During the summer holiday thousands of migrant families travel with their young daughters to their native countries to undergo female genital mutilation.
FGM is banned in most countries, but it's still legal in Somalia, which - together with the rest of Somalia - has the highest rate of female genital mutilation in the world. Over 90 percent of girls in Somalia are cut by traditional cutters, most of whom have no medical training.
So why does this dangerous, painful and sometimes deadly practice continue in so many countries? And what would it take to stop it?
Female genital mutilation or cutting
Female genital mutilation or cutting (FGM/C) means piercing, cutting, removing, or sewing closed all or part of a girl's or woman's external genitals for no medical reason.
Researchers estimate more than 513,000 girls and women in the U.S. have experienced or are at risk of FGM/C. Worldwide, as many as 140 million girls and women alive today have been cut.
FGM/C is often a part of the culture in countries where it is practiced. But FGM/C has no health benefits and can cause long-term health problems. FGM/C is against the law in the U.S. and many other countries.
What is FGM/C?
The World Health Organization (WHO) and the United Nations (UN) define FGM/C as "any partial or total removal of the external female genitalia or any other injury of the female genital organs for nonmedical reasons." The United States also uses this definition in its efforts to end the practice.
FGM/C is sometimes called "female circumcision." FGM/C is not the same as male circumcision.
What are the different types of FGM/C?
The World Health Organization (WHO) describes four major types of FGM/C. Types 1 and 2 are the most common, but all types may be harmful.
The four types of FGM/C are:
Type 1: Partial or total removal of the clitoris. This is also called clitoridectomy.
Type 2: Partial or total removal of the clitoris and the labia (the inner and outer "lips" that surround the vagina)
Type 3: Sewing the labia together to make the vaginal opening smaller. This is called infibulation. The clitoris may be left in place.
Type 4: All other harm to the female genitalia for non-medical purposes, including pricking, piercing, cutting, scraping, and cauterization (burning)
Where is FGM/C done?
FGM/C is done mostly in parts of northern and central Africa, in the southern Sahara, and in parts of the Middle East and Asia.
Some immigrants in the United States and Western Europe from these countries also practice FGM/C illegally, or may send their daughters back to their family homeland for FGM/C. Other immigrant families stop practicing FGM/C once they are in a new country.
Why is FGM/C done?
Girls and women who live in the countries where FGM/C is practiced most often have the highest risk. In some countries, only a small number of girls and women are cut. In other countries, nearly all girls and women are cut.
The specific community or part of the country a girl or woman lives in can increase or decrease her risk of certain types of FGM/C. For example, different ethnic groups may perform different types of FGM/C.
Also, how much wealth, education, and the type of education a girl's parents receive may influence their choice to have a daughter cut. Lastly, whether a community is urban or rural can affect the practice of FGM/C.
The age when girls are cut varies from country to country and even within communities.
Girls are most at risk between birth and 15 years. In about half of the countries in which FGM/C is practiced, girls are cut before 5 years old. In other countries, most girls are cut between 5 and 14.
Sometimes, FGM/C is done to adult women. Women may be cut just before marriage. Some communities wait until the first pregnancy.
How many girls and women are affected by FGM/C?
FGM/C can cause immediate and long-term medical problems. How bad these problems are depends on:
How clean (sterile) the place is where cutting happens. FGM/C is illegal in most countries and must be done in secret. In most of these countries, FGM/C is usually done on a floor, table, bed, or the ground. But, in some countries, such as Egypt, a loophole in the law allows doctors to do FGM/C in a sterile, medical site.
The experience of the person performing FGM/C and the tools used. The cutting is often done with glass, razor blades, or knives. The tools may not be sterilized between cuttings. In type 3 FGM/C, the sewing may be done with thorns and without sterile thread.
The type of FGM/C. Type 3 causes more health problems than type 1 or type 2.
The general health of the girl or woman
How does FGM/C affect a girl's or woman's health immediately after the cutting?
The type of FGM/C done may affect how much and how serious health problems are after FGM/C. Type 3 causes more health problems than type 1 or type 2.
Immediate medical problems can include:
Severe pain. Girls usually don't get any pain medicine before or after they are cut.
Infection of the wound. Girls can get fever, shock, and even die if the infection is not treated.
Trauma. Girls are held down often against their will and may not understand why.
Problems going to the bathroom, including burning and pain
Tetanus and other infectious diseases, such as HIV, from unsterilized cutting tools
Death. Researchers do not know how many girls die because of FGM/C. Few records are kept, and deaths that may have been caused by FGM/C are often not reported as related to FGM/C.
How does FGM/C affect a girl's or woman's health in the long term?
FGM/C can cause long-term problems with a girl's or woman's physical, mental, and sexual health. The type of FGM/C done may affect how much and how serious the health problems are. Type 2 and type 3 cause more serious health problems than type 1.
Long-term health problems include:
Infections, such as genital abscesses (sores filled with pus that must be drained) and infectious diseases such as hepatitis B. In one large study, more infections and infectious diseases such as urinary tract infections, bacterial vaginosis, and HIV were found in women with type 3 FGM/C. This is probably because the damage caused by FGM/C can make vaginal tissue more likely to tear during sex. This increases the risk of HIV and other sexually transmitted infections (STIs).
Problems having sex. Extra scar tissue from FGM/C (most common after type 2 or type 3) can cause pain, especially during sex. This can lead to a lack of interest in sex, vaginal dryness, and lower overall satisfaction. Scarring can also cause vaginal tissue to be less elastic than normal vaginal tissue. It might not stretch as easily for sex or childbirth.
Depression and anxiety. Girls may not understand what is being done to them or why. The effects of this painful experience are similar to those of post-traumatic stress disorder. Girls or women who have already been cut and are living in the United States may be disgraced or humiliated when they receive medical care. They may also fear that health care providers in the United States do not know how to take care of them. This can make adjusting to a new country more challenging.
Painful and prolonged menstrual periods. Type 3 FGM/C may cause some girls and women to have painful menstrual periods. Some women are left with only a small opening for urinating and menstrual bleeding. They may not be able to pass all of their menstrual blood. This can cause pain and periods that are longer than normal. Some women may also have infections over and over again.
Urinary problems. Type 3 FGM/C may slow or strain the normal flow of urine, which can cause urinary tract infections. Urine can also get trapped behind the scar and crystallize, forming hard masses called bladder, or urinary, stones.
Fistula, an opening between the urethra and vagina that lets urine run into the vagina. This can happen when the urethra is damaged during FGM/C. Fistula causes incontinence and other problems, including odors, and can cause girls and women to become social outcasts.
Girls and women who come to the United States and have already been cut may face additional health problems. Doctors and other health care providers may not know how to adequately treat the girls' and women's unique health needs. In some cases, health care providers lack training on counseling and caring for girls and women who have been cut.