Arefa  00:16

The Michigan case infuriated me, because that doctor is one degree off for me. She and I are exactly the same age. We were undergrads at the same time. We have mutual friends from med(ical) school. I mean, she literally could have been someone that I knew well and just, I happen to not.

Mariya  00:39

(That’s Arefa Cassoobhoy, who came to a Voices digital storytelling workshop and shared a story. Here’s an excerpt from the video she created.)

Arefa Story Excerpt  00:50

In 2017, I heard about a doctor in Michigan who was arrested for female genital cutting. I was stunned. I’m a physician too, and I wondered, how could she cut a little girl and think it was okay? I was also mad at myself for being surprised. I really didn’t think it was happening in the U.S. I heard rumors, but I hadn’t believed them.

Mariya  01:17

(I’m Marya Taher, and this is the Voices Podcast. Welcome to Episode Four, The Michigan Case. Again a reminder, this podcast includes frank discussions about what female genital mutilation and cutting is and how survivors can be affected, in terms of their physical and mental health. Like me, Arefa and this doctor in Michigan grew up in the Dawoodi Bohra community. We talked a lot about the Bohra community in our last episode, but just in case you’ve forgotten, the Bohras are a small, tightly knit South Asian Shia Muslim sect with diasporic communities living globally. Within this community, the practice of FGM/C, also known as khatna, continues. In her video, Arefa goes on to talk about attending a Bohra community event shortly after learning about the case in Michigan.)

Arefa  02:06

As I watched my daughter with a group of girls, a few toddlers wandered by. All of a sudden I felt something like a punch in my gut. I had to get up and walk outside to catch my breath. I thought, it’s not just the adult women who’ve experienced khatna … how many of these teenagers and young girls were also cut? How many of these babies will be cut?

Mariya  02:31

(Arefa is not the only Voices storyteller whose entry point into her story was the case in Michigan. Here’s an excerpt from a video whose creator prefers to remain anonymous.)

Anonymous Story Excerpt  02:43

Why do you think they’re doing this to us?

Is it because we’re part of the Bohra community? We should stand up for our own community.

That’s what echoed in my family’s WhatsApp chat during the Michigan FGM case.

Mariya  03:03

(I really relate to these thoughts, because when I first started talking publicly about khatna, I worried that doing so would play into Islamophobia in the U.S. The year that the Michigan case went to trial was 2017, the same year that Trump signed the infamous travel ban against people from Muslim countries. Anyway, even though the WhatsApp chat this anonymous storyteller referred to was private, she hesitated to add to it.)

Anonymous Story Excerpt  03:29

There were several of us in that Whatsapp group. When we were young, my cousins and I talked about khatna. I know they had it done. But during this chat, they said nothing. I waited for the chat bubbles to pop up for someone to say, khatna’s not right. Nothing.

Mariya  03:51

(If you’re part of the Bohra community, when you hear the words “Michigan case,” you know exactly what they mean. The case marked a turning point for Bohras. Before, most of the discussion on cutting was internal to the community. After, the fact that our community continues to cut little girls became big news. There had already been a case in Australia that we mentioned in our last episode, but this Michigan case blew up in the U.S. media. So why was this case so significant? How did it impact the legal landscape around FGM/C in the U.S., and how did it influence work being done to support survivors? Let’s start by looking at what happened. The U.S. passed a federal law banning FGM/C back in 1996. Twenty years later, this law had never been tested in court. So the Department of Justice decided to pursue a case against eight people for cutting young Bhra girls. The lead defendant was Dr. Jumana Nagarwala. This is the physician whose involvement shocked Arefa. Dr. Nagarwala was charged with cutting the genitals of nine girls. Prosecutors estimate she had harmed at least 100 girls over a 12 year period. Yep. You heard that right: 100 girls. Also charged in the case were a doctor who let Nagarwala use his clinic in Michigan to perform the procedure, two women who assisted Nagarwala, and four mothers. The defendants, all from the Bohra community, denied any wrongdoing. They maintain that they caused no harm to any child and were practicing their, “protected religious beliefs.“ Here’s another excerpt from Arefa’s video.)

