected by FGM if they are part of a community originally from a country where FGM is prevalent. In 2000, the U.S. states with the greatest estimated numbers of girls and women at risk were (in descending order): California, New “People in the U.S. think vacation York, New Jersey, Virginia, Maryland, Minnesota, Texas, cutting happens only in New York Georgia, Washington and Pennsylvania.71 (See Appendix because that is the capital of B, Fig. 1.) In particular, the metropolitan areas with the immigration, but FGM is impacting greatest numbers of girls and women at risk in 2000 children in their communities; it is were (in descending order): New York-New Jersey-Long happening to the kids that go to their Island, Washington DC-Baltimore, Los Angeles-Riversideschools and enter their hospitals.” Orange County, Minneapolis-St. Paul, San Francisco- Jaha, 23, The Gambia Oakland-San Jose, Atlanta, Seattle-Tacoma-Bremerto, San Diego, Houston-Galveston-Brazoria and PhiladelphiaWilmington-Atlantic City (see Appendix B, Fig. 2).72 Given the large number of states home to girls and women potentially at risk of FGM, this practice is a significant issue on a national level. Immigrant parents and relatives in the U.S. who continue to adhere to the practice often view female genital mutilation as an important step towards maintaining their first-generation children’s identity within their cultural community of origin.73 Others see it as a “bulwark” “My family gets frustrated with against Western influence on their daughters, and a way of me when I try to talk about reinforcing their culture in a foreign land.74 Many other families, [FGM]. They believe that I have despite their personal opposition to FGM, feel immense pressure abandoned my culture in favor from their spouses, elders and community members to pass on of Western ideas.” the traditions of their homeland, or are tricked into relinquishing - Mamasa, 27, Guinea their daughters into the care of relatives who arrange to have their daughters forcibly cut without their knowledge.
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Christie, 19, United States Christie, born in New York City, went to visit Guinea on vacation with her father. Unbeknownst to Christie, her father had arranged this trip for the purpose of forcing her to undergo female genital mutilation. In fact, Christie’s father was angry with her mother, Fanta, who had called the police in response to his violent abuse, and told Fanta that this was Fanta’s punishment for involving the “system” in their marriage. One day, while in Guinea, Christie returned from school to find many people from the village making food and preparing for a ceremony, and one of her aunts told her that she would soon undergo FGM. Opposed to FGM and afraid for her safety, Christie escaped to the U.S. embassy to seek help. There, she was able to speak with Fanta for the first time in several months, and they were reunited in New York.

VACATION CUTTING

Each year, young immigrants, permanent residents and U.S. citizens are sent abroad to undergo female genital mutilation in a practice that has been termed “vacation cutting.” Although a more extensive official study on vacation cutting is needed, testimony from survivors indicates that family members are increasingly sending their female children overseas to undergo FGM, typically during their school vacations, as part of a trip organized to expose the girls to the customs of their homelands. Although the motivations underlying vacation cutting are largely similar to those “When I was 16, my father told me that used for FGM in the countries to which girls are sent, ‘the world is far beyond America,’ and vacation cutting is sometimes also used by parents as a that he had arranged for me and my way of tempering the influence of American culture, little sister to travel with a family friend and families may threaten to return children to their back to Gambia, his country of origin, country of origin if that child demonstrates too much during our time off from school. When assimilation to U.S. social mores. we arrived in Gambia, my grandmother greeted us warmly and spent the next few days teaching us ‘what it takes to earn respect’ from our future husband and others in society, and explaining that FGM would remove ‘unclean’ body parts that were susceptible to disease. She warned us that if we refused to undergo FGM, she would be disappointed in us, and that the entire village would find out and force FGM upon us against our will.” - Kadiatou, 27, The Gambia

In some cases, girls are unaware that they are being sent abroad to be cut until they are actually forced to undergo the procedure. Others explain that even after they learned of their family’s plans to have them subjected to female genital mutilation, they did not know enough about the ritual to know they should resist their family’s wishes. One 17-year-old girl who was sent to Angola was told by family members that she was being prepared for “circumcision” in order “to become a woman, in order for her husband to respect her, [and] in order for her to get her place [in society].” She did not know exactly what the procedure involved, and concluded from her family’s reassurances that “this was the best thing for her.”

Often, girls are sent to be cut overseas not only without their own consent but without the knowledge or permission of one or both of their parents.75 There are thousands of women living in the United States who have been through female genital mutilation, and many of them desperately wish to protect their
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daughters from the same fate. However, controlling spouses, elder relatives and community members often have great overriding authority over these women’s wishes.76 Consequently, mothers may agree to send their daughter to their homeland to meet relatives and learn about their culture, unaware of arrangements by grandparents or other family members living in the U.S. or abroad to subject her to FGM.77 In other cases, daughters may be abducted and sent abroad to undergo the procedure against their mother’s express will.78 As one Guinean survivor explains, “My two elder daughters and my niece were victims of FGM without my knowledge and against my clear wishes. I myself am a victim of FGM, which I suffered when I was seven or eight years old, and I do not want to see my youngest daughter suffer the same fate.” This survivor’s situation mirrors that of countless immigrant women. One young mother from The Gambia, who is vehemently opposed to FGM, but whose abusive and controlling husband belongs to a tribe that mandates the procedure, refused to sign her infant daughter’s U.S. passport in an effort to prevent her husband from abducting her, only to have him threaten to forge the signature himself in order to send her abroad to be cut. Another immigrant survivor from Mali sought legal protection from her relatives abroad the instant she discovered she was expecting a baby girl. However, because many of these mothers are themselves undocumented, they are frequently afraid of seeking help from the authorities for fear of being forcibly removed from the U.S., where the chance of their daughters undergoing FGM may go from potential to certain.

Aida, 25, Ivory Coast Aida was born in a country in West Africa and came to the United States to join her parents when she was 13 years old. Aida learned English quickly, made friends with her American-born peers, and excelled in her classes. Unfortunately, Aida’s parents started threatening to send her back to Africa to undergo female genital mutilation, saying that this was a family tradition and would ensure that she would stay a virgin and make her an acceptable bride to her much older cousin, to whom she had already been promised in marriage. Aida was aware of the potential sexual, physical, and mental health consequences of FGM and refused to comply. She also knew that her parents had done the same thing to two of her unwitting older sisters, and was determined to protect herself. But her parents’ threats intensified, and they began to beat Aida for trying to refuse. Aida was scared to report the abuse and the threat of cutting because she was undocumented, and also because she had a younger sister to worry about, but she found the courage to confide in one of her guidance counselors. Unfortunately, her counselor felt that this was a cultural problem, one best sorted out by the family, and he did not report the abuse and threat of grave harm to the police or children’s protective services, which he was obligated to do under state law. Aida, who was undocumented, eventually found a youth group that referred her to a lawyer who helped her to obtain immigration status. Aida then set up an independent life, free from the threat of FGM.

