It's revolting and disgusting but I'm not at all surprised.
Below is an article from the Minnesota Medical Association. http://www.mmaonline.net/default.aspx I cannot find it online so I assume it's been removed but saved it some years ago and have posted it in full here, it was written almost ten years ago. Minnesota has a large Somali minority, the majority of the womenfolk have been mutilated.
Note how they call the mutilation 'Genital Cutting' I did a search for FGM on their site, nothing.
'A second, less-visible but no less complex, health issue for those treating Somali immigrants is female genital cutting, a widespread practice in Somalia. Because nearly all Somali women have been cut or "circumcised," Minnesota gynecologists and obstetricians should be aware of the practice.'
A refusal to call it what it is, mutilation, torture. A torture that lasts throughout the woman's life.
Minnesota gynecologists and obstetricians should be appalled at the practice!
As should the American Academy of Pediatrics and the Minnesota Medical Association.
On a side note. The male 'equivalent' of FGM is penile sub incision, some Australian Aboriginal tribes used to practice it, here's Wikipedia.....http://en.wikipedia.org/wiki/Penile_subincision
'Subincision (like circumcision) is widespread[citation needed] in the traditional cultures of Indigenous Australians, and is well documented[citation needed] among the peoples of the central desert such as the Arrernte and Luritja. The Arrernte word for subincision is arilta, and occurs as a rite of passage ritual for adolescent boys.[citation needed] It was gifted to the Arrernte by Mangar-kunjer-kujaIt, a lizard-man spirit being from the Dreamtime. A subincised penis is thought to resemble a vulva, and the bleeding is likened to menstruation.[1]'
A Lizard Man Spirit eh! No surprises there!
Take care all.
Minnesota Medicine
Published monthly by the Minnesota Medical Association
December 2000/Volume 83
Embracing Diversity
Minnesota physicians have much to learn about—and from—their Somali patients.
By Patricia Ohmans, M.P.H.
When the childbirth video zoomed in for a graphic, bloody shot of the baby’s head crowning, Hani (not her real name) buried her face in her head scarf, crying, "I can’t look!"
I wasn’t surprised. After all, at 22, Hani was the youngest of the eight Somali women in my weekly health class for English language students, and she was visibly pregnant, despite her enveloping traditional robes. I had expected her to be moved by the video’s detailed footage of an American woman in active labor delivering her first child. The video was explicit, but I thought that it would be a good thing for Hani, especially, to view. I didn’t want her to go into labor without a clue of what lay in store for her.
Video over, I turned to the class. "What did you think?" I asked. Hani is usually chatty, but this time she was silent. Darn, I thought. It frightened her.
Finally, she spoke. "Well, that’s not how it was when my other babies were born."
"Your other babies?" I tried not to let my surprise register.
"Oh, yes," she said. "This one will be my fifth. I have one child living. The other three died; one stillborn, one at eight months, and the third at a year and a half. I never knew why any of them died. I’m praying to Allah that this one will live."
I am a health educator with a graduate degree from an American university, but that day I felt like a fool. With two healthy, living daughters, my experience in matters of life and death paled compared with those of my student, who is half my age. Yet I believed that only she should learn from me.
After class, I stopped Hani on the way out. "Will you tell me a little more about how Somali women take care of themselves and their families?" I asked. "I’d really like to know."
Somalis are among the newest Minnesotans to wonderfully confound our expectations, the latest strand in the state’s variegated tapestry of people and cultures. In just 10 years since civil war in their home country made ordinary life impossible, somewhere between 20,000 and 40,000 Somalis have resettled in Minnesota.
They are hard to miss: the women in billowing hijabs that cover them from brow to sole, the men tall and elegant in Western dress, clustered in coffee shops on the West Bank in Minneapolis, the children flocking through our public schools, more than 500 of them in one south Minneapolis high school alone. Most Somalis have settled in Hennepin County, especially in Minneapolis, but there are smaller Somali communities in many Minnesota towns, including Rochester, Marshall, and Owatonna.
Why are they here? For the same reasons that the parents or grandparents or great-grandparents of other Minnesotans came here—because life in the home country had become untenable; because farming could no longer sustain a family; because men with guns were threatening to harm them. Somalis come to Minnesota because they hear about the state’s excellent schools, or because they are looking for work, or because they have family here.
They find Minnesota weather harsh but the state itself hospitable, and they tell others. Many Somalis here are "secondary migrants" who originally settled in another state, a fact that accounts for the widely varying estimates of the size of the Somali community. Originally herdsmen and fishermen, Somalis are nomadic people, used to traveling in search of better conditions.
