Un­do­ing fe­male mu­ti­la­tioGENITALn

IMAG­INE NEVER HAV­ING BEEN ABLE TO EN­JOY IN­TER­COURSE. A CON­TRO­VER­SIAL SUR­GI­CAL PRO­CE­DURE AIMS TO GIVE VIC­TIMS OF FE­MALE GEN­I­TAL MU­TI­LA­TION THE ABIL­ITY TO EX­PE­RI­ENCE SEX­UAL SEN­SA­TION

Marie Claire (South Africa) - - GENDER REPORT - WORDS JOANNA WAL­TERS

anon­de­script sub­urb on the out­skirts of San Fran­cisco. A plain brick build­ing. Seven ner­vous women wait in the sun­light. They are here for surgery, which per­haps has as much claim as any other to de­scribe it­self as ‘mirac­u­lous’. The lit­tle build­ing doesn’t shout its pur­pose, for many rea­sons. Firstly, this surgery is about fe­male sex­u­al­ity. Sec­ondly, it is con­trary to the be­liefs and tra­di­tions of mil­lions of fam­i­lies world­wide – bru­tal be­liefs and tra­di­tions. And then there’s the sur­re­al­ism of the pair be­hind the pro­ce­dure: the tall, blonde fe­male sur­geon – one of the best in the US – who hap­pens to have been born male, and the cheer­ful French coun­sel­lor who fol­lows the bizarre 1970s Raëlian sect that be­lieves hu­mans were cre­ated by ex­trater­res­tri­als for the pur­pose of un­al­loyed joy. Soon af­ter­wards, one of the first pa­tients, Zaria, 24, is un­der anaes­thetic.‘This one’s pretty bad,’ says the sur­geon, glanc­ing at me from the stool where she sits be­tween the legs of her pa­tients, scalpel poised. When I’d met Zaria, just be­fore her oper­a­tion, I was struck by the en­ergy of this funny, feisty and beau­ti­ful med­i­cal stu­dent with a tat­too and bun­dles of raven hair. Now, by her in­vi­ta­tion, I am look­ing at her gen­i­tals over the sur­geon’s shoul­der and try­ing not to cry. Zaria looks more like a doll than a real woman. Her gen­i­tals are fea­ture­less, com­pletely smooth apart from the open­ing. Barbie might ac­tu­ally be more anatom­i­cally cor­rect.

The sur­geon lifts her scalpel and be­gins slic­ing away at the flat skin sur­face; a thick layer of scar tis­sue. It is the sec­ond time in Zaria’s life that some­one has taken a knife to her most in­ti­mate parts. The first was at age 11 in Sierra Leone, and that time there was no anaes­thetic. Rel­a­tives had taken her to the coun­try­side ‘to pick or­anges’. Once there, she was lined up with 20 other girls and forced to the ground by a clus­ter of older women. Her labia and cli­toris were sliced off in a rit­ual once called fe­male cir­cum­ci­sion but now known more ac­cu­rately as Fe­male Gen­i­tal Mu­ti­la­tion (FGM). ‘I re­mem­ber I strug­gled and was yelling so loudly that one of the women ac­tu­ally sat on my head and prac­ti­cally suf­fo­cated me while they cut me,’ Zaria told her fel­low FGM vic­tims as they shared sto­ries be­fore their op­er­a­tions. Ac­cord­ing to the World Health Or­ga­ni­za­tion (WHO) more than 140 mil­lion women world­wide live with the ef­fects of FGM, most com­monly prac­tised in north­east and West Africa, but also in places such as Ye­men and In­done­sia. But an in­fin­i­tes­i­mal frac­tion, al­most ex­clu­sively those who em­i­grated to the west, are now find­ing their way to an emerg­ing hand­ful of surgeons who of­fer a rad­i­cal at­tempt at re­ha­bil­i­ta­tion.