FGM AS A RESULT OF CONSTRUCTIVE DEPORTATION

Undocumented parents with final deportation orders to countries where FGM is prevalent face an agonizing decision between being permanently and irrevocably separated from their children, and taking them back to a country where they will face a practice they oppose.79 In many cases, these U.S.-born daughters, still very young and entirely dependent on their parents, have no choice but to follow the family back to their
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home country, where they are subjected to FGM. A growing number of girls face this “constructive deportation” when their parents are removed; in 2009, 350,000 children were born in the U.S. to at least one undocumented immigrant parent,80 and despite recent changes in policy directing immigration agents to consider an undocumented immigrant’s U.S.-citizen family ties in discretionary enforcement decisions,81 U.S. Immigration and Customs Enforcement (ICE) reports that 45,000 of these parents were deported in just the first 6 months of 2012 alone.82
FGM ON U.S. SOIL

Anecdotal evidence indicates that female genital mutilation also continues to be performed within the United States. Typically, FGM in the U.S. is carried out by traditional practitioners who operate covertly and illegally.83 When U.S. health care providers carry out the procedure, they frequently come from countries where the practice is prevalent, and they operate on girls from their own communities at the request of a child’s parents.84 Some health care providers may not personally support FGM, “People in Africa will not let it but do not want to question their patients’ cultural practices.85 go. They will say, ‘see, even in These medical professionals sometimes agree to make “clitoral America they permit FGM.’ It nicks,” small incisions in the clitoral hood under local anesthesia, doesn’t matter how you cut, the in lieu of more extensive FGM.86 This and other “symbolic” fact that someone has touched forms of FGM have been the focus of debate among health and modified your genitals will care professionals, and the practice of nicking was even briefly stay with you the rest of your endorsed by the American Academy of Pediatrics (AAP) as a life.” way of meeting families’ perceived cultural requirements while - Kadi, 43, Ivory Coast avoiding more severe physical injury.87 However, after swift efforts to educate the medical community on the discrimination inherent in all forms of the practice, and the harmful role that even “symbolic” FGM can play in perpetuating gender-based violence, the AAP quickly retracted its controversial policy and issued a statement that, consistent with WHO and U.N. policy, “it does not endorse the practice of offering a ‘clitoral nick.’”88

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PART III: THE LEGAL FRAMEWORK FOR ADDRESSING FGM

Female genital mutilation is explicitly and implicitly prohibited by an evolving framework of international, federal and state laws. Historically, however, many of these laws have suffered from crippling loopholes or lacked the implementation mechanisms and political resolve necessary to effectively enforce them and successfully defend those at risk of the practice, both in the U.S. and abroad.
INTERNATIONAL LAWS PROHIBITING FGM

Female genital mutilation has long been considered a violation of the human rights of girls and women under international law. The Universal Declaration of Human Rights (1948) (“UDHR”) and the International Covenant on Civil and Political Rights (1966) (“ICCPR”) provide for every person’s rights to life, liberty and security of person, and to be free from cruel, inhumane or degrading treatment.89 The International Covenant on Economic, Social and Cultural Rights (1976) (“ICESCR”) requires countries to uphold the right to the enjoyment of the highest attainable standard of physical and mental health.90 In addition, the Convention on the Rights of the Child (1989) (“CRC”) requires countries that signed the treaty to “take all appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical and mental violence” and to provide “social programmes to provide necessary support for the child and for those who have the care of the child, as well as for other forms of prevention and for identification, reporting, referral, investigation, treatment and follow-up of instances of child maltreatment.”91 The Convention on the Elimination of All Forms of Discrimination Against Women (1979) (“CEDAW”) not only bars discrimination against women but also requires countries to modify their “social and cultural patterns of conduct . . . with a view to achieving the elimination of prejudices and customary and all other practices which are based on the idea of the inferiority or the superiority of either of the sexes or on stereotyped roles for men and women.”92 The governing body of this treaty, the CEDAW Committee, adopted three General Recommendations (Nos. 14, 19, and 24) to further clarify these requirements, which make clear that FGM is a “form of violence against women” and that it carries “severe health and other consequences for women and girls.”93 Since 1997, WHO has issued multiple joint statements with the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), and other agencies decrying the practice of FGM.94 Since then, progress has been made in the development of international monitoring bodies and resolutions that condemn the practice, a revised legal framework, and growing political support to stop the practice.

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UNITED STATES LAWS PROTECTING GIRLS AND WOMEN FROM FGM

In 1996, the federal immigration appeals court (the Board of Immigration Appeals or “BIA”) issued a landmark decision granting asylum to a woman fleeing female genital mutilation in her native country of Togo.95 In its opinion, the court established that FGM is a harm severe enough to constitute “persecution” under immigration law, and that women threatened with FGM deserve the protection of the U.S. government because they are targeted on account of their social group.96 Asylum represents a significant form of protection for girls and women in the U.S. who lack immigration status and fear being deported to their home country to undergo FGM. The same year the BIA issued this decision, the U.S. Congress enacted legislation criminalizing the performance of female genital mutilation in the United States on anyone less than 18 years of age. 97 The statute, which made the act of performing FGM on a minor punishable by a 5-year term of imprisonment, and clearly excluded culture as a defense to the crime, was intended to protect girls and to bring U.S. law in line with obligations under the International Covenant on Civil and Political Rights.98 With its passage of the law, Congress also directed the Immigration and Naturalization Service (now the U.S. Citizenship and Immigration Services) and the State Department to make information available to all immigrants about the harms and legal consequences of performing FGM.99 The law further appropriated money for the Department of Health and Human Services to undertake a study of the prevalence of FGM across the country and to carry out outreach and educational activities in communities that practice FGM.100 None of these activities have taken place since the passage of the law.
“…This means a lot… when I heard about this law being passed, I think it was probably the best day of my life, because that’s just how important this issue is to me, and not just to me, it’s important to my cousins, to my nieces that were born in the U.S. that have gone through this. I’m happy to know that kids like my daughter will not have to worry about someone sending them back home and having this done to them, so this is a huge step…. You have no idea what this means to me…” - Jaha, 23, The Gambia

Nearly two decades later, long after other countries issued similar laws, the “Transport for Female Genital Mutilation” amendment was signed into law by President Barack Obama in January of 2013.101 This new “extraterritoriality” or “vacation” provision, as it has been called, was the result of a multi-year effort by Representatives Joseph Crowley of New York and Mary Bono Mack of California to criminalize the act of transporting girls abroad with the purpose of subjecting them to FGM. The bill was introduced in 2010 and again in 2011102 by Senate Majority Leader Harry Reid as the “Girls Protection Act,” and was ultimately passed as an amendment to the National Defense Authorization Act for Fiscal Year 2013.103 The Act amends the federal criminal statute under 18 U.S.C. § 116(d) to read:

Whoever knowingly transports from the United States and its territories a person in foreign commerce for the purpose of conduct with regard to that person that would be a violation of subsection (a) if the conduct occurred within the United States, or attempts to do so, shall be fined under this title or imprisoned not more than 5 years, or both.104 This amendment, which was passed by Congress on the same day that the United Nations General Assembly passed the first resolution calling for a global ban on the practice of FGM, establishes parity
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between the sanctions levied on acts of FGM in the U.S. and acts of FGM planned within U.S. borders and executed abroad.105 The Act’s passage was celebrated by women’s rights advocates for closing the pernicious loophole in the federal FGM ban, and for “set[ting] an example for other countries and send[ing] a clear message to all that FGM is a criminal act that carries serious consequences” wherever it is performed.106 In addition to the federal legislation addressing FGM, twenty states have laws that specifically criminalize FGM.107 Although the law of each of these states differs in some respects from the federal statute, the basic definition of FGM is largely the same.108 However, many of the state laws extend protections against FGM beyond the scope of the federal statute. In a departure from both the federal law and the majority of jurisdictions that criminalize FGM, Tennessee, Minnesota, and Rhode Island do not require victims of FGM to be minors.109 Furthermore, at least twelve states make it a felony for a parent or guardian to permit a minor to undergo FGM, even if the parent or guardian is not the person who ultimately carries out the mutilation.110 For example, the Delaware Code provides that a “parent, guardian or other person legally responsible or charged with the care or custody of a female minor allows the circumcision, excision, or infibulations, in whole or in part, of such minor’s labia majora, labia minora or clitoris” is guilty of FGM.111 Colorado, Georgia, Illinois, Louisiana, Maryland, Missouri, New York, Oregon, and West Virginia also take this approach.112 Florida likewise makes it a crime for a parent or guardian to subject a minor child under their care to FGM, but the Florida statute distinguishes between a person who commits FGM and a person who only provides his or her consent: under Florida law, committing FGM is classified as a first degree felony, while knowingly consenting to FGM on behalf of a minor is classified as a third degree felony.113 California criminalizes FGM within the scope of its child abuse statute, and applies an additional term of imprisonment to those who carry out FGM, “in addition and consecutive to the punishment” given for violating the general child abuse provisions.114 Of the twenty states with laws prohibiting the practice of female genital mutilation, however, only four have statutes broad enough to cover vacation cutting. These laws were passed in response to efforts by antiFGM activists or community outrage after the occurrence of vacation cutting was exposed: • Florida: Under the Florida statute, “[a] person who knowingly removes, or causes or permits the removal of, a female person younger than 18 years of age from [the] state for purposes of committing female genital mutilation” is guilty of a felony.115 • Georgia: Under Georgia law, a person “who knowingly removes or causes or permits the removal of a female under 18 years of age from [the] state for the purpose of circumcising, excising, or infibulating, in whole or in part, the labia majora, labia minora, or clitoris of such female” is guilty of FGM.116 • Louisiana: Under Louisiana law, a person is guilty of female genital mutilation if that person “knowingly removes or causes or permits the removal of a female minor from this state for the purpose of circumcising, excising, or infibulating, in whole or in part, the labia majora, labia minora, or clitoris of such female.”117 • Nevada: The Nevada law against FGM extends to any person who willfully “[r]emoves a female child from [the] State for the purpose of mutilating the genitalia of the child.”118
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Where states lack specific legislation criminalizing female genital mutilation, child abuse statutes can provide protection for young girls facing FGM within the U.S. The Federal Child Abuse Prevention and Treatment Act provides minimum standards for state law definitions of child abuse and neglect. It states that “the term ‘child abuse and neglect’ means, at a minimum, any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.”119 Furthermore, all states have laws defining and criminalizing child abuse and neglect, which, although often broadly defined, encompass the harm of FGM.120 California and Illinois have already explicitly enumerated FGM as a type of child abuse within their child welfare laws,121 while Rhode Island defines FGM within its assault and battery statute.122
THE ENFORCEMENT GAP

