Should women who have undergone FGM be granted asylum in the U.S. on medical grounds?

 Since 1994, when a Nigerian woman and her two daughters were granted asylum in the U.S. based on fear of female genital mutilation (FGM) in their native country, the legal community has been avidly debating the question of whether FGM should be considered grounds for asylum. A 1996 case, in re Kasinga, established a precedent for granting asylum to women based on a well-found fear of persecution in the form of FGM.

Today, the question is still, however, controversial. There is no standard definition of “persecution,” a fear of which is required for asylum seekers to gain asylum, and even though “membership in a particular social group” may help an individual gain asylum, this definition has not been officially extended to include women subject to gender-based injustices. In addition, the Kasinga case doesn’t apply to women who have already undergone FGM, who are almost never granted asylum on the logic that they have no real grounds to fear further persecution. In other words, since the persecution has already occurred, there is no requirement to protect these women under the Refugee Act of 1980 .

Although the law does not generally allow it, many legal scholars remain advocates of granting asylum to women who have already undergone FGM. Yet whether granting asylum for women who have already undergone FGM on clinical grounds is legitimate remains an open question. It is our belief that clinicians have a significant role to play in asserting that women who have undergone FGM have significant grounds to be granted asylum in the U.S. and other Western countries.

There is abundant evidence that female genital mutilation results in both short-term and long-term obstetric and gynecologic damage. A World Health Organization (WHO) prospective study of 6 African countries found that women with FGM were more likely to have postpartum hemorrhaging, extended maternal hospital stays, stillbirth or early neonatal death, and give birth to infants with low birthweight than women without FGM. Several studies have established that risk of transmission of HIV is increased for women with FGM. The practice of FGM may indeed be contributing to the perpetually increasing HIV epidemic in sub-Saharan Africa. In the case of infibulation, in which the vaginal orifice is narrowed by cutting and appositioning the labia minora and/or labia majora, complications include dysmenorrhea, stagnation of blood in the uterus or vagina, chronic pelvic infection, repeated urinary tract infections, chronic vaginitis, and dysuria.

These medical complications have frequently been cited as reasons to grant asylum to young women who fear the possibility of future FGM if returned to their native countries. But what about women who have already undergone FGM? There are two essential reasons to insure that these women are not returned to the countries in which FGM took place and in which the practice is still sanctioned. First, the surgical procedure deinfibulation, which is performed in the United States and other Western countries, can reverse some of the anatomical damage done by female circumcision and reduce risks for medical and obstetrical complications. It is unlikely that women will be able to access this procedure in their native countries. Moreover, those who do undergo reparative deinfibulation are at risk of facing ostracism, stigmatization, discrimination and even re-infibulation in their home countries. Given that clinicians have an ethical duty to recommend the reparative procedure for their patients who are victims of FGM, it would seem clear that there is an affirmative duty to insure that these patients not be returned to an environment that would disrupt the benefits of surgical repair.

Second, it is essential to examine the psychological consequences of FGM in order to understand the risks of forced repatriation. Although it  has always been assumed that FGM causes increased rates of mental disorders, especially trauma responses, measuring the adverse psychological effects of FGM is difficult, particularly because of the pride some women feel in having taken part in an ancient cultural tradition. Some reactions to FGM among women might include feelings of pride, beauty, cleanliness, and faithfulness and respect to tradition. Despite these positive associations, several recent studies have determined that women with FGM may be more prone to psychiatric disorders than women without FGM. In one study, circumcised women in Senegal showed significantly higher rates of PTSD, psychiatric illnesses, and memory problems than uncircumcised women. In a more recent study of 4800 pregnant women, 38% of whom had undergone FGM, 80% of those circumcised continued to have flashbacks to the FGM event, 58% had some form of affective disorder, 38% had anxiety disorders, and 30% had PTSD. Evidence has begun to accumulate that FGM does indeed have a significant impact on women’s mental health. A hallmark of PTSD is pathological “re-experiencing” of the original trauma and avoidance of cues related to the original traumatic event. Clearly, returning a woman who has undergone FGM to the scene of her traumatic event engenders substantial risk of worsening trauma-related psychiatric illness. This is especially unacceptable given the likelihood that treatment for the psychological and psychiatric consequences of FGM is not readily available in cultures that encourage the practice in the first place.

Sending women with psychological disorders as a result of FGM back to their native countries is akin to denying them a basic human right: healthcare. In cultures in which FGM is considered a point of pride, women are not likely to be able to obtain mental healthcare for the psychological consequences of their circumcision experience. While it is absolutely essential that Western physicians not stigmatize those women, some of whom may value and take pride in their circumcision, it is equally important that the medical field take a more vocal stand on the reality of the psychological fallout from FGM. A heated legal debate about whether women who have already undergone FGM should be granted asylum continues. Clinicians should add their voices to this debate, armed with clinical evidence that FGM has serious consequences for physical and mental health.