This surgery doesn’t just make in­ter­course and child­birth eas­ier. Con­tro­ver­sially, it also aims to give the women the ca­pac­ity to feel sex­ual plea­sure – most for the very first time – by re­ha­bil­i­tat­ing the cli­toris. Zaria has trav­elled to Cal­i­for­nia from her home on the east coast of the US, where she moved from West Africa as a teenager. The wounds from Zaria’s cuts healed long ago, but in the process formed a layer of thick scar tis­sue that left her gen­i­tals numb to the touch. ‘My fi­ancé left me two months ago be­cause I don’t want sex,’ she’d told me when she first ar­rived at the clinic, her sad and be­wil­dered tone mixed with a note of de­fi­ance. ‘I did start hav­ing sex with him, but I don’t feel any­thing and I don’t care for it. He’s from Sierra Leone too, so he un­der­stands about FGM and was sup­port­ive at first, but in the end he went off with an­other African girl who hadn’t gone through it and wasn’t in­hib­ited like me,’ she had said.

While some of Zaria’s rel­a­tives dealt with her heart­break by telling her to just ‘get on with it’ and have sex out of obe­di­ence, Zaria had what she de­scribes as a ‘light­bulb mo­ment’ and be­gan search­ing the in­ter­net and came across an al­ter­na­tive so­lu­tion. Next thing, she had taken out a loan, which she has ‘no idea’ how she’ll pay back, jumped on a plane and found her­self in this plain brick build­ing.

At the clinic, she and the other pa­tients (in­clud­ing one from Aus­tralia, who had been ‘cut’ when liv­ing in Kenya as a young girl and who had hugged Zaria as she first told her story) were greeted by the two women who were in­stru­men­tal in en­cour­ag­ing them to break their bonds of cul­tural taboo. They are an in­trigu­ing pair. One is the sur­geon, Dr Marci Bow­ers, who spe­cial­izes in sex-change surgery and was born male be­fore she tran­si­tioned. There’s a 14-month wait­ing list for her $21 000 (over R210 000) gen­der-re­as­sign­ment surgery, but twice a year she clears her diary to op­er­ate pro bono on FGM vic­tims – al­though they must pay a $1 700 (over R17 000) fee to the clinic, near San Fran­cisco air­port, where Bow­ers rents an op­er­at­ing theatre. So far she’s op­er­ated on 50 women.

The other is Na­dine Gary, a French­woman who lives in Las Ve­gas. A school­teacher, she was in­spired to help FGM vic­tims by her fol­low­ing of the Raëlian sect. Founded by Claude Vo­ril­hon (‘Raël’), who spouts ab­surd claims about be­ing taken up in an alien space­ship to meet Moses,Je­sus and Buddha,it pro­fesses that hu­mans and all liv­ing things on earth were cre­ated by ex­trater­res­tri­als us­ing ge­netic en­gi­neer­ing. Fol­low­ers strive to cam­paign

for world peace, shar­ing and non­vi­o­lence, but also un­fet­tered sex­ual joy, which drives their move­ment against FGM.They were re­cently in the news for of­fend­ing people with their use of the swastika, of­ten set in­side the Star of David.When I meet her, Gary is wear­ing this scan­dalous com­bi­na­tion on a gold neck­lace and, not­ing my alarm, ex­plains why it sym­bol­izes in­fin­ity for Raëlians and em­ploys the swastika in the an­cient east­ern sense of sa­cred good­ness ‘be­fore Hitler hi­jacked it’. I wa­ver be­tween dis­may and be­muse­ment. She comes across as a para­dox: a dy­namic, charm­ing, kind and gen­er­ous per­son in all our con­ver­sa­tions who, un­til she starts talk­ing about UFOs, seems ra­tio­nal. I lis­ten po­litely, then turn back to the prac­ti­cal and po­lit­i­cal im­pli­ca­tions of the char­ity she helps run, provoca­tively called Cl­i­toraid. Formed by the Raëlians, it cam­paigns for the end of FGM and, mean­while, pro­motes the surgery to vic­tims and of­fers free long-term emo­tional and sex­ual coun­selling. Gary has driven from Ve­gas to sup­port the women, many of whom have not told their fam­i­lies about their jour­ney. The at­mos­phere in the clinic is strained, with much ner­vous laugh­ter.