Arefa  05:31

It’s hard to understand why the ritual of female genital cutting continues amongst different people who in so many other facets of their lives are thoughtful and kind, and certainly don’t intentionally want to harm anyone.

Mariya  05:48

(Of course, I agree with Arefa that it’s hard to understand. So does Karen McDonnell, a professor of Public Health who has been working with survivors and on FGM/C prevention for years now.)

Karen  05:59

This was a U.S. educated MD performing this. And that should not be a justification for why it’s okay. There are some reasons why we need harm reduction for some public health issues. This is not one of them. You know, when you think about the Hippocratic Oath, first, “do no harm.” And I would think we can objectively say that FGM/C, the actual action of it being done– there is no consent. You know, these young girls did not say, “yes, please do this to me,” you know, there is something being done to their genitals.

Mariya  06:40

(I’m going to digress for a moment on that point about consent. Bohra groups in favor of khatna have incorrectly compared it with a medical procedure called clitoral unhooding, which is the voluntary removal of the prepuce, or clitoral hood, of a sexually active adult. This is recommended by doctors only for those very few consenting, adult women who have excess prepuce tissue that is interfering with their ability to orgasm. By contrast, cutting is the non consensual removal of the prepuce of a sexually inexperienced child. It’s performed indiscriminately on all Bohra girls, even if their prepuce is average sized or smaller. The two practices could not be more different. But now, let’s hear more from Karen, who told me how she got interested in FGM/C.

Karen  07:31

I can’t believe I’m saying this, but I think it was 30 years ago when I started graduate work in my doctoral program. And the professor talked about FGM and was presenting pictures and talking about it. And I came from looking at trauma and stress and domestic violence and child abuse. And so I was asking questions about it. And the professor basically cut me off and said, “it’s a cultural practice, you have nothing to say about it.”

Mariya  08:14

(Even though Karen was pretty taken aback by this response, she was young, and she was a student who didn’t feel like she could contradict her professor. Remember, this was three decades ago. So she continued her work on other kinds of gender-based violence. Then, early in her teaching career, she had a student from what’s called a practicing country, meaning a country where FGM/C is done.)

Karen  08:35

He was a physician. And he was incredibly diligent. I mean, this gentleman came into class, took notes in English, translated them back into French to study from, and then translated them back into English. And he was at class every single day. And then he was missing.

Mariya  08:54

(Karen approached her student when he came back to the next class session.)

Karen  08:59

And I said, “hey, we missed you. Where were you?” And he said, “I am so sorry for missing the class, but we almost lost my wife.”

Mariya  09:09

(He told her that his wife had given birth at a teaching hospital in the area, and that she had hemorrhaged and almost died.)

Karen  09:15

And I said, “oh my god, I’m so sorry.” We started talking it through and come to find out she had type three FGM and the the physicians on staff at that night didn’t know what had happened, and didn’t know what to do.

Mariya  09:32

(A couple of episodes ago, we described the different types of FGM/C. Type three, known as infibulation, involves the removal of the clitoris and the labia minora and majora and the stitching together of the edges of the vulva to narrow or completely close the vaginal opening until it’s torn open again when a girl loses her virginity. Women who have undergone infibulation are more likely to suffer from prolonged and obstructed labor and to experience hemorrhaging. Sometimes they have to be cut again, because the vaginal opening is too small to allow for the passage of a baby. Not only did the doctors not understand what was happening with Karen’s student’s wife, they were so shocked by what they saw that they treated her as someone to gawk at.)

Karen  10:17

They didn’t know what to do. And they really kind of messed up. Listening to him brought back like, wait a minute, we need to start asking questions, this woman has had it done. And our healthcare system, and our physicians at that time were not trained to know what to do.