To date, there has been a glaring absence of prosecutions in the U.S. related to cases of FGM under both state and federal law: as of 2012, there have been no prosecutions under federal law, and only one criminal case has been brought forward under a state statute.123 The failure to enforce existing FGM legislation may leave potential FGM victims without adequate protection. State and local child abuse laws are also frequently “FGM is something that has affected all of underutilized in the context of FGM, especially our lives… at least now we know that there’s in states where there is no explicit state law a law out there that’s protecting us, there’s criminalizing FGM. In many states, child abuse a law out there that’s defending us, we can statutes contain certain exceptions for certain stand up and say that, you know what? culturally influenced decisions regarding the medical This can’t keep happening to us anymore, treatment of children,124 and local authorities we have a law in the U.S. that says that it’s often lack guidance as to whether this exception illegal to take these kids out of the country extends to a “cultural” practice such as FGM.125 and take them to another country and have Furthermore, because reporting obligations depend this performed on them.” on the state’s definition of “child abuse,” mandated - Jaha, 23, The Gambia reporters, such as social workers, psychologists, and physicians, are likely to be unsure as to whether they have a clear legal responsibility to inform authorities of suspected cases of vacation cutting. Authorities are expected to take seriously any complaints of child abuse or threats of child abuse, and FGM should be treated the same. State procedures typically take the need for family unity into consideration when all forms of child abuse are investigated; there is no reason why FGM should be considered a special category of violence. In addition, very few reports have been made by those individuals at immediate risk of FGM here or through vacation cutting. This underreporting can be partly attributed to lack of knowledge among victims, community members and service providers about the laws protecting girls at risk. However, reasons for underreporting likely also include reluctance on the part of the girl or her family to come forward, precisely because they know and fear the legal penalties for doing so. Many girls fear that innocent family members, especially their mothers, will be considered complicit in their family’s efforts to force them to undergo FGM, or worry that if they report their relatives, they will be arrested, prosecuted, and possibly deported. Community pressure to avoid involvement of law enforcement can also be highly influential upon young people.
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PART IV: RECOMMENDATIONS FOR BUILDING A MOVEMENT TO END FGM IN THE U.S.

As the prevalence of domestic and vacation cutting rises in the U.S., a small number of advocates, survivors, counselors, lawyers, and doctors across the country are examining ways to support and serve those who have experienced FGM and to protect girls and women at risk. International experience suggests that successful prevention of female genital mutilation requires a proactive and coordinated approach that includes:126 1. Community and survivor-led outreach and education; 2. Guidelines and training to assist front-line professionals to identify and protect girls at risk; 3. Robust, consistently enforced laws that prohibit FGM locally and extraterritorially; and 4. Reporting and data collection.

“I would never want anyone to cut me like that. I want to be able to enjoy the same things other girls do, to be healthy, to be free from infections, scarring, pain, bleeding, and other problems I know girls who have undergone FGM have to deal with. I firmly believe that the practice of FGM is a health risk to women and girls, and I know for sure that I would risk everything to avoid it if I could. If I ever had a daughter, I would certainly fight to be sure she couldn’t be cut either.” – Salima, 21, Guinea

OBJECTIVE 1: Community and survivor-led outreach and education

The cornerstone of the effort to protect affected girls and women in the United States is outreach and education about the consequences of FGM. While a few community-based and advocacy organizations currently conduct such outreach, more and coordinated efforts are needed to broaden awareness and effectively break the silence around this practice, especially in light of the new vacation cutting amendment. Sensitive, culturally competent collaboration between advocates, community leaders, survivors, family members, and those at risk can prevent FGM from occurring. Education must move beyond theoretical justifications for ending the practice and emphasize a victim-centered, prevention-focused approach. An effective campaign must successfully galvanize the following stakeholders:

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• Religious and community leaders: Faith leaders such as Imams and neighborhood country association presidents are highly respected in their communities, and thus represent crucial allies in the quest to educate their constituencies about the harms and illegality of FGM. • Parents: Parents must understand the importance of educating their daughters about the practice of FGM, what the procedure entails, and the names by which it may be referred in their native language. They should also be encouraged to create safety plans with their children in the event that they are sent abroad. These safety plans can include simple measures like memorizing emergency phone numbers, locating and keeping on hand the address of the nearest U.S. embassy, and ensuring that they have pocket money for a cab in the event that they need to flee. • Adolescent girls: Young women at risk of female genital mutilation must be given a safe space in which to voice possible concerns they may have about FGM, and receive education on the laws in place to protect their rights. Presentations and group-led discussions on female genital mutilation can easily be integrated into similar programs already offered by middle schools and high schools about self-defense, domestic violence, or reproductive health.

“[The law] is not the end of it, now we need to spread the word out there, we need to let people know that this law is out there, we need to educate people in our community, we need to educate our teachers, we need to educate our doctors, our nurses, and let them know to look out for kids that have gone through this, because they need counseling, they need help. So this is the first step, and it’s the most important step. Now all of us collectively have to do something to do the rest.” - Jaha, 23, The Gambia

• Survivors: Initial outreach efforts have demonstrated the powerful influence of experience-based advocacy in combating FGM. Where possible, survivor-led community education can provide an incredibly convincing and empowering argument that FGM is hurting the communities in which it is practiced. Although historically it has been difficult and even dangerous for survivors and their allies to voice opposition, youth from affected communities living in the United States are organizing to change this, and a number of young women are beginning to speak out.
OBJECTIVE 2: Guidelines and training to assist in the identification and protection of those at risk

When a girl fears that her parents or other family members are arranging for her to be cut overseas, she may confide in her guidance counselor, social worker, therapist, or doctor. As such, school officials, public service providers, and health care professionals must play a fundamental role in preventing FGM from occurring. Unfortunately, currently these front-line agents lack the education on the issue and the tools they need to interview FGM survivors and identify and assist individuals at risk of the practice. Appropriate guidelines should be developed in the United States that provide best practices for identification and protection of those at risk, and should address: • The impact of female genital mutilation on the physical and mental health of girls and women in the United States;

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•

Descriptions of the various federal and state legal provisions that must be upheld by all service providers, including their obligations to report instances of actual or threatened female genital mutilation; Tailored guidelines on prevention and intervention; Resources available to at-risk and affected women and girls; and Creative, strategic tactics currently being used in other countries to tackle the many barriers to effective protection of girls and women at risk of FGM.