On the op­er­at­ing ta­ble, how­ever, ev­ery­thing is clin­i­cally me­thod­i­cal. Af­ter strip­ping off old scar tis­sue, Bow­ers makes deeper in­ci­sions to dis­con­nect small lig­a­ments around the area where Zaria’s cli­toris was be­fore it was re­moved. At the stroke of the scalpel, a prom­i­nent nub of raw pink flesh prac­ti­cally pops up, sud­denly pro­trud­ing from the tis­sue sur­round­ing it. ‘There! That’s her wom­an­hood right there,’ Bow­ers de­clares tri­umphantly. ‘It’s like a mag­nif­i­cent tower in the for­est.’ When the cli­toris is cut off in FGM, Bow­ers ex­plains, it’s like los­ing just the vis­i­ble ‘tip of the ice­berg’. ‘Even af­ter they cut off the tip, about 99 per cent of the cli­toris is ac­tu­ally still in­tact, but hid­den be­neath the sur­face. We can ac­cess that.’ Ap­par­ently women pos­sess an­other eight inches of un­seen cli­toral erec­tile tis­sue that lies un­der the skin, arch­ing around the vagina. ‘Two inches longer than the aver­age pe­nis,’ says Bow­ers archly. By re­mov­ing the ob­struc­tive and of­ten painful scar­ring and ex­pos­ing some of that re­main­ing erec­tile tis­sue, then stitch­ing it finely into place, she as­serts that af­ter about two months of heal­ing it can func­tion as a new cli­toris, restor­ing the po­ten­tial for plea­sur­able sex. Af­ter that pro­ce­dure, known as cli­toro­plasty, Bow­ers stitches side folds of spare skin near the vagina to give Zaria the to­ken ap­pear­ance of labia mi­nora. It can never be her nat­u­ral per­fec­tion, Bow­ers warns, but even to my non-med­i­cal eye, I can see that this trav­esty, this sub-Barbie, has been trans­formed into a fair sim­u­lacrum of what Zaria was born with. Luck­ily, she hasn’t suf­fered the in­fibu­la­tion rit­ual that stitches the vagina par­tially shut.Af­ter 55 min­utes she is wheeled out of surgery and the next pa­tient, Sara, 29, is wheeled in.

Sara was cut in Eritrea, East Africa, at just three months old and it was more a sym­bolic slash than a mu­ti­la­tion. But, the man­ner in which her scar tis­sue formed fused a sec­tion of the labia, restrict­ing the vagina and cli­toris. Now liv­ing on the west coast of Amer­ica, Sara suf­fers pain, not only if her boyfriend at­tempts to touch her there, but even when do­ing ex­er­cise. In just 12 min­utes of del­i­cate scalpel work, Bow­ers re­moves a life­time of dis­com­fort for Sara. Be­tween ses­sions, Bow­ers checks her e-mails, gulps a cof­fee and chats with the nurses in an an­te­room. She’s ex­as­per­ated that more surgeons aren’t train­ing and re­search hos­pi­tals aren’t adopt­ing this oper­a­tion. Com­pared with the del­i­cate gy­nae­co­log­i­cal, uro­log­i­cal and plas­tic surgery she uses for five-hour gen­der-re­as­sign­ment op­er­a­tions, FGM restora­tions are a dod­dle.‘Cli­toro­plasty isn’t rocket sci­ence. If I wanted to be con­tro­ver­sial I’d say that the three rea­sons why more surgeons don’t train for it are that these pa­tients are African, Is­lamic and fe­male.There’s a cul­tural bias or in­dif­fer­ence there, com­bined with good old racism and sex­ism in a tra­di­tion­ally pa­ter­nal­is­tic med­i­cal pro­fes­sion. There may be some le­git­i­mate fear about in­ter­fer­ing with other people’s cul­tures, but when you talk to the hus­bands and boyfriends of the women they’re not happy that their wives and girl­friends can­not re­spond sex­u­ally – and that’s even with­out go­ing into the mis­ery that the women suf­fer,’ says Bow­ers.

