Nour paints this schoolyard picture not to be flip but to illustrate just how common, and commonplace, female circumcision was when she was growing up in Africa in the 1970s. It still is. The World Health Organization estimates that 130 million girls and women globally have been circumcised. And despite recent laws prohibiting the practice in the United States and in several of the African countries where it is traditional, an estimated two million girls a year continue to be cut - most before the age of sixteen.
Two years ago, in the department of obstetrics and gynecology at Brigham and Women's Hospital in Boston, Nour founded a clinic for African women, the vast majority of them circumcised. The African Women's Health Practice offers all the services of a top-flight ob-gyn practice in a major teaching hospital, but with a distinctly African accent. On a Friday morning last summer, the clinic's waiting room was an oasis of calm in the hospital's otherwise frenzied atmosphere. A willowy woman wearing a paisley lace headscarf and a floor-length beige dress gently rocked a newborn as her husband discussed insurance forms with the receptionist. Another couple sat and waited for an appointment, he in baggy American jeans and she in head-to-toe black robes ornately embroidered with gold thread and mirrors. An infant slept in an Evenflow baby carrier at their sandaled feet. "Salaam," a staff member greeted them as she bent down to fuss over the baby.
The clinic is the only one of its kind in the United States, and one of just two in the West. (The other is in London.) "We talk a lot in this country about access to health care," Nour says, "and in general what we mean by that is poverty or lack of transportation or inability to find a primary-care provider." For immigrants, those problems are further complicated by language and cultural barriers. And then, having overcome all those hurdles, circumcised women too often find themselves confronted with a doctor's shock, she says. "I'm trying to provide care in such a way that patients don't require acute care."
As waves of refugees and immigrants have fled civil wars in Africa, increasing numbers of circumcised women are encountering Western health providers who, however technically sophisticated, can be strikingly naive to their medical needs and cultural mores. Boston, Seattle, Oakland, Chicago, New York City, Philadelphia, Houston, Dallas, Atlanta, Washington, D.C. - all have burgeoning populations of African immigrants and refugees. Although Nour was not circumcised herself, she is keenly aware of the sensitivities her patients bring and the humiliations they endure. When a circumcised woman shows up in a U.S. emergency room with a bladder infection or ready to deliver a baby, Nour says, an inexperienced provider can make her feel like a freak. In a teaching hospital, the doctor may bring in a roomful of medical students, residents, and nurses to observe a patient's genitals. "Think about it," Nour says, "you have a woman so modest that she only wants a female provider; she's lying there in stirrups and all these other people are brought in."
In 1995, when Nour came to the Brigham as chief resident, she quickly developed a following among local African immigrants. "Women started coming to the Brigham looking for Դthe African woman doctor,' " says Layla Guled, who had settled that year among Boston's tight-knit Somali community. Guled's own history sheds light on that of many of the refugees being treated at the clinic, and accentuates the need for what Nour calls "cultural competency" in dealing with these patients. In 1990, during the Somalian civil war, Guled was stabbed and left for dead (her brother was killed); she escaped to the United Arab Emirates, where she assisted other Somali refugees before seeking asylum in the United States. Now pursuing a degree in social work, she translates for Somali patients at the Brigham and several other local hospitals. "I see a lot of African patients," Guled says, "and they don't trust doctors . Nawal is like a miracle for them."
As her informal practice grew, Nour asked members of the African community if they would like to see her start a clinic. "People were very excited," she told Claudia Dreifus of the New York Times, in a July 2000 interview. "We did a focus-group study and asked where they wanted this clinic - West Roxbury, Mission Hill? People wanted to go to the Brigham. They felt that this was where the wealthy Americans go and they should go to the same hospital."
ACROSS AFRICA and the middle east the practice of female circumcision varies widely from region to region, tribe to tribe, and even within families. Though its roots are unclear, it is thought to have originated in Europe and spread with the ancient Greeks. The least invasive procedure, type one, which is common in Ethiopia, removes only the clitoris. An unsuspecting doctor examining a patient with type-one circumcision might miss it all together, Nour says. Type two removes the clitoris and the labia minora, the inner vaginal lips. Type three is unmistakable: all of the external genitalia are removed and the remaining tissue is stitched tight in a procedure called infibulation, leaving only a tiny opening near the anus for the passage of urine and menstrual blood. To illustrate, Nour shows a slide from a kit she prepared for the American College of Obstetricians and Gynecologists: the image looks like a Barbie doll's genital area - except that it's scar tissue. "Most of the time when I give grand rounds or lectures, I show the worst slide and discuss how the women consider that beautiful," Nour says. She leaves the image up while she talks about medical complications so that her audience can absorb it and deal with the emotions it sparks. "That way," she says, "when they see it on a patient, they're not going to be shocked. They'll know what to expect." Although she says most American doctors are unlikely to see such extreme cases, she sees them frequently in her Boston practice. Nearly 100 percent of circumcized Somalian girls are infibulated, and they represent a sizable percentage of Boston's 12,000 African immigrants.