• • •

Other countries, such as the United Kingdom, have put protocols in place to educate service providers and to require them to investigate the possibility of female genital mutilation with clients and patients.127 U.S. law enforcement and children’s protection agencies, as well as school counselors, teachers, lawyers, and medical personnel, should likewise be provided with comprehensive training on how to sensitively raise issues surrounding the risks and consequences of FGM, how to identify common indicators that suggest an imminent risk of FGM, and how to quickly and effectively respond to requests for help. It is particularly vital that this training be provided to those service providers most likely to come into contact with girls and women at risk: • Teachers: Teachers must be educated about the practice and consequences of FGM, taught to identify common signs indicating that a student may be at risk of undergoing the procedure, and trained to educate families about the importance of complying with federal and state FGM laws. Likewise, teachers should be trained to monitor children who return to the classroom and to investigate red flags that may indicate the child has undergone FGM. When appropriate, teachers must be educated about the importance of their duty to report FGM. • Children’s protection agencies: Case managers, social workers and other child protective specialists require training on how to respond to reports of FGM, how to identify signs of FGM, and how to distinguish FGM from cultural practices that may be exempted from child abuse standards. • Social service and public benefits agencies: Local, state and federal service agencies that routinely interact with immigrant communities should be trained to sensitively raise issues surrounding FGM and to educate their clients on the importance of complying with FGM laws. • Doctors, counselors, and legal service providers: Practitioners who routinely interact with girls and women in immigrant communities should be trained to raise issues surrounding FGM and to sensitively and supportively address the needs or concerns of affected patients. Information on FGM’s consequences and context should be integrated into trainings on patient care, domestic violence, and cultural competency at medical schools, social work schools, and law schools. • Airport security, border patrol, and embassy personnel: The Transportation Security Administration and Customs and Border Patrol must be educated about the prevalence of vacation cutting and trained to respond quickly and effectively to girls and women who seek help and inform them that they are
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afraid they may be about to be transported abroad for the purpose of female genital mutilation. The Department of State must likewise train its embassy staff in countries where FGM is prevalent to address requests for help from girls who have been taken abroad. • Law enforcement: Law enforcement personnel must also be trained to understand and support victims who seek help from police or make reports about a threat of FGM. Trainings should emphasize the importance of immediate assistance to the victim, and the proper procedures that must be followed to respectfully and sensitively investigate allegations of wrongdoing. Law enforcement officials should also be equipped with appropriate referrals to shelters, legal representation, and supportive counseling for victims.
OBJECTIVE 3: Robust, consistently applied laws that prohibit FGM locally and extraterritorially

Through the decades-long efforts of survivors, community members, and advocates, an evolving body of laws has been developed that represents the first steps towards better safeguarding vulnerable women’s rights and health against female genital mutilation in the United States. Now, these laws must be strengthened and upheld in the following ways: • States that do not yet have laws prohibiting female genital mutilation should adopt such laws. The laws should include protections for girls and women against forcible FGM in the U.S. and abroad through vacation cutting. State laws that protect children from abuse should be interpreted to include female genital mutilation as a form of child abuse. Where such an interpretation is not possible, child protection laws should explicitly incorporate FGM. Any complaints of a risk of FGM should be carefully investigated just like other forms of child abuse. The federal ban on FGM and its recent amendment should be upheld. This means that mandated reporters must uphold their legal duty to respond to suspected female genital mutilation and report its threat or practice accordingly, and that reports of female genital mutilation occurring on U.S. soil as well as any transport for the purpose of FGM should be investigated by the appropriate authorities. The provisions of the 1996 federal law requiring outreach and data collection with regard to female genital mutilation should be respected; the federal government should allocate funds so that communitybased organizations, local non-profit organizations, and federal agencies can inform communities about the illegality of FGM. In order to be successfully implemented, guidelines should be promulgated that explicitly charge crime units, agencies, and authorities responsible for investigating child abuse and sexual assault with enforcement of FGM laws. Due to the unique and sensitive nature of the circumstances surrounding FGM, these laws should mandate detailed, sensitized training on how to enforce legislation in a way that is not discriminatory against family members and immigrant communities. Federal guidelines can also strengthen enforcement of state mandatory reporting laws by clarifying that FGM in all forms is child abuse.

•

•

•

•

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OBJECTIVE 4: Reporting and data collection

Currently, the U.S. government maintains no data on the number of girls and women who have undergone female genital mutilation in this country or through vacation cutting. With no accurate, objective figures available on the prevalence of the practice, affected girls and women continue to live in the shadows. Comprehensive data would enable advocates and providers to better serve the needs of survivors, target and develop outreach and education efforts aimed at prevention, and ultimately better ensure the safety and health of at-risk women and girls.

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CONCLUSION

As female genital mutilation becomes better understood as a form of gender violence that perpetuates inequality, survivors, human rights advocates and governments in the countries where FGM is most commonly practiced have formed a global community of voices calling for an eradication of the custom. Across the world, its members are fighting—against all odds and sometimes in the face of great personal peril—to protect the safety and dignity of at-risk girls and women wherever they can be found. It is time for the United States to establish itself as a committed leader within this community. Although the U.S. now grants safe haven to those seeking protection from female genital mutilation abroad, our country has failed to adequately protect the girls and women—whether undocumented, U.S. citizens, adults, or infants rushed to advocates’ doors by terrified mothers—who fear FGM that is performed or planned in the U.S. Until we can protect the girls and women within our borders as well as we protect those who are fleeing harm from distant shores, we have not adequately fulfilled our international obligation to help women and their families build lives free from the threat of violence.

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APPENDIX A: Global prevalence of FGM
Fig. 1: Countries where FGM has been widely documented (girls and women aged 15-49)
Country Year Estimated prevalence of FGM (%) 12.9 72.5 1.4 25.7 44.9 36.4 93.1 91.1 88.7 74.3 78.3 3.8 95.6 44.5 27.1 58.2 85.2 72.2 2.2 29.6 28.2 94 97.9 90 Source: MICS, DHS, and other national surveys, 19972006. Map developed by UNICEF, 2007.129

Fig. 2: Prevalence of FGM in Africa and Yemen (girls and women aged 15-49)

Benin Burkina Faso Cameroon Central African Republic Chad Côte d’Ivoire Djibouti Egypt Eritrea Ethiopia Gambia Ghana Guinea Guinea-Bissau Kenya Liberia Mali Mauritania Niger Nigeria Senegal Sierra Leone Somalia Sudan, northern* (approximately 80% of total population in survey) Togo Uganda United Republic of Tanzania Yemen

2006 2006 2004 2008 2004 2006 2006 2008 2002 2005 2005/6 2006 2005 2006 2008/9 2007 2006 2007 2006 2008 2005 2006 2006 2000

2006 2006 2004 2003

5.8 0.8 14.6 38.2

Source: MICS, DHS, and other national surveys. Table developed by WHO.128 *Note: Research conducted before the independence of South Sudan in July 2011.
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APPENDIX B: Prevalence of FGM in the U.S.
Fig. 1: Girls and women living in the U.S. estimated to be at risk of FGM, by state130
State U.S. Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Total 227,887 657 96 2,741 157 38,353 1,885 1,008 375 2,619 4,894 9,531 103 528 6,420 1,480 828 114 1,052 1,239 16,264 5,231 5,175 13,196 46 1,320 4 497 604 92 18,584 123 25,949 4,297 1,134 4,834 410 3,524 6,508 1,271 680 1,344 2,823 13,100 377 97 17,980 7,292 257 791 Under 18 62,519 118 999 9,631 516 272 237 418 919 2,404 386 1,307 446 213 67 434 4,466 1,318 1,578 3,691 23 440 274 83 5,605 7,675 973 837 1,680 43 766 1,357 214 261 866 1,275 3,790 232 4,312 1,943 159 291 18+ 539 96 1,742 157 28,722 1,369 736 139 2,201 3,975 7,128 103 141 5,114 1,035 614 114 985 805 11,798 3,912 3,596 9,505 23 879 4 223 604 9 12,978 123 18,274 3,325 298 3,154 368 2,758 5,151 1,057 419 477 1,549 9,310 145 97 13,669 5,349 98 499 -

