Female genital cutting (FGC) is a tradition that many assume to be affecting girls living only in Africa and Asia. But this rite of passage procedure is all too familiar for many women living in the U.S.
The practice of cutting encompasses all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons, according to the World Health Organization. In some countries, many of these girls will have their clitoris completely removed to deny them sexual pleasure. And at its most severe, some of them will have their vaginas sewn shut to preserve their virginity.
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"It's worse than anything in this world," said one young woman living in America, known as Mary, who asked to conceal her real name for fear of retribution from her community.
Mary had the most radical form of cutting performed on her in her home country. Her clitoris was removed and her vagina was stitched together.
Another young woman, anonymously identified as Amy, told ABC News that if her parents found out she was speaking out about female genital cutting they would "literally" kill her.
Although the procedure has been officially banned in the U.S. since 1996, some parents who want to stay true to their traditions ask American doctors to cut their daughters, leaving many doctors with a complicated choice.
Female genital cutting, a ritual thousands of years old, is a tradition many mothers and fathers feel obligated to have their daughters undergo because, without it, they are deemed unworthy of marriage. It is a cultural practice, without religious basis or any medical benefits. In fact, studies show that women who have been through it may suffer a lifetime of devastating complications, from severe infections, to pain and bleeding, and even a higher risk of death during childbirth. Some women die from the procedure itself.
Each day in Africa and Asia, more than 8,000 girls between infancy and age 15 undergo female genital cutting, an estimated total of three million girls annually.
"Obviously [parents] don't use the word 'female genital mutilation,' said Terry Dunn, an obstretrician gynecologist in Denver, Colo. "What the mom of the patient says is, 'I want to have the procedure that makes my daughter like me.'" Many physicians who consider FGC a horrifying treatment of a girl suffer a dreadful dilemma. If they say no, the young patient may become one of tens of thousands of young girls taken back to their home countries, in a process known as 'vacation-cutting.' Once there, the girls are often cut using a broken glass or unsterilized razor blades, and, more often than not, without anesthesia. While FGC may be banned in the U.S., there is no law protecting girls from being taken overseas to have the procedure in another country.
The CDC estimates that between 150,000 to 200,000 girls in the United States are in danger of being taken overseas during their time off from school to undergo vacation cutting. In fact, Amy said her parents were pressuring her to return to their home country. Instead, Amy said, she ran away from home.
"If I went back, I would have been cut," said Amy.
According to Dr. Doug Diekema, a pediatrician at Seattle's Children's Hospital and former chairman of the American Academy of Pediatrics' bioethics committee, by refusing to cut girls in the U.S., many doctors may be putting these girls' lives in jeopardy.
"It's very easy to take the high road in cases like this," said Diekema. "But when you're dealing with religious or cultural beliefs, saying no sometimes is not sufficient for people and it will not necessarily eliminate the practice."
In fact, Diekema and a few of his colleagues put forth the idea that American doctors use a so-called ritual nick as an alternative , to keep parents from seeking more dangerous methods of cutting. And, based on Diekema's recommendation, the American Academy of Pediatrics (AAP) released an official policy statement saying, "the ritual nick would not cause physical harm."
"The cut itself would be tiny, really just like a poke with a needle so that there might be a drop of blood," said Diekema.
But to many opponents of any form of procedure resembling the traditional female cutting, a ritual nick should not be acceptable as a substitute.
"What the AAP is in fact doing is 'wink, wink, nod, nod' in order to protect your patient from a possible worse form of [FGC], let's just spread her legs and nick her," said Taine Bien-Aime, president of the international human rights organization, Equality Now. "The reality is that what [that] statement does is perpetuate female genital mutilation. There is no other way around it."
But Diekema said that the proposed ritual nicking should not be considered a form of mutilation. "If you look up any definition of mutilation in the dictionary, it doesn't apply to this particular procedure," said Diekema.
For Mary, who has seen too many friends suffer through this, ritual nicking is not an acceptable compromise by doctors to keep parents from vacation cutting.
When asked by senior health and medical editor, Dr. Richard Besser, what pediatricians should do when faced with a family who wants to take their daughter back to their home country to undergo genital cutting, Mary said, "Call child services on them."
But, Dr. Nawal Nour, director of the African Women's Health Center at Brigham and Women's Hospital in Boston, Mass., said it is important not to vilify the immigrant community.
"Blame is never the solution," said Nour. "Empower them, rather than let's cut them and hurt them."
The center, which exclusively helps immigrant women deal with the complications caused by FGC, educates women about the dangers of FGC to prevent cutting for future generations. Layla Guled, a Somali language interpreter, says parents often feel as though they don't have a choice. Moreover, she says, they have the best intentions.
"Our mothers are trying to do the right thing for us," said Guled. "But our generation is trying to fight it."
The AAP offered clarification to their initial policy statement, saying that while the ritual nick may be considered an option, the practice of cutting is still harmful to girls. But after questions by ABC News regarding ritual nicking recommendations, the AAP withdrew their policy statement completely, saying that it had caused too much confusion and controversy.
"I want to make it very clear that the American Academy of Pediatrics opposes any form of female genital cutting, and that would include the ritual nick," Dr. Judith Palfrey, president of the AAP, told ABC News.
Still, Diekema said he stands behind the idea of ritual nicking as an alternative to vacation cutting.
Yet so many U.S. doctors still face a terrible set of options. And while millions of young girls wait for some answer on their fate, some who speak publically about it say they are not giving up the fight.
"We have to change a whole culture," said Mary. "Maybe we can't change their generation but we can change our own generation. We know it's wrong. There's nothing right about this."