Mariya  10:39

(The incident solidified Karen’s commitment to making sure doctors will know what to do and to challenge the kind of cultural defense of cutting that she got from her professor in graduate school. She saw clearly that all types of FGM/C can be harmful.)

Karen  10:56

So when we think about the short term, you think about what that person is going through, there’s severe pain, excessive bleeding, you can have bacterial or viral infections, injury, including swelling, and of course, problems with urination. And these can all compound and be chronic and have long term physical effects. Okay, if you’ve got a scar, so like I have a scar on my hand, when I touch it, it feels different. It’s not as elastic. And so think about that same scar, that adhesion, you know, now forming a scar in your genital region. And now you talk about what happens when you are sexually pleasured, that you don’t have that, less tissue. We know that there’s documented chronic vaginal and pelvic infections, difficulties with urination, urinary tract infections, genital scars, such as cysts or keloids pain or lack of pleasure during sex, and infertility due to chronic infections, including chronic pelvic pain, difficulties with labor and delivery.

Mariya  12:13

(None of that even touches on the potential for long term trauma for those who’ve been cut. We talked in Episode One about some of the well documented mental health implications for survivors. And there is an impact on their partners too, since couples have to figure out what all of this means for their relationship.)

Karen  12:32

Let’s think about why would a mother or auntie subject this onto a young girl, okay, what is their reasoning? It’s not that they hate this person. This is their daughter, their granddaughter, their, their niece. So what else is going on?

Mariya  12:54

(Arefa’s experience says a lot about the, what else. Her grandmother was obviously very aware of the cultural pressure to have Bohra girls cut.)

Arefa  13:04

So I was nine when my grandmother told me, just to say, yes.

Mariya  13:11

(Arefa had gone to Nairobi for the summer with her mother and brother. There’s a small Bohra community in Kenya, part of a larger South Asian presence in the country.)

Arefa  13:22

It was actually my father who stopped me from having it done. So he’s a pediatrician. He was in the U.S. And so he was the one that made that decision. My mom thought cutting was painful and unnecessary, and so supported it. And then my grandmother, out of respect for my parents, this is how she addressed it, just say yes.

Mariya  13:47

(What Arefa means is that this is what her grandmother told her to say, if anyone asked her if she had been cut.)

Arefa  13:54

So that was really what happened, and all the other women, from what I understand, were having cutting done. So I was the outlier really, coming from the west.

Mariya  14:09

I’ve heard that story from many other people where their mothers or others in their family decided not to have it done, but told them, “you need to say yes,” and I understand that too. They said, “you need to say yes,“ to protect yourself, essentially, to make sure that someone doesn’t trick you or take you to have it done because you haven’t had it done, and so it was protection.

Arefa  14:30

I didn’t understand what khatna was, and it really didn’t come up again in my world until college, and everything I read about it in the class that I was taking where it came up, really supported khatna and were reasons for why it was being done. 

Mariya  14:49

(Like Karen, Arefa didn’t hear anything during her undergraduate studies that framed FGM/C as a form of gender-based violence and a human rights issue. She went to medical school and went on with her life for years, assuming cutting wasn’t happening here in the U.S. I wanted to know what eventually made her decide to speak out publicly)

In what ways do you think your professional role has really influenced your views on FGM/C? You do talk about this in your video, and particularly the Michigan case. And so I’m wondering if you might be able to just elaborate on that and talk about your own experiences and how it influenced your thinking around this issue.

Arefa  15:29

It was mind boggling. And that really challenged me to realize that just as in many other aspects of life, people do think and act differently from me, and that some things that are obvious to me aren’t obvious to others, even people who I would think have a similar enough background that their conclusion would be the same as mine. So that was one place that really helped me even move to more of an empathetic view of others who may be still doing khatna and really challenged me to be someone who’s going to help change their mind, basically, or at least show them a different way of looking at it, and hopefully spare girls in the future.