Source: Population Reference Bureau, analysis of data from the 2000 Census 1-Percent Microdata Sample. Table developed by African Women’s Health Center, Brigham and Women’s Hospital.131

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APPENDIX B CONT’D.: Prevalence of FGM in the U.S.
Fig. 2: Girls and women living in the U.S. estimated to have had or be at risk of FGM, by metropolitan area
Metropolitan Statistical Area U.S. New York-Northern New Jersey-Long Island, NY-NJ-CT-PA CMSA Washington-Baltimore, DCMD-VA-WV CMSA Los Angeles-RiversideOrange County, CA CMSA Minneapolis-St. Paul, MNWI MSA San Francisco-Oakland-San Jose, CA CMSA Atlanta, GA MSA Seattle-Tacoma-Bremerton, WA CMSA Philadelphia-WilmingtonAtlantic City, PA-NJ-DE-MD CMSA Chicago-Gary-Kenosha, ILIN-WI CMSA Houston-GalvestonBrazoria, TX CMSA Dallas-Fort Worth, TX CMSA San Diego, CA MSA Boston-WorcesterLawrence, MA-NH-ME-CT CMSA Detroit-Ann Arbor-Flint, MI CMSA Portland-Salem, OR-WA CMSA Columbus, OH MSA Phoenix-Mesa, AZ MSA Denver-Boulder-Greeley, CO CMSA Miami-Fort Lauderdale, FL CMSA Providence-Fall RiverWarwick, RI-MA MSA Other metropolitan areas Total 227,887 40,813 33,221 18,866 12,708 9,763 8,472 6,786 5,859 5,455 6,412 4,977 6,498 3,585 3,925 2,902 3,157 2,319 1,734 1,221 1,247 47,968 Under 18 62,519 11,809 8,308 4,077 3,622 1,869 1,883 1,745 1,213 1,082 2,138 1,045 2,680 598 1,152 517 1,036 935 516 117 214 15,965 18+ 165,368 29,004 24,913 14,789 9,086 7,894 6,588 5,041 4,646 4,373 4,274 3,932 3,818 2,987 2,773 2,385 2,121 1,384 1,219 1,105 1,033 32,003

Source: Population Reference Bureau, analysis of data from the 2000 Census 1-Percent Microdata Sample. Table developed and designed by African Women’s Health Center, Brigham and Women’s Hospital.132 *Note: CMSA refers to Consolidated Metropolitan Statistical Area.
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ENDNOTES
1 FGM violates human rights guaranteed in the Universal Declaration of Human Rights and the following international conventions: International Covenant on Civil and Political Rights (ICCPR); International Covenant on Economic, Social and Cultural Rights (ICESCR); Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT); Convention Relating to the Status of Refugees (Refugee Convention) and its Protocol relating to the Status of Refugees; Convention on the Elimination of all Forms of Discrimination against Women (CEDAW); and Convention on the Rights of the Child (CRC). See World Health Organization (WHO), An update on WHO’s work on female genital mutilation (FGM): Progress report 8 (2011), available at http://whqlibdoc.who.int/hq/2011/WHO_RHR_11.18_ eng.pdf. The practice of FGM is specifically addressed in UN General Assembly Resolution 56/128 on Traditional or Customary Practices Affecting the Health of Women and Girls, which reaffirms that “harmful traditional or customary practices, including female genital mutilation . . . constitute a definite form of violence against women and girls and a serious violation of their human rights.” G.A. Res. 56/128, U.N. Doc. A/RES/56/128 (Dec. 19, 2001). 2 UNICEF Innocenti Research Center, Changing a Harmful Social Convention: Female Genital Mutilation/Cutting [hereinafter Changing a Harmful Social Convention] at 3 (2008), available at http://www.unicef-irc.org/publications/pdf/fgm_eng.pdf. 3 W K Jones, J Smith, B Kieke, Jr, and L Wilcox, “Female genital mutilation. Female circumcision. Who is at risk in the U.S.?” Public Health Rep. 1997 Sep-Oct; 112(5): 368–377, available at http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1381943/. 4 African Women’s Health Center, Research Performed by the African Women’s Center, Brigham and Women’s Hospital, available at http://www.brighamandwomens. org/Departments_and_Services/obgyn/services/ africanwomenscenter/research.aspx (last modified Feb. 19, 2013). 5 See Els Leye & Alexia Sabbe, Overview of Legislation in the European Union to Address Female Genital Mutilation: Challenges and Recommendations for the Implementation of Laws at 10 (2009), available at http://www.un.org/womenwatch/daw/egm/vaw_ legislation_2009/Expert%20Paper%20EGMGPLHP%20_ Els%20Leye_.pdf. See also, e.g., Foundation For Women’s Health, Research and Development, A Statistical Study to Estimate the Prevalence of Female Genital Mutilation in England and Wales: Summary Report at 9 (2007), available at http:// www.forwarduk.org.uk/key-issues/fgm/research; Ireland’s National Plan of Action to Address Female Genital

Mutilation (2008) at 1, 12-17, available at http://www.akidwa. ie/FGM%20Plan%20of%20Action%20Report.pdf; Le praticien face aux mutilations sexuelles féminines, Annex 4, available at http://dl.free.fr/fD4iRj82t/OUVRAGE1_praticien_face_ MSF_Versionfinaleseptembre2010.pdf. 6 The official congressional findings accompanying the 1996 federal law’s passage recognized that FGM violates not only international law, but also “the guarantees of rights secured by Federal and State law, both statutory and constitutional.” Pub. L. No. 104-208, § 645(a) (included as a note at 18 U.S.C. § 116). 7 UNICEF Innocenti Research Ctr., Changing a Harmful Social Convention at 3. 8 Id. at 2. 9 World Health Organization (WHO), An update on WHO’s work on female genital mutilation (FGM): Progress report [hereinafter Progress Report] at 1 (2011), available at http://whqlibdoc.who. int/hq/2011/WHO_RHR_11.18_eng.pdf. 10 Id. 11 Human Rights Watch, “They Took Me and Told Me Nothing”: Female Genital Mutilation in Iraqi Kurdistan 56-63 (2011), available at http://www.hrw.org/en/reports/2010/06/16/they-tookme-and-told-me-nothing-0. 12 Amnesty International, What is female genital mutilation? (Sept. 30, 1997), AI Index: ACT 77/06/97, available at http:// www.amnesty.org/en/library/asset/ACT77/006/1997/ en/3ed9f8e9-e984-11dd-8224-a709898295f2/ act770061997en.html. 13 See World Health Organization (WHO), Eliminating female genital mutilation: An interagency statement [hereinafter Interagency Statement] (2008), available at http://whqlibdoc.who.int/ publications/2008/9789241596442_eng.pdf. 14 See World Health Organization (WHO), Female genital mutilation: Fact sheet No. 241 [hereinafter Fact Sheet] (Feb. 2013), http://www.who.int/mediacentre/factsheets/fs241/en/index. html; see also Amnesty Int’l, What is female genital mutilation? (Sept. 30, 1997). 15 WHO, Progress report. See also Hannah Osborne, “Female Genital Mutilation: 30 Million Girls Still Vulnerable to Practice,” International Business Times, Feb. 7, 2013, reporting preliminary data from the UNFPA-UNICEF Joint Programme on FGM/C showing that among the 29 countries studied, “36 per cent of girls aged between 15 and 19 have been cut, while 53 per cent of women aged between 45 and 49 have been subjected to FGM.” 16 Id.; see also WHO, Fact Sheet.

