It started simply enough: a pregnant Somali patient and a doctor in an examining room at Harborview Medical Center. The doctor asked what she thought was a routine question: "If it's a boy, do you want him circumcised?"
"Yes," the Somali woman replied. "But what if it's a girl?"
The refugee woman's question and its implications sent doctors and administrators at Harborview reeling. Circumcision for girls? Surely no doctor would ever consider performing removing healthy tissue, a procedure dubbed by some accounts from Africa and other Third World countries as "female genital mutilation."
And yet, these were women of another culture, a culture the doctors believed they should respect. Soon, some began to listen. And what they heard convinced them that as strongly as a Jewish mother believes her son must be circumcised to be a member of the faith, so do some Somali Muslim refugees in Seattle believe that their daughters' genitals must be cut to comply with their religion and demands of their culture.
The question facing Harborview: Was there any alternative to cutting away healthy genital tissue that would satisfy what some Somalis believe is a religious and cultural requirement?
"It's very important for the Somalian people, because it's a very old culture," says Fardosa Abdullahi, speaking through a translator. Her head and upper body draped in a black hijab, a traditional Muslim covering, Abdullahi insists that each of her
three young daughters must be cut. "It's important for her health; it's important for religion. We have to keep the religion."
How important is it? Enough to go back to Africa or to another country to get it done, enough to offer bundles of money to native "midwives" to do it, the Somali women say. "It's important enough to take your three kids and get a ticket, $1,500 for each person," says Kadija Ahmed, a Somali woman with three daughters.
A Harborview committee chaired by Dr. Abraham Bergman, chief of pediatrics, found that there was something called a "sunna" circumcision, which, as envisioned, would entail no more than a small cut in the prepuce, the hood above a girl's clitoris. It would remove no tissue and leave only a small scar. The Somali women say it would fulfill their religious and cultural needs.
Dr. James LoGerfo, Harborview's medical director, has sent the committee's recommendation to the state's attorney general for legal review. No doctors at Harborview have done the procedure, nor is there any plan to do anything before a communitywide discussion of the issue is held, LoGerfo says.
None of that has placated those who say that even talking about cutting female genitals legitimizes a barbaric practice, one that disempowers women and serves to keep them out of the American mainstream.
Mimi Ramsey, a 43-year-old Ethiopian who heads Forward International, a California-based group working to stop genital cutting, said she was mutilated when she was 6 years old and would do anything to stop doctors from cutting girls' genitals.
"This is the most horrible, horrible thing that is happening to children. This is the sort of pain they want to create for the helpless little girls that are Americans. They are born in this country. They have a right to protect their bodies."
"This is barbaric," agrees Diane Dupuy, a local member of the group. "I can't imagine doing this to girls; this is taking away their rights."
On the contrary, says LoGerfo, the compromise may be the only available ethical, legal and humane alternative "short of throwing the kids and the mother in jail for 20 years to make sure nothing happens to them."
Bergman says outsiders should be careful when making judgments about the cultures of others. "It behooves us to show some respect," he says, adding that decisions should not be made without thorough information.
As for the mothers who asked the Harborview doctors if their daughters could be circumcised, they, too, find themselves trying to understand a strange culture.
Most of them were cut in Somalia, the majority in ways that removed much tissue and sewed together what was left. In procedures called "infibulations" or "Pharaonic" circumcisions, most lost their clitorises and surrounding flesh, becoming scarred in ways that sometimes cause pain and difficulty in childbirth and can make intercourse painful. But they say that such cutting was a mark of a respectable family that cared about its daughter, a safeguardof her virginity, a sign that the girl was a good Muslim.
Many Somali women are shocked to find that, in this country, some people think cutting young girls' genitals amounts to child abuse.
Without circumcision, a girl would feel embarrassed, says one 28-year-old Somali woman, a mother of three. If other girls knew, they would laugh at her, and she would feel shamed. If her daughters are not circumcised, she says, no man will want to marry them.