Mariya  16:19

(Some of the people who think and act differently from Arefa are the Bohra women who are what we could call pro-khatna. The Michigan case dragged on into 2018, and in December of that year, a group of Bohra women who described themselves as “business owners, lawyers, doctors, teachers and educated women from a range of professions” wrote an open letter that was published in the Detroit free press. Here’s part of the letter:

To be clear, we members of the Bohra faith are proud and patriotic American citizens who obey every law of the land — even those with which we disagree. We firmly believe that a practice that is harmless, far less invasive than male circumcision, and much more akin to a body piercing should in no way be put in the same category as some more barbaric practices from around the world that we wholeheartedly condemn.

Ok, so this letter is problematic on so many levels. First, to say that khatna is harmless is completely inconsistent with the survivor testimonies and research studies that document the lasting harms it can cause. Second, khatna is in fact as invasive if not more invasive than male circumcision. Third, comparing the non consensual cutting of children’s genitalia to body piercings in consenting adults is ridiculous. And fourth, describing some forms of FGM/C as “barbaric“ when they are just as culturally based as khatna is completely racist, not to mention totally lacking in compassion.

On a crazier note, a few months before this letter came out, a group called the Dawoodi Bohra Women for Religious Freedom posted several videos of Bohra women defending khatna on social media. One somehow found its way onto the Twitter feeds of lots of people who don’t follow the group, and it went viral. In the post, a woman who had her three daughters cut claimed, quote, “they’re growing up as perfectly as other children of their age. As a mother, I can never do anything to harm them.” In response, one person wrote, “Speak for yourself woman. Don’t speak on behalf of innocent girls. FGM is FGM no matter how you want (to) sugar coat it.”

There’s more, but I’ll leave it at that, because I’m guessing at this point, you’re probably wondering, what happened with the Michigan case? Unfortunately, it was thrown out on a technicality having to do with congressional authority and  federal versus state jurisdiction. Here’s Karen again.)

Karen  18:51

This case really showed that we really do need to make sure that we have other laws in place for the protection of these, you know, these, these girls were seven years old, having this done to them.

Mariya  19:03

(The good news about the Michigan case is that it helped advocates figure out what needed to go into a solid federal law against FGM/C, and prompted them to come up with an updated bill.)

Karen  19:14

The bill increased from five to 10 years, the maximum prison term for an FGM offense. And it also prohibited the defendant from asserting culture, religion, tradition, ritual, or standard practice as a defense. And so it made it to the desk. I think it was signed into law on January … of all days, January 5, of 2021. And it did not get the press that it deserved because of what transpired on January 6.

Mariya  19:51

(Yes, that is a direct reference to the attack on the Capitol that took place. Just imagine then President Trump signing landmark legislation and conspiring to overthrow democracy all in one day. Anyway, more good news about the Michigan case is that after it was dismissed, a group of criminal justice and public health advocates came together and really solidified their commitment to a holistic approach to addressing FGM/C. But the bad news about all the media attention on court cases and legal remedies is that some advocates believe it might increase the medicalization of these practices.)

Karen  20:29

People are sending me things from Indonesia, which is also concerning, that FGM is being in some regards placed within the birthing package.

Mariya  20:42

(What Karen referred to is the fact that hospitals are advertising to expectant parents that when they come in for delivery, their newborn girls will be cut.)

Karen  20:53

And that’s incredibly scary, because just the action itself, but it’s a newborn. And things haven’t fully developed. And so you are already engaging in what we know to be a harmful practice right after birth, because they can hide it in the diaper.

Mariya  21:16

(Indonesia does not have a national law criminalizing FGM/C, although last spring, a group of Indonesian women did call for an end to FGM/C. In the U.S., women’s health advocates and survivors have been pushing to make sure the health sector knows about FGM/C– knows about its harmful effects, and what it means to provide survivor-centered care. Some of Karen’s work is to make sure that training on how to address FGM/C as part of the medical school curriculum.)