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17 Amnesty International, What is female genital mutilation? (Sept. 30, 1997). 18 According to the World Health Organization, more than 18% of all FGM is performed by health care providers. See WHO, Fact Sheet. 19 UNICEF Innocenti Research Ctr., Changing a Harmful Social Convention. 20 Id. 21 See WHO, Interagency Statement. 22 See WHO, Health complications of female genital mutilation, available at http://www.who.int/reproductivehealth/topics/ fgm/health_consequences_fgm/en/. 23 See WHO, Interagency Statement. 24 See id.; see also Amnesty International, What is female genital mutilation? (Sept. 30, 1997). 25 See WHO, Interagency Statement at 34. 26 Id. 27 Id. 28 WHO, Progress Report at 3. 29 Id. 30 WHO, Interagency Statement at 34. 31 See Human Rights Watch, “They Took Me and Told Me Nothing,” at 38-39. 32 See id. at 39; WHO, Interagency Statement at 34. 33 See Human Rights Watch, “They Took Me and Told Me Nothing,” at 39. 34 See WHO, Interagency Statement at 34; Human Rights Watch, “They Took Me and Told Me Nothing,” at 38. 35 See Human Rights Watch, “They Took Me and Told Me Nothing,” at 38. 36 Rossella Lorenzi, “How did female genital mutilation begin?” Discovery News, Dec. 10, 2012, available at http:// news.discovery.com/history/female-genital-mutilationbegin-121210.html. 37 UNICEF, The dynamics of social change: Towards the abandonment of FGM/C in five african countries, Innocenti Insight, 2010, available at http://www.unicef-irc.org/ publications/618. 38 Amnesty International, What is female genital mutilation? (Sept. 30, 1997). 39 WHO, Progress report; Amnesty International, What is female

genital mutilation? (Sept. 30, 1997). 40 Amnesty International, What is female genital mutilation? (Sept. 30, 1997). 41 Id. 42 WHO, Progress report. 43 An Egyptian woman, quoted in Amnesty International’s report on FGM, stated, “‘We . . . insist on circumcising our daughters so that there is no mixing between male and female . . . . An uncircumcised woman is put to shame by her husband, who calls her ‘you with the clitoris.’ People say she is like a man.’” Amnesty International, What is female genital mutilation? (Sept. 30, 1997). 44 Id. 45 WHO, Interagency Statement at 6. 46 WHO, Fact Sheet. 47 UNICEF Innocenti Research Ctr., Changing a Harmful Social Convention at 17. 48 WHO, Progress Report. 49 Amnesty International, What is female genital mutilation? (Sept. 30, 1997). 50 Id. 51 Id. 52 Id. 53 Human Rights Watch, “They Took Me and Told Me Nothing.” 54 UNICEF Innocenti Research Ctr., Changing a Harmful Social Convention at 12. 55 Id. 56 Id. at 12-13. 57 Amnesty International, What is female genital mutilation? (Sept. 30, 1997). 58 See id.; Beatrice Paez, U.S. Bill Would Outlaw FGM “Holidays,” Inter Press Service News Agency, June 12, 2010, available at http://ipsnews.net/text/news.asp?idnews=51802. 59 UNICEF Innocenti Research Ctr., Changing a Harmful Social Convention at 12. 60 UNICEF, Female Genital Mutilation/Cutting: A Statistical Exploration 17 (2005), available at http://www.unicef.org/ publications/files/FGM-C_final_10_October.pdf. 61 According to a statistical study by UNICEF, FGM prevalence is greater among Muslim groups than Christian groups in Benin, Côte d’Ivoire, Ethiopia, Ghana, Kenya, and

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Senegal. However, in Niger, Nigeria, and United Tanzania, FGM prevalence is higher among Christian groups, and in Burkina Faso, Central African Republic, Eritrea, Ethiopia, Guinea, and Mali, there is no significant difference between religious groups. UNICEF, Female Genital Mutilation/Cutting: A Statistical Exploration at 10. 62 WHO, Progress Report at 7. 63 FGM was practiced in Sudanese or Nubian populations before the arrival of Islam, and there is no evidence of FGM in several Muslim countries, particularly in North Africa, including Algeria, Libya, Morocco, and Tunisia. UNICEF Innocenti Research Ctr., Changing a Harmful Social Convention at 12. 64 WHO, Fact Sheet. 65 TrustLaw, “OIC chief calls for abolition of female genital mutilation,” Dec. 4, 2012, available at http://www.trust.org/ trustlaw/news/oic-chief-calls-for-abolition-of-female-genitalmutilation/. 66 UNICEF Innocenti Research Ctr., Changing a Harmful Social Convention. 67 Id. 68 Brinda Adhikari & Lara Salahi, “Female Genital Cutting: Affecting Young Girls in America,” ABC World News, June 14, 2010, available at http://abcnews.go.com/WN/ WorldNews/female-genital-cutting-affecting-young-girlsamerica/story?id=10859231. 69 Amnesty International, What is female genital mutilation? (Sept. 30, 1997); Lynn Harris, “Our daughters should not be cut,” [hereinafter “Our Daughters”], Salon, Jan. 24, 2010, available at http://www.salon.com/life/feature/2010/01/24/ fgm_in_america. 70 Amnesty International, What is female genital mutilation? (Sept. 30, 1997); Harris, “Our daughters,” Salon. 71 See African Women’s Health Center, Research Performed by the African Women’s Center, tbl. 4 [hereinafter Table 4], Brigham and Women’s Hospital, available at http://www. brighamandwomens.org/Departments_and_Services/ obgyn/services/africanwomenscenter/FGCbystate.aspx (last modified Feb. 19, 2013). 72 Id., tbl. 5 [hereinafter Table 5]. 73 Amnesty International, What is female genital mutilation? (Sept. 30, 1997). 74 See Lynn Harris, “Female genital mutilation in the U.S.: No compromise” [hereinafter “No Compromise”], Salon, June 2, 2010, available at http://www.salon.com/life/ feature/2010/06/02/fgm_genital_nick; UNICEF Innocenti

Research Ctr., Changing a Harmful Social Convention at 11. 75 Nadia Sussman, “After School in Brooklyn, West African Girls Share Memories of a Painful Ritual,” New York Times, Apr. 25, 2011, available at http://www.nytimes. com/2011/04/26/nyregion/brooklyn-girls-from-west-africarecall-genital-cutting.html?_r=2&ref=femalegenitalmutilation (“[Some] girls are cut by relatives without their parents’ knowledge while on vacation abroad.”). 76 Id. (“In some families, parents oppose female genital cutting, but the decision about whether or not to have it done is not always theirs to make. Many elders in West African communities hold great social authority and do not seek parental permission to have it done to a girl.”); see also Harris, “Our daughters,” Salon (“Older relatives with ‘seniority’ often push for the procedure.”). 77 See Paez, U.S. Bill Would Outlaw FGM “Holidays,” Inter Press Service News Agency (noting that mothers are often treated as having “second-class citizenship within her culture” and “‘do not have the power to decide whether or not their girls will be cut’”). 78 See WHO, Interagency Statement at 7 (“[T]here are cases [of FGM] in which some family members, against the will of others, have organized the procedure.”). 79 The University of Arizona Southwest Institute for Research on Women, Disappearing Parents: A Report on Immigration Enforcement and the Child Welfare System, May 2011 at 1, available at http://www.detentionwatchnetwork. org/sites/detentionwatchnetwork.org/files/06.09.2011_ DisappearingParents.pdf. 80 Pew Research Center, Unauthorized Immigrant Population: National and State Trends, 2010, February 2011, available at http://pewhispanic.org/files/reports/133.pdf. 81 U.S. Department of Immigration and Customs Enforcement, Office of the Director, Memo: Exercising Prosecutorial Discretion Consistent with the Civil Immigration Enforcement Priorities of the Agency for the Apprehension, Detention, and Removal of Aliens, June 17, 2011, available at http://www. ice.gov/doclib/secure-communities/pdf/prosecutorialdiscretion-memo.pdf. 82 Helen O’Neill, “U.S.-Born Kids Of Deported Parents Struggle As Family Life Is ‘Destroyed’,” Huffington Post, Aug. 25, 2012, available at http://www. huffingtonpost.com/2012/08/25/us-born-kids-deportedparents_n_1830496.html. 83 See Amnesty International, What is female genital mutilation? (Sept. 30, 1997); Harris, “Our daughters,” Salon. 84 See Amnesty International, What is female genital mutilation?