there is,as you might imag­ine,dis­agree­ment in the med­i­cal world about the ef­fec­tive­ness of the surgery. The pioneer of FGM-re­pair surgery is Dr Pierre Foldès in Paris, who be­gan of­fer­ing cli­toro­plasty two decades ago and has op­er­ated on al­most 3 000 women. He trained Bow­ers, 10 surgeons in France, one in Barcelona and an­other doc­tor who of­fers the surgery in New York.(The rea­son,in­ci­den­tally,why there are so many French trainees is that cli­toro­plasty is paid for by the state as cor­rec­tive surgery, not only to in­crease the chance of sex­ual plea­sure, or re­duce the chance of sex­ual pain but,cru­cially,to make women feel nor­mal again; the French see this as a hu­man right.) Just one sur­geon in Bri­tain,Dr Ka­mal Iskan­der,based at North­wick Park Hospi­tal in Mid­dle­sex,is known to per­form the oc­ca­sional cli­toro­plasty on a pa­tient but, he ex­plains, only if he’s al­ready op­er­at­ing on them for more ex­ten­sive post-FGM prob­lems, such as chronic pain or in­fibu­la­tion. There are an es­ti­mated quar­ter of a mil­lion women in the US who have suf­fered FGM or are at risk of it. In Bri­tain, there are an es­ti­mated 66 000 vic­tims, largely among the African di­as­pora, and a fur­ther 20 000 of their chil­dren are be­lieved to be at risk, mostly of be­ing taken abroad for the rit­ual, even though this is il­le­gal. An ar­ti­cle in The Lancet by Foldès in June 2012 stated that of those who at­tended a one-year sur­gi­cal fol­low-up con­sul­ta­tion (ad­mit­tedly only 29 per cent of his pa­tients), more than half were now hav­ing or­gasms and al­most 98 per cent felt cli­toral plea­sure. But leading Bri­tish doc­tors Sarah Creighton, con­sul­tant gy­nae­col­o­gist at the pri­vate Port­land Hospi­tal, Su­san Bew­ley, con­sul­tant ob­ste­tri­cian at St Thomas’, and Lih-Mei Liao, clin­i­cal psy­chol­o­gist in women’s health

‘Sex with my hus­band is fun now; it was just a duty be­fore. I haven’t reached the or­gasm part yet, but I’m work­ing on it’

at Univer­sity Col­lege Lon­don Hospi­tal, wrote to the jour­nal coun­ter­ing that his cli­toral­restora­tion claims were ‘anatom­i­cally im­pos­si­ble’ – his re­sults were not ‘sup­ported by cur­rent ev­i­dence’ and ‘ where the body of the cli­toris has been re­moved, the neu­rovas­cu­lar bun­dle can­not be pre­served’. Bow­ers de­scribed the let­ter as ‘sneer­ing’, cit­ing pa­tients who ring her up cry­ing with hap­pi­ness af­ter their firstever or­gasm.

Efua Dorkenoo, who leads the cam­paign against FGM at the women’s anti-vi­o­lence pres­sure group Equal­ity Now in Lon­don, called on the WHO to ini­ti­ate clin­i­cal tri­als on the surgery – the lack of in­for­ma­tion meant she could not dis­miss ei­ther side’s ar­gu­ments. Bow­ers tells FGM pa­tients that ‘there are no guar­an­tees’ but that eight out of 10 re­port im­prove­ments in their sex life af­ter surgery, rang­ing from elim­i­nat­ing pain and ac­quir­ing some plea­sure to full-on or­gasm. Gary or­ga­nizes a pre-surgery work­shop about the men­tal tran­si­tion needed from lin­ger­ing trauma to em­brac­ing sen­su­al­ity and sends them all home with a vi­bra­tor. Once healed, she sends them lit­er­a­ture on dis­cov­er­ing mas­tur­ba­tion.‘The phys­i­cal surgery is just one step of the jour­ney. Many reli­gions re­press women’s sex­u­al­ity – we break the taboo.A woman’s body is con­nected to her self-es­teem – we ex­plain to pa­tients what hap­pens when a woman feels plea­sure and that it’s nat­u­ral,’ Gary says. Miriama, 30, who was born in Guinea but now lives in the US, had the surgery with Bow­ers three years ago and says it has changed her mar­riage.‘Sex with my hus­band is fun now; it was just a duty be­fore. I haven’t reached the or­gasm part yet, but I’m work­ing on it.’