Nour's Sudanese classmates were circumcised between the ages of twelve and fourteen, but in other parts of Africa the procedure is done on much younger girls. "In some places on the Red Sea," Nour says, "they do it at birth." Layla Guled was circumcised when she was six. Fortunately, she says, her family lived in the city, so she was anesthetized for the procedure, though she was in a great deal of pain afterward, and has suffered ever since. Girls from the countryside aren't so lucky, she says, and are often circumcised at home, their genitals cut or scraped away with unsanitary knives, razors, or shards of glass, and the remaining flesh stitched with household needles or even thorns.
The medical complications are predictable: the pain and blood loss from at-home surgery can lead to shock, and infections can follow from poor hygiene. Death is not uncommon. Even girls operated on in medical centers can suffer lifelong discomfort, recurrent bladder infections, and acutely painful intercourse. Childbirth can be fatal for a closed woman.
Maternal mortality is Nour's overarching medical concern. Too often, she says, doctors wrongly assume that an infibulated woman can only give birth via Caesarean section. Whenever possible, Nour prefers to surgically reopen her patients, a relatively simple procedure called deinfibulation, which restores, as much as possible, their normal anatomy. She performed about twenty deinfibulations last year - on women with chronic infections, on women planning to get married, and on others who managed to get pregnant and were going to give birth. (How they get pregnant mystifies even Nour.)
FINE BONED, with an intensely expressive face, nour greets patients and their husbands warmly as she passes down the hallway outside her office. She smiles broadly, touching them lightly on the shoulder or arm. "She takes her time with patients," Guled says. "She asks questions first, rather than rushing into the exam. Dr. Nour will say, ԈHello, how's your family? How are your kids?' And then she'll ask, ԈHow are you doing now?' And later, when it's time to do the Pap smear, she will explain that we do this kind of procedure, and she will ask, ԄDo you want to do it, or do you want to talk to your husband about it?' Because you have to understand, a Somalian woman cannot just do it. She needs to talk to a family member - her husband, or her mother, a brother. It's not acceptable to make such a decision for yourself. You'd have to be very Americanized to do that." Nour says she tries to involve husbands in their wives' treatment, to make them aware of the pain some of the women endure and of ways to reduce it.
In addition to running the clinic and operating on patients, Nour travels nationally and globally, lecturing and running workshops to educate refugee workers, asylum officers, and medical professionals about female circumcision. Through that work, she has emerged as an influential and temperate force in the heated public debate about the practice. Western critics reject, for instance, the term "circumcision," arguing that the ritual cutting is more like castration. "Westerners tend to talk about this as female genital mutilation - FGM," Nour says. "But if you talk to my patients, they don't consider themselves mutilated." In deference to her patients, Nour uses the term they do, circumcision, and with medical audiences, she tends to use the bipartisan abbreviation FC/FGM.
Although Nour is harshly critical of the practice, she is just as critical of Westerners who attack it with little sensitivity toward the cultures that embrace it. And she blames the media for sensationalizing the issue. Ever since the 1996 landmark asylum case of Fauziya Kassindja, a seventeen-year-old girl who fled Togo to avoid forced circumcision and a polygamous marriage, American media have seized on the most sensational aspects of the practice, Nour argues, ignoring its more subtle and deep-seated roots. "Most circumcised women don't see themselves as victims," Nour emphasizes. "They don't understand Westerners' fascination with their genitals, and they're sick of talking about it. They want to be seen as healthy human beings." Nour worries that overzealous feminists and journalists may cause African women rightfully protective of their culture to defend a practice that threatens their daughters.
As a doctor, Nour is chiefly concerned with alerting her fellow physicians to the medical complications of circumcision. As a feminist she is troubled by other aspects of the practice. Although proponents defend circumcision on religious, aesthetic, and hygienic grounds, Nour believes it is really fear that motivates women to cut their daughters: They do it to make their daughters marriageable. In cultures that place a high premium on women's chastity, circumcision guarantees a girl's virginity. "In Arabic," Nour says, "there are some really, really horrible words that are spoken about girls who haven't been circumcised - words that mean she's filthy, unclean, that she stinks. They're really degrading words." Asked for an English equivalent, she thinks for a minute and frowns, shaking her head. "It's a horrible label that's given to a girl who isn't circumcised."