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(Sept. 30, 1997); WHO, Global strategy to stop health-care providers from performing female genital mutilation [hereinafter Global Strategy] 6 (2010), available at http://whqlibdoc.who. int/hq/2010/WHO_RHR_10.9_eng.pdf at 7; Harris, “No Compromise,” Salon; Brinda Adhikari & Lara Salahi, “Female Genital Cutting: Affecting Young Girls in America,” ABC World News. 85 WHO, Global Strategy at 7. 86 See Harris, “No Compromise,” Salon; Adhikari & Salahi, “Female Genital Cutting: Affecting Young Girls in America,” ABC World News. 87 On April 26, 2010, the AAP issued a policy stating, in part, “[T]he the ritual nick suggested by some pediatricians is not physically harmful and is much less extensive than routine newborn male genital cutting. There is reason to believe that offering such a compromise may build trust between hospitals and immigrant communities, save some girls from undergoing disfiguring and life-threatening procedures in their native countries, and play a role in the eventual eradication of FGC. It might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick as a possible compromise to avoid greater harm.” See “Policy Statement: Ritual Genital Cutting of Female Minors,” Pediatrics, Vol. 125 No. 5, May 1, 2010, pp. 1088-1093, available at http://pediatrics.aappublications.org/content/125/5/1088. full. See also Belinda Luscombe, “Has a U.S. Pediatrics Group Condoned Genital Cutting?” Time Magazine, May 11, 2010, available at http://www.time.com/time/health/ article/0,8599,1988434,00.html. 88 See “Policy Statement: Ritual Genital Cutting of Female Minors,” Pediatrics, Vol. 126, No. 1, July 2010, available at http://pediatrics.aappublications.org/content/ early/2010/06/07/peds.2010-1568.full.pdf+html. The president of the AAP explained to media outlets that “We retracted the policy because it is important that the world health community understands the AAP is totally opposed to all forms of female genital cutting, both here in the U.S. and anywhere else in the world.” See Stephanie Chen, “Pediatricians now reject all female genital mutilation,” CNN. com, May 27, 2010, available at http://www.cnn.com/2010/ HEALTH/05/27/AAP.retracts.female.genital.cutting/index. html. 89 See UN General Assembly, Universal Declaration of Human Rights, 10 December 1948, 217 A (III), available at http:// www.unhcr.org/refworld/docid/3ae6b3712c.html; UN General Assembly, International Covenant on Civil and Political Rights, 16 December 1966, United Nations, Treaty Series, vol. 999, p. 171, available at http://www.unhcr.org/refworld/ docid/3ae6b3aa0.html.

90 UN General Assembly, International Covenant on Economic, Social and Cultural Rights, 16 December 1966, United Nations, Treaty Series, vol. 993, p. 3, available at http://www.unhcr.org/ refworld/docid/3ae6b36c0.html. 91 UN General Assembly, Convention on the Rights of the Child, 20 November 1989, United Nations, Treaty Series, vol. 1577, p. 3, available at http://www.unhcr.org/refworld/ docid/3ae6b38f0.html. 92 UN General Assembly, Convention on the Elimination of All Forms of Discrimination Against Women, 18 December 1979, United Nations, Treaty Series, vol. 1249, p. 13, available at http://www.unhcr.org/refworld/docid/3ae6b3970.html. 93 See “Female circumcision,” CEDAW General Recommendation No. 14 (9th Session, 1990); “Violence against women,” CEDAW General Recommendation No. 19 (11th Session, 1992); “Women and health,” CEDAW General Recommendation No. 24 (20th Session, 1999), available at http://www.un.org/womenwatch/daw/cedaw/ recommendations/. 94 See WHO, Interagency Statement; for a timeline outlining the international response, see WHO, Fact Sheet. 95 See Matter of Kasinga, 21 I. & N. Dec. 357 (BIA 1996). 96 Matter of Kasinga, 21 I. & N. Dec. 357 (BIA 1996). Subsequent case law has also recognized female genital mutilation as an ongoing, often lifelong harm, and established women that have already undergone FGM may also warrant asylum, see Bah v. Mukasey, 529 F.3d 99 (2d Cir. 2008). 97 18 U.S.C.A. § 116(a) (West 2011); See Celia W. Dugger, “New Law Bans Genital Cutting in the United States,” New York Times, Oct. 12, 1996, available at http://www.nytimes. com/1996/10/12/nyregion/new-law-bans-genital-cutting-inunited-states.html. 98 18 U.S.C.A. § 116(c) (“[N]o account shall be taken of the effect on the person on whom the operation is to be performed of any belief on the part of that person, or any other person, that the operation is required as a matter of custom or ritual.”). The U.S. is a party to the ICCPR, CAT, and the Protocol to the Refugee Convention, and one of the original reasons for Representative Patricia Schroeder’s introduction of the current federal FGM statute was to align U.S. law with international human rights obligations. See Federal Prohibition of Female Genital Mutilation Act of 1995, H.R. 941, 104th Cong. (1st Sess. 1995). 99 See Pub. L. No. 104-208, § 644, 110 Stat. 3009-708 (1996). 100 See Pub. L. No. 104-134, §§ 520(b)(1) & (2), 110 Stat. 1321 (1996). The 1997 CDC study based on the 1990 U.S. Census is the result of Congress’s directive to HHS to

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compile data on the prevalence of FGM in the U.S. HHS was also required to develop recommendations for the education of medical students about FGM and its health consequences. See Pub. L. No. 104-134, at § 520(b)(3). Furthermore, Congress obligated U.S. executive directors of international financial institutions, such as the World Bank, to oppose nonhumanitarian loans to countries that have not undertaken educational steps designed to prevent FGM. See 22 U.S.C.A. § 262k-2 (West 2011). 101 See 18 U.S.C.A. § 116(d) (West 2013), Pub. L. No. 112239, § 1088, 126 Stat. 1970 (2013). 102 See Girls Protection Act of 2010, H.R. 5137, 111th Cong. (2010); See Girls Protection Act of 2011, H.R. 2221, 112th Cong. (2011). 103 See ‘‘National Defense Authorization Act for Fiscal Year 2013,” available at http://www.gpo.gov/fdsys/pkg/BILLS112hr4310enr/pdf/BILLS-112hr4310enr.pdf. 104 18 U.S.C.A. § 116(d) (West 2013), Pub. L. No. 112-239, § 1088, 126 Stat. 1970 (2013). 105 UN General Assembly, Intensifying Global Efforts for the Elimination of Female Genital Mutilations, 20 December 2012, available at http://www.awdf.org/wp-content/ uploads/2013/01/Resolution-UNGA-English.pdf. 106 Yasmeen Hassan, “As Global Consensus Accelerates, Obama Strengthens Federal Law Protecting Girls in the Fight Against Female Genital Mutilation,” Huffington Post, Jan. 3, 2013, available at http://www.huffingtonpost.com/yasmeenhassan/new-wins-speed-gains_b_2403941.html. 107 These states are: California, Colorado, Delaware, Florida, Georgia, Illinois, Louisiana, Maryland, Minnesota, Missouri, Nevada, New York, North Dakota, Oklahoma, Oregon, Rhode Island, Tennessee, Texas, West Virginia, and Wisconsin. See AHA Foundation, Female Genital Mutilation in the U.S. Factsheet, available at http://theahafoundation.org/wp/ wp-content/uploads/2011/05/AHA-Foundation-FGM-FactSheet-2012.pdf. 108 See e.g., Md. Code Ann. Health-Gen. § 20-601 (2011) (stating that a person commits FGM when he or she “knowingly circumcises, excises, or infibulates the whole or any part of the labia majora or labia minora or clitoris of an individual who is under the age of 18 years”); Del. Code Ann. tit. 11, § 780 (2011) (stating that a person is guilty of FGM when he or she “knowingly circumcises, excises, or infibulates the whole or any part of the labia majora, labia minora, or clitoris of a female minor”). 109 See 720 Ill. Comp. Stat. Ann. § 5/12-34 (2011); Minn. Stat. § 609.2245 (2010); R.I. Gen. Laws § 11-5-2 (2011); Tenn. Code Ann. § 39-13-110 (2011).