Trav­el­ling to Bow­ers’s clinic was a huge step.‘When I told a cousin what I was get­ting done she called me a slut,’ Miriama re­calls. She has a daugh­ter who is eight,but Miriama re­fuses to take her to visit her mother, who still lives in Africa. She has never met her grand­daugh­ter, in case the child is taken to be cut, as Miriama’s mother did to her. Natasha, 35, who also moved to the US from Guinea, had the first or­gasm of her life three months af­ter her 2010 surgery with Bow­ers, us­ing the vi­bra­tor Gary gave her.‘I’d never felt any­thing like it be­fore.’She now has reg­u­lar or­gasms and, in case doubters think they’re imag­ined in an ea­ger­ness to be con­vinced the surgery worked,she points out that she cli­maxes in her re­stored cli­toris de­spite what’s in her head, not be­cause of it.‘I was sur­prised I ac­tu­ally felt ashamed I was do­ing some­thing self­ish and dirty.’The so­cial con­di­tion­ing of her up­bring­ing is hard to shake. Her hus­band is mak­ing ef­forts to re­as­sure her, she said, and she turns to Gary for sup­port. ‘I can talk to Na­dine freely. She feels like a big sis­ter.’ Natasha and the other women say Gary talks of the Raëlian phi­los­o­phy of sex­ual free­dom, but de­nies the treat­ment has been used to con­vert them to the out­landish re­li­gion.

When I ques­tion Gary on her be­liefs, she ex­plains that the aliens who cre­ated hu­mans are called Elo­him, He­brew for God or gods but, to the Raëlians, means ‘those who came from the sky’.‘The Bi­ble is es­sen­tially an athe­ist book,’ she tells me earnestly. ‘There is no God.’ Gary says this set of be­liefs seemed more ‘ma­ture’ to her when she con­verted at 17 from the Catholi­cism she grew up with near Lyon. She is now, she adds, a Raëlian priest­ess. I turn to Bow­ers, who shrugs.‘The Raëlians are un­abashed about their sex­u­al­ity and un­apolo­getic about erotic plea­sure, but it’s a red her­ring in terms of my work. It doesn’t af­fect the price of bread,’ she says,‘but they do de­serve credit for pro­mot­ing women’s sex­ual health and Na­dine has got me talk­ing more frankly about sex­ual mat­ters with my pa­tients.’

The day af­ter her surgery in San Ma­teo, Sara is tired but ec­static. Most of the women re­cover in cheap ho­tels near the clinic, but Sara is col­lected by her boyfriend.‘I feel free. I’d felt so un­heard and my whole life had felt like there was some­thing miss­ing. Now the anger I’ve had for years has gone,’ she says. Her boyfriend Jack, who was born in Eritrea, puts up with the fact that they’ve been to­gether for three years but don’t have sex.‘I’m not go­ing to rush. I love her and she is my good match,’ he says, smil­ing shyly. ‘I’m very glad she’s had surgery – it’s nec­es­sary for her to feel like a full woman.’

An­other of the women Bow­ers has just op­er­ated on, Ayanna, 23, a mar­ket­ing as­sis­tant from the Pa­cific North­west who fled the civil war in So­ma­lia,is in a quandary af­ter her cli­toro­plasty,for she isn’t in love with her cur­rent boyfriend.‘I told him I was com­ing for the surgery… I’m wor­ried he’s go­ing to ex­pect me to be an in­stant sex ma­chine,’ she says.Ayanna lied to her con­ser­va­tive mother that she was vis­it­ing friends in San Fran­cisco,then snuck off to Bow­ers’s clinic with her best friend Emma for sup­port. Emma’s par­ents are from Ethiopia, but she was born in Amer­ica and was never cut. The two ex­ude such an all-Amer­i­can youth­ful mis­chief it’s hard to be­lieve Ayanna was once steeped in a very dif­fer­ent tra­di­tion. They ban­ter about par­ties and dat­ing.They or­der room ser­vice while gig­gling in their dress­ing gowns. But then she is sud­denly solemn. ‘My friends and I will all be in a night­club hav­ing a crazy time, but while they are get­ting guys’ num­bers, I hang back,’ she says. ‘Tech­ni­cally there’s no rea­son why, just be­cause I’m cut down there, I couldn’t feel sexy when a guy is kiss­ing me or touch­ing my breasts. But my mind leaps to what that leads to next and then I shut down,’ she says. She has high hopes of a ful­fill­ing sex life now that she’s had surgery, but still has years of neg­a­tive mind games to over­come. Some names have been changed.

Two friends – Emma and Ayanna – re­lax dur­ing Ayanna’s re­cov­ery pe­riod.

Left Dr Marci Bow­ers is on a mis­sion to put plea­sure back into women’s lives. Op­po­site Fac­ing the fu­ture: Sara awaits surgery while Zaria re­cov­ers.

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