Newsweek Web Exclusive "The Kindest Cut"

http://www.newsweek.com/id/218692

The Kindest Cut

In Colorado, a surgeon helps restore feeling—and so much more—to victims of female genital mutilation.
photos of "sila" (psuedonym) before, during and after treatment to reverse female genital mutilