This is the second in a series of articles on the feminization of migration. The first article was The Feminization of Migration. Support for this series is provided by the Fred H. Bixby Foundation.

(January 2007) Migrant women and men share some health problems but experience others separately, because of culture as well as biology. As the number of female international migrants increases, obstacles to their care need to be considered when health services are designed and delivered.

At the three Finger Lakes Migrant Health Care Project clinics in upstate New York, which are part of a national network of services, men and women complain of back pain, stomach ailments and injuries. Diabetes and high blood pressure are common. However, physicians there observe that men are more likely to suffer from alcoholism, while women suffer from stress and exhaustion, perhaps related to tiring schedules of paid work and the second shift of domestic duties. Women also come to the clinics to obtain birth control, often without their partner's knowledge, and to deal with the consequences of abuse.

One obstacle to care is that female migrants from some cultures and countries have a deep-seated reticence to talk about reproductive health with male providers. Many also lack the money to seek care, or the education to understand and adapt to the health system in a new country.

According to Dr. Genevieve Johnson Stuber, a family practice physician with the clinics, "Lack of transportation is a more burdensome problem for women patients, almost none of whom drive, and even though the clinics will provide transportation on request, many of the female migrants do not have access to a telephone or understand how to use the "800+ number system to make a free call."1

A vivid example of the need to view health care through the gender lens is the issue of female genital cutting. Also known as female circumcision or female genital mutilation, this is a common practice in many societies in the northern half of sub-Saharan Africa as well as Egypt and Yemen. Nearly universal in a few countries, it is practiced by various groups in at least 26 developing countries and in immigrant populations in Europe and North America. Over 130 million women worldwide have undergone female genital cutting. It varies from a symbolic nicking of the clitoris to excision of tissue and partial closure of the vaginal area, known as infibulation.2

A practice that horrifies most Americans and that is considered around the world as a violation of human rights, female genital cutting increasingly is being banned by law in developed and developing countries. It has been a federal crime in the United States since 1997. Yet many immigrant families continue the practice, leading to clashes of culture. Only recently, in November 2006, an Ethiopian immigrant in Georgia was sentenced to 10 years in prison for cutting his 2-year-old daughter, according to an Associated Press account in the Washington Post.3

The practice continues, however, because most parents who cut girls think they are not doing it to their daughters, but for them. Girls who are not cut may be labeled as filthy and undesirable. Some communities believe that the clitoris is toxic and must be removed so that it will not grow or touch and kill a baby during delivery. Other parents fear that uncut girls will never marry. In their eyes, cutting protects a girl's chances of marriage, keeping her chaste until she does and able to enhance her husband’s sexual pleasure after. Others perform this practice to be good Muslims, because they believe it is sanctioned by the Prophet Mohammed, even though this tradition predates Islam and was never mentioned in the Koran.4

The impact of this practice is potentially profound and growing in the United States. Research by Dr. Nawal Nour, director of the African Women’s Health Center at Brigham and Women’s Hospital in Boston and Population Reference Bureau analysts shows that nearly 228,000 women and girls in the United States have experienced or are at risk for female genital cutting. This reflects growing immigration from countries where female circumcision is prevalent. The number has increased 35 percent since 1990. The highest numbers are in states with large numbers from countries where cutting is prevalent: California, New York, New Jersey, Virginia and Maryland.5


U.S. States With the Highest and Lowest Number of Women Estimated to Be at Risk of Female Genital Cutting, 2000

State
Total
Under age 18
18 years or older
Total for U.S.
227,887
62,519
165,368
States with the highest number
California
38,353
9,613
28,722
New York
25,949
7,675
18,274
New Jersey
18,584
5,605
12,978
Virginia
17,980
4,312
13,669
Maryland
16,264
4,466
11,798
States with the lowest number
Alaska
96
96
Vermont
97
97
New Hampshire
92
83
9
Mississippi
46
23
23
Montana
4
4

Source: Population Reference Bureau analysis of data from the 2000 Census 1% Microdata Sample.


"Many of these women have received inadequate culturally appropriate care," according to Dr. Nour. "Given that health providers will increasingly be seeing women with female genital cutting, a greater knowledge and understanding is necessary in order to provide them with better care and treatment."

Dr. Nour tells the story about one of her patients, Nafisa, a recent arrival to the United States from Somalia. She went to the emergency room in a New York City hospital complaining of persistent nausea and vomiting. The health providers there became distracted by a scar that covered her vagina. They brought in male and female medical students and residents to examine her. Humiliated by the experience, she hoped that in time, they might refocus on her nausea. Fighting her fears, she lay there while strangers examined her. She saw their shocked and horrified faces.

Because they focused on her genital scarring, the health providers failed to elicit a critical part of their patient’s medical history. During the height of the Somali war, Nafisa hid in her home with her younger sister. Five men stormed in while their parents were out. They gang-raped her, after slitting her scar open with a knife because they were unable to penetrate her easily. Her sister was raped and killed. Nafisa never found her parents. She was cared for by a neighbor until she was strong enough to reach Mogadishu, Somalia's capital, and eventually get to New York.

After her humiliating experience in the New York City emergency room, it was a year before Nafisa visited another doctor, this time at the African Women’s Health Center. There she was diagnosed with post-traumatic stress disorder and depression. Her feelings about circumcision were much like those of Dr. Nour’s other patients: She was not upset with her mother for cutting her. Rather, she loved and missed her mother very much. It was the rape that traumatized her and made her feel like a victim.

There is a range of strategies to address obstacles to providing high-quality, culturally competent health care to female migrants. Both sides must consciously work to stay on the edge of their comfort zones by learning each other's personal and professional languages, and listening at a deep level to establish trust.

The African Women's Health Clinic, founded in 1999, does that kind of two-way training. Its staff conducts two-day reproductive health workshops throughout the United States. The first day is devoted to teaching refugee women about access to health care, reproductive health, child care and issues involving female genital cutting. The second day educated health and service providers on how to give culturally and linguistically competent care to women who have been circumcised. At the end of the workshop, the two groups join to find ways of improving communication and access to health of women who have been circumcised.


Nancy V. Yinger was director of International Programs at the Population Reference Bureau from January 2000 to June 2006.


References

  1. Personal conversation, Nov. 3, 2006.
  2. P. Stanley Yoder, Noureddine Abderrahim, and Arlinda Zhuzhuni, Female Genital Cutting in the Demographic and Health Surveys: A Critical and Comparative Analysis (Columbia, MD: ORC Macro, 2004.)
  3. Associated Press, "Man Sentenced for Mutilating Daughter," The Washington Post, Nov. 2, 2006.
  4. Adapted from Dr. Nawal Nour’s presentation at the Population Reference Bureau's media briefing on female genital cutting, National Press Club, Washington, DC, Feb. 6, 2004.
  5. Statistics for other states and metropolitan areas are at www.brighamandwomens.org/africanwomenscenter, accessed online on Jan. 4, 2007.