"He will think he is getting a girl already used," she says. Circumcision, even a tiny cut, she says, will somehow help her daughters avoid what she sees as the American disease: "Girls 13, 14, 15 get pregnant, go wild, get welfare." It won't prevent a girl from having sex, she concedes, but it would be a sign that "she's trying to control herself."
Like other Muslin women, she says her religion requires girls be circumcised. She and others who have studied the issue say female circumcision is not spelled out in the Koran, but is mentioned in the Hadith, the collection of oral religious teachings.
Ahmed Scego, a 29-year-old Somali man who has been in the U.S. since 1988, worries that if mothers take their daughters back to Africa, there is more chance that a grandmother who believes in the old way, the Pharaonic circumcision, will call the shots. "I know a lot of people who are saving their money to take their daughters somewhere," he says.
These women already have moved from being radically cut themselves to wanting only a virtually symbolic cut for their daughters, he says. Somalis are a proud culture, he says, and they don't change easily.
According to studies, Somalia has one of the highest rates of female circumcision, which is practiced in more than 30 countries in the world, predominantly in Africa. In some countries, including Somalia, over 80 percent of the women are cut.
A teenager from Togo was recently given asylum amid a rash of stories depicting screaming girls being held down by relatives as their flesh was scraped away.
The World Health Organization says that the more severe forms have caused infections, tetanus, bleeding, shock, hemorrhage and even death. A woman who survives all that may have difficulties in childbirth, scarring and pain.
Estimates place the Somali population in the Seattle area at about 3,000. Other states with relatively large populations of immigrants from African countries that practice female circumcision - Rhode Island, Tennessee, Minnesota and North Dakota - have outlawed the practice. A similar bill in California has passed the Legislature and is awaiting the governor's signature. In Congress, a bill introduced by Rep. Pat Schroeder of Colorado would outlaw the practice.
Some doctors at Harborview don't like the idea of a national law. In fact, says Dr. Leslie Miller, an obstetrician-gynecologist, a sunna circumcision of girls would be a good deal less drastic than what is done to boys during circumcision, a common and accepted procedure.
Miller says she can understand why the refugees are confused. "We will cut the whole foreskin off a penis, but we won't even consider a cut, a sunna, cutting the prepuce, a little bloodletting (on a girl)," she says.
Medical doctors in this country also do cosmetic surgery on genitals, Miller notes.
"We're not discussing circumcision with (the Somalis) because we want to mutilate their daughters' genitals; it's because it's a reasonable request," says Miller.
Not all Somali women want to have their daughters circumcised, Miller says. But perhaps doctors should consider doing sunna circumcisions if such a procedure would help make the transition from the generation with radical circumcisions to one where no cutting at all would need to be done, she suggests.
Not all Muslim countries practice female circumcision, and the procedure appears to be dictated by culture and tradition as much as by religion. Tradition also dictates the age at which a girl is cut: In Somalia, a girl is typically 6 to 8 years old. In this country, such a young girl would not be considered able to give consent, noted LoGerfo. If any such procedure were ever done, LoGerfo says, age 12 would be the minimum.
At Children's Hospital & Medical Center, medical director Dr. John Neff says only procedures that are deemed medically necessary are performed. But he concedes there is debate as to the medical necessity of circumcisions for boys. "Male circumcision is a controversial issue," he says. "Female circumcision, as far as we're concerned, is not a controversial issue. It just should not be done."
Kadija Ahmed says she knows Americans find it difficult to understand her religion and culture, the underpinnings of a country where she was married at 13 to a much older man who paid her parents 100 camels for his beautiful young bride.
"Everything we do comes from religion - how we eat, how we dress, how we talk to people," she says.
Fardosa Abdullahi says Allah spells out what is right, and she and other Muslims must follow.
"Anyone who thinks this is wrong or weird is not respecting my culture or my religion or who I am," she says, "and they should be educated."