Nour says her aunts were circumcised despite the objections of their father. "Let's cut her just a little," their mother suggested, and their father agreed to the compromise. "But they did the full cut," Nour says. "According to my aunt, my grandfather never knew how much had been removed, because he's not going to look. These are things women do. Women's things."
Nour, however, believes men can prevent their daughters from being cut. "There's an Arabic saying that silence is a sign of agreement, or acceptance. And so for men to say, ԉIt's a woman's thing,' is a cop-out. These men are head of the household. If they put their foot down, it goes."
Geraldine Brooks, in her book on women and Islam, Nine Parts of Desire, describes female circumcision as an attempt to contain women's otherwise irrepressible sexual yearnings. The book's title comes from the Islamic saying that women were granted nine parts of desire and men one. Brooks argues that nowhere in the Koran does Muhammad endorse circumcising girls. "[T]he lessening of women's sexual pleasure directly contradicts the teachings of Muhammad," she writes.
Nour agrees. Only one hadith, or saying traditionally attributed to Muhammad, recommends female circumcision, and it is disputed, she says. Nour wrote her thesis at Brown on the emancipation of Egyptian women, and she sees Muhammad as an enlightened reformer when it came to women's rights. Still, she regularly encounters patients who say they plan to circumcise their daughters "to be good Muslims." She recounts a conversation with a patient, then twenty weeks pregnant with a baby girl, who was discussing her plans to circumcise her daughter. "Do you know it's illegal in this country?" Nour asked.
"No, I didn't," the woman said. "Oh, no problem - I'll just take her back and have it done there."
Nour told the woman that circumcision was illegal in England and France, as well. "Why do you need to do it?" she asked the woman. "I said to her, ԉI've read the Koran. At your next visit, you bring the hadith or the place where it's written in the Koran that you need to circumcise your daughter.' "
Telling this, Nour looks down at her knees, jutting out from beneath the hem of her skirt: "Now this is very difficult. She's all covered and I'm not. Who am I to tell her about being a good Muslim?"
More effective, she says, are encounters with other Muslims who don't practice circumcision. She describes a breakthrough confrontation at a workshop she led for Somali and Kurdish Iraqi refugees and immigrants. At one point, after breaking for prayers, the Somali women were scheduled to talk about circumcision and Nour invited the Kurds to leave, since it wasn't part of their religious tradition. But the Kurdish women stayed, intrigued, and challenged the Somalis: "We don't circumcise our daughters. We're Muslims! Where does it say that in the Koran?"
"I can sit and preach," Nour says, "and I have the credibility of [speaking] Arabic, but I'm not mahajjabah. I don't wear a hijab. These women educated each other."
NOUR IS A BIT of a cultural chameleon. Mondays through Thursdays she dresses like any American doctor - knee-length skirt and flats beneath her white doctor's coat. Fridays, when the African clinic is open, she wears long skirts and boots to avoid embarrassing the husbands of her Islamic patients. Giving a presentation in the Sudan last February, she says, "I wore long sleeves and a long skirt," she says. "I spoke in Arabic, and they saw me as a successful Sudanese who had made it in America."
And she is.
The daughter of a Sudanese father and an American mother, Nour has dual citizenship. She spent her childhood in the Sudan, where her father was minister of agriculture, and Egypt, where he was a diplomat. She attended the American School in London and then came to the United States to attend Brown, concentrating in international relations and development studies.
"I was a budding feminist before I came to Brown, and then Brown really solidified it," she jokes. "Freshman year I remember hearing people say, ԄDon't call us girls!' and thinking that is the dumbest thing I've ever heard. By the time I graduated I was saying, ԃCall me a woman!' " During her junior year, homesick, she went back to Cairo and found that the liberalism that had prevailed in her childhood was gone. She returned to Brown and focused her thesis on Egyptian women.
After graduation she pursued a career in international development, landing a job at the United Nations. She hated it. "At Brown you feel that you can change the world," she says. "The U.N. was frustrating." With a minority health fellowship, she earned her master's degree in public health at Harvard and then enrolled in medical school there.
"My job is perfect for me," she says. "I work with patients and get to see immediate results, and then in the background I'm also trying to eradicate female genital mutilation." Last summer she received a grant from the
U.S. Department of Health and Human Services' Office of Refugee Resettlement to run workshops for immigrant women and health providers in ten American cities with large African populations. She travels constantly. Long-range, she says, she would like to work for the World Health Organization.
"My friends tell me I'm married to my work," she says with a sheepish grin. "But I'm really not. I just want to change the world."
Charlotte Bruce Harvey is the BAM's managing editor.