110 These states are California (see Cal Pen Code § 273a(a)); Colorado (see Colo. Rev. Stat. §18-6-401(b)(I)); Delaware (see Del. St. Ti. 11 § 780(a)(2)); Florida (see West’s F.S.A. § 794.08(4)); Georgia (see Ga. Code Ann. § 16-5-27(a)(2)); Illinois (see 325 ILCS 5/3(f)); Louisiana (see LA Rev Stat § 14:43.4(A)(2)); Maryland (see Md Code, Health-General § 20-601(b)); Missouri (see V.A.M.S. § 568.065.1(2)); New York (see NY Penal § 130.85.1(b)); Oregon (see ORS § 163.207(1) (b)); and West Virginia (see W. Va. Code, § 61-8D-3a(a)). In addition, Nevada makes it a felony to “aid, abet, encourage, or participate in” FGM. See Nev. Rev. Stat. § 200.5083.1(a)). 111 Del. Code Ann. tit. 11, § 780. 112 See Colo. Rev. Stat. 18-6-401(1)(b) (2010); Ga. Code Ann. § 16-5-27; Md. Code Ann. Health-Gen § 20-601; Mo. Rev. Stat. § 568.065 (2011); N.Y. Penal Law § 130.85 (2011); Or. Rev. Stat. § 163.207 (2009); W. Va. Code Ann. § 61-8D-3a (2011). 113 Fla. Stat. Ann. § 794.08(2), (4). 114 Cal Pen Code 273.4(a)-(b) 115 Fla. Stat. Ann. § 794.08. 116 Ga. Code Ann. § 16-5-27. 117 La. Rev. Stat § 14:43.4(A)(3). 118 Nev. Rev. Stat. Ann. § 200.5083 (2011). 119 42 U.S.C.A. § 5106(g)(2) (West 2003). 120 See, e.g., Conn. Gen. Stat. § 46b-120(3) (2011) (defining “abused” to include”a child or youth [who] has been inflicted with physical injury or injuries other than by accidental means”); 23 Pa. Cons. Stat. § 6303(b)(1) (2011) (including in the definition of ”child abuse” “[a]ny recent act or failure to act . . . which causes nonaccidental serious physical injury . . . . [or] imminent risk of serious physical injury to . . . a child under age 18”). See also Ala. Code § 26-14-7.2; Alaska Stat. § 47.17.020(d); Idaho Code § 16-1602; Ind. Ann. Code § 3134-1-15; Iowa Ann. Stat. § 232.68; Kan. Ann. Stat § 38-2202; Kentucky Rev. Stat. § 600.020; La. Ch. Code art. 603; Maine Ann. Stat. Tit. 22, § 4010; Mich. Comp. Laws § 722.634; Miss. Ann. Code § 43-21-105; N.H. Rev. Stat. § 169-C:3; N.J. Ann. Stat. § 9:6-8.21; N.M. Ann. Stat. § 32A-4-2; Ohio Rev. Stat. §§ 2151.03(B); Okla. Ann. Stat. Tit. 10A § 1-1-105; Penn. Cons. Stat. Tit. 23 § 6303; Utah Ann. Code § 78A-6-105; Vermont Ann. Stat. Tit. 33 § 4912; Virginia Ann. Code § 63.2-100; Wy. Ann. Stat. § 14-3-202. 121 Cal Pen Code § 273a(a), § 273.4(a); 325 Ill. Comp. Stat. Ann. § 5/3(f). 122 R.I. Gen. Laws § 11-5-2 (2011). 123 In 2010, a 35 year-old mother in Georgia was accused

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of performing FGM on her infant daughter. See Annie McCallum, “LaGrange crime: Woman charged with female genital mutilation, 2nd-degree cruelty to children,” LedgerEnquirer, Mar. 11, 2010, available at http://www.ledgerenquirer.com/2010/03/11/1047702/lagrange-womancharged-with-female.html; Julia Lalla-Maharajh, “Female Genital Mutilation in Georgia, USA,” Huffington Post, Mar. 15, 2010, available at http://www.huffingtonpost.com/julialallamaharajh/female-genital-mutilation_b_498529.html. 124 See e.g., Ala. Code § 26-14-7.2; Alaska Stat. § 47.17.020(d); Idaho Code § 16-1602; Ind. Ann. Code § 31-34-1-15; Iowa Ann. Stat. § 232.68; Kan. Ann. Stat § 38-2202; Kentucky Rev. Stat. § 600.020; La. Ch. Code art. 603; Maine Ann. Stat. Tit. 22, § 4010; Mich. Comp. Laws § 722.634; Miss. Ann. Code § 43-21-105; N.H. Rev. Stat. § 169-C:3; N.J. Ann. Stat. § 9:6-8.21; N.M. Ann. Stat. § 32A-4-2; Ohio Rev. Stat. §§ 2151.03(B); Okla. Ann. Stat. Tit. 10A § 1-1-105; Penn. Cons. Stat. Tit. 23 § 6303; Utah Ann. Code § 78A-6-105; Vermont Ann. Stat. Tit. 33 § 4912; Virginia Ann. Code § 63.2-100; Wy. Ann. Stat. § 14-3-202. 125 See Harris, “Our Daughters,” Salon (stating that mandated reporters may wonder, “Is it a ‘cultural’ practice that others somehow must respect? Is reporting it anti-Muslim?”). 126 International Center for Reproductive Health (ICHR), Responding to Female Genital Mutilation in Europe: Striking the Right Balance Between Prosecution and Prevention 40 (2009), available at http://www.icrh.org/files/ICRH_rapport%202009_def%20 -%20high%20resolution.pdf. 127 See HM Government, Multi-Agency Practice Guidelines: Female Genital Mutilation (2011), available at http://www.fco. gov.uk/resources/en/pdf/travel-living-abroad/when-thingsgo-wrong/multi-agency-fgm-guidelines.pdf; Dep’t of Health, Working Together to Safeguard Children (1999) at 74, available at http://www.dh.gov.uk/prod_consum_dh/groups/dh_ digitalassets/@dh/@en/documents/ digitalasset/dh_4075824.pdf (noting that “[a] local authority may exercise its powers under s.47 of the Children Act 1989 if it has reason to believe that a child is likely to be or has been the subject of FGM”). 128 WHO, Female genital mutilation and other harmful practices, available at http://www.who.int/reproductivehealth/topics/ fgm/prevalence/en/index.html. 129 UNICEF Innocenti Research Ctr., Changing a Harmful Social Convention at 4. 130 AWHC states that the numbers in this table “only represent the total number of African immigrants and refugees in an individual state. Because the number of women is not broken down by reported place of birth or ancestry, estimates of the prevalence of FGC cannot be

obtained.” AWHC, note to Table 4. 131 AWHC, Table 4. 132 AWHC, Table 5.

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