Karen  21:48

I want to see health care providers and health care systems want to take an active approach in treatment, intervention, and prevention. So the whole public health cycle. So I want to see that there is primary prevention in place educating on the harms, there is no medical benefit to this practice. And if it has been done, we should be asking about it, but asking and being able to afford resources to that person should they want them, need them, and want to access them. These young girls and women who have experienced FGM/C are silent, because they’re hiding somebody else’s secret. And it’s not theirs. But they’ve been tasked with that. And so they’ve held this silence. And then they feel the shame and experience the stigma. And if we can’t talk about it as healthcare providers, how can we expect our patients, our clients, the women and girls that we’re working with, to be able to talk about it, if we can’t talk about it?

Mariya  23:02

(It’s one thing to say this from the perspective of an advocate. It’s another from the perspective of someone within a practicing community like the Bohra community, which has a pretty vocal faction of khatna supporters. I asked Arefa about this.)

I know you’re very involved in the community in Atlanta, and I was just thinking about, what has it been like to have these conversations. And in particular, you talked about in your story how you were at a community event and the realization hit you, you know that many of those girls and women might have undergone FGM/C. So I’m just wondering, how do you handle that while being in the community, but also potentially talking about this issue within the community?

Arefa  23:47

So I’m active more in the cultural world of being a Bohri in Atlanta, rather than the going to the mosque on a regular basis part of being a Bohri. And so, with that, I don’t necessarily bring up khatna, you know, at a dinner party. But because I have a lot of family and close friends, I have known people that may be more progressive, and it’s an interesting phenomenon. But what I have noticed is that my presence online has let my ideas and opinions be known.

Mariya  24:24

Did you have anyone talk to you about the story that you released on Voices? I’m wondering what the reaction was like to your specific story.

Arefa  24:34

I don’t think anyone who is pro FGM would say anything to me, based on you know, knowing me online and in person. What did come up was people just were really shocked that this was happening and really didn’t think it was happening and thought everybody was saying yes, but no one was really having their daughters experience khatna. I do feel an obligation as a physician, and as an auntie, at these gatherings that I want to help young women. So that really motivates me, and I do you believe, like, our actions matter. So with my daughter, letting people know that we have chosen not to do khatna is important so that others can see that and, and get some support from that. I also think now that I’m out there, when people bring it up, it’s also an opportunity to ground FGM/C within the world of violence against girls and women, and other topics that are also still ongoing, like child marriage. And that, I think, has been very important, to let other people know that this is not isolated. This is not a one off. This is really part of multiple infractions against females around the world.

Mariya  26:04

(I absolutely agree with this. So does Karen.)

Karen  26:07

This is an intergenerational cycle. We do know that worldwide, we’d like to discontinue this practice by 2030. That’s only seven years from now. So how are you gonna stop this intergenerational practice is, we have to do this from different points. And we can’t just say, it is of the purview of the pediatrician, it’s of the purview of the OBGYN, it’s in the hands of law enforcement. And we have to think about, yes, we have to stop the practice. And so laws help. But as you said, laws aren’t enough. So what else is going on? That keeps that practice being perpetuated? Let’s look at patriarchy. Why do we hold young girls so accountable for their sexuality? Why can they not embrace their sexuality but are having irreparable harm done to them, not only physically but mentally, to control their sexuality and make them marriageable? Everybody’s got to be working together toward the same goal. So we’ve got to be looking at, just like we do in public health, looking at using multiple tools to prevent FGM/C, not only in the U.S., but worldwide.

Mariya  27:35

To watch the digital story created by Arefa, visit our website at voicestoendfgmc.org. To access the amazing FGM/C resources created through Karen’s work, search online for “Women and FGM/C Toolkit.”

Next on the Voices to End FGM/C podcast, three women explore what it means to not be counted. This episode was created by Amy Hill and Mariya Taher, with editorial and production support from Armand Jayne and Kristel Mendoza Castillo. Featuring the music of Blue Dot Sessions. Special thanks to Arefa, Karen, and everyone who has told a story in a Voices to End FGM/C digital storytelling workshop.