"The exact number of Somalis in Minnesota is anybody’s guess," says Ann O’Fallon, refugee health coordinator for the state health department. "The estimates range downward to 8,000 and upward past 40,000."
Most Somalis in Minnesota have spent months, if not years, in refugee camps near the Kenyan border before being allowed to emigrate. For them, life in Minnesota is just another challenge in a series of hurdles, a series most of their health care providers can only imagine.
Juan Bowen, M.D., an internist at the Mayo Clinic, acknowledges the critical need for more education of those providing health care to Somali refugees. "We have had a large increase in Somali immigrants in Olmsted County." (County figures place the Somali population at about 4,000.) "We here at Mayo and other providers in the area are faced with new challenges, communication and cultural barriers, as well as treating diseases that are common to many African immigrants like tuberculosis, parasites, and chronic hepatitis."
Bowen chairs the Minnesota Medical Association’s subcommittee on cultural competence, which in January 2001 will host a training conference focusing on health care needs of Somalis. The conference, part of what Bowen hopes will be an ongoing series on cultural competence and immigrant health, looks at the Somali group first "because it is relatively new and therefore less well understood," Bowen explains.
Speakers at the January conference will focus on health conditions that are common among Somalis. They will also discuss how Somalis view health care and how their religious and cultural beliefs may collide with the expectations of their Western-trained caregivers.
The concern is not a trivial one: Cross-cultural misunderstandings have led to many disappointing or even dangerous experiences for patients and health care providers, say conference planners. An emergency room physician, for example, should know that a Somali parent may resist a blood transfusion for an injured child or that a patient from one Somali clan may be reluctant to talk with an interpreter from another clan, despite their shared nationality and language. In Somali cultures (as in many more traditional immigrant cultures), female patients strongly prefer to be treated by a female practitioner, especially for reproductive health concerns. Bowen points out that the session on Somalis is simply the first step in exploring what it means to be medically competent across cultures. (For more on the conference, see "The Somali Patient" sidebar, page 23.)
Bowen suggests that tuberculosis is one of the conditions that health care providers treating Somali patients should keep in mind. "Think TB!" urges a recent newsletter on refugee health from the Minnesota Department of Health. Despite a national downward trend, the incidence of TB is increasing markedly in Minnesota, largely due to recent immigrants from sub-Saharan Africa. In 1999, nearly 80 percent of the state’s 201 reported new TB cases occurred in people born outside the United States, according to the health department’s TB Prevention and Control Program.
"Any physician seeing a Somali patient for the first time needs to be aware of the diseases, like TB, that are endemic in that patient’s country of origin," cautions Wendy Mills, TB program director. Estimates of TB prevalence in Somalia are hard to come by; civil war makes public health demographics inexact. But the estimated global prevalence of TB infection (as distinct from active TB) is approximately 33 percent, according to the World Health Organization, with most of the cases concentrated in nine African countries, including Somalia. It’s safe to assume that all Somali patients have been exposed to TB at some point in their lives.
Mills urges physicians who have questions about possible TB cases among their patients to contact the state health department (see Resources sidebar, page 23, for contact information). Laboratory tests, expert consultation, and even free medications are provided for any patient with active or latent TB.
Screening and diagnosing TB is difficult in many patients, since its symptoms can be frustratingly vague: fatigue, night sweats, weight loss, and a cough that won’t go away. Providing care is even more difficult with patients who do not speak English and must rely on an interpreter to convey the complicated, multidrug TB treatment regimen.
But screening, diagnosis, and treatment of TB in Somali patients is almost always complicated by the fact that for Somalis, tuberculosis is a curse, literally. "When a Somali wants to curse someone, he says, "May God give you TB," says Fozia Abrar, M.D., M.P.H., a Mogadishu-born physician who practices at Regions Hospital. "Somalis fear TB worse than HIV. Often, they have never seen someone be treated for TB and recover."
For Abrar, the solution is painstaking explanation, as often as necessary. "I often have to see a patient more than once, just to go over the exact same, half-hour long discussion of what it means to have a positive PPD test," she says. "I need to spend much more time on health education with some of my Somali patients."
A treatment process known as DOT, for Directly Observed Therapy, is also recommended for patients who may not complete their recommended TB treatment. Public health nurses and other specially trained outreach workers will personally visit patients who need help adhering to the long, and sometimes complex, drug regimen.
Judy Christensen, R.N., a nurse with the Hennepin County Community Health Department, supervises the home visitors who track down dozens of Somali patients a day "at home, at school, at work, wherever they are" to make sure that they swallow their oral medications.
"It’s hard to keep track of people sometimes," Christensen says. "Homelessness is a big problem for Somalis. They may not be living on the street, but 10 or 15 people might be living in a one-bedroom apartment. It’s disheartening to go into an apartment and see half a dozen cribs lined up against the walls and to know that sometimes Mom is sleeping under the crib because there’s no other place for her."
Such provisional housing arrangements usually don’t last long, and Christensen often finds herself tracking her patients from one address to the next. "Not every health department can do things the way we do," she says. "It’s a really expensive way to do it, but we have to in order to keep people on their meds and keep TB under control," she says.
A second, less-visible but no less complex, health issue for those treating Somali immigrants is female genital cutting, a widespread practice in Somalia. Because nearly all Somali women have been cut or "circumcised," Minnesota gynecologists and obstetricians should be aware of the practice.
Female genital cutting, or the surgical removal of genital tissue, is done for traditional and cultural reasons and not, as many people believe, as a requirement of the Muslim faith. Parents who take their daughters to be cut believe that the operation makes the genitals more hygienic and easier to keep clean. Some believe that a girl who has been cut is more marriageable and less likely to be promiscuous.
In Somalia, the surgery is sometimes carried out in hospitals by doctors or midwives, but more often it is done by traditional practitioners working in homes or villages. Somali women who are circumcised, usually as young girls, may have only the clitoris or outer labia amputated. But most have inner labia removed and the vaginal opening sewn almost closed, in a practice known as infibulation.
Women who have been infibulated develop infections and reproductive system problems more frequently, according to Mary Malotky, a certified nurse-midwife at Hennepin County Medical Center. They have difficulty with sexual intercourse and severe pain during childbirth. "We have to de-infibulate [by cutting through the scar tissue holding the labia together] at the point where the baby’s head is crowning, when it is putting pressure on the perineum. That means that all through her pregnancy, a woman may be wondering, ‘How will my baby get out? How much pain will I suffer?’ " Malotky says.
Because of the trauma associated with the cutting (often performed without anesthesia) and the likelihood of physical and psychological complications, the World Health Organization has called for an end to the practice worldwide, rejecting it as "an infringement on the physical and psychosexual integrity of women and girls and a form of violence against them." In the United States, female genital cutting is illegal.
Opponents of female genital cutting liken it to child abuse, and refer to the practice as "genital mutilation." As a Somali woman, Abrar has a more nuanced view. "Remember, nearly all adult Somali women in America have been circumcised," she explains. "It is not a healthy thing, it is not legal to do in the U.S., and it is a practice that should be discouraged." On the other hand, Abrar continues, "I feel strongly that female circumcision should not be characterized as abuse. People who talk about it as mutilation want to make a victim of us."
Reproductive health providers should be prepared for the likelihood that a Somali woman will have been cut, that the cutting will have scarred over, and that the woman’s outer genitals will look very different from most women’s, Abrar says. "Be ready to treat the circumcised woman as normal," she urges. A nonjudgmental reaction on the part of the provider will increase the chances that any complications of genital cutting can be openly discussed.
Health issues such as female genital cutting and tuberculosis are only the most dramatic health concerns facing Minnesota’s Somali community. Other diagnostic and treatment challenges include parasites, chronic hepatitis, and even malaria. Complicating the differential diagnosis is the likelihood of depression, or other emotional illness, often expressed in physical symptoms. As in many immigrant cultures, the concept of mental illness is not widely understood or accepted.
"So many of my immigrant patients, not just Somalis, have masked depression," says Abrar. "They come in complaining of back pain, or headaches, of not being able to sleep. I prescribe a lot of antidepressants, but I also talk about exercise, about eating right, and getting out socially. In Somalia, we were used to getting out of our homes and walking about, visiting with one another. Here, we are so isolated, by the weather, by poverty and television, and the fear of crime."
To counteract the isolation, Abrar dreams of creating an aerobic exercise program for Somali women, perhaps at Skyline Towers, a large public housing apartment building in St. Paul that is home to hundreds of Somali immigrants. "A program that got women dancing our traditional dances would do a lot to counteract the unhealthy effects of trauma and displacement," she says.
In the long run, she believes, Somalis will thrive in Minnesota. "Somalis are incredibly strong, incredibly hard workers," she says. "A Somali nomad is a guy who will sleep for three hours and work for 20, and the women work even harder.
"But we are also very flexible. We get a lot of strength from our culture, but we don’t condemn the culture of others. We embrace what is good about other cultures, and there is a lot that is good for us here."
Patricia Ohmans is a health educator who runs Health Advocates, a St. Paul–based research and training organization focusing on immigrant and cross-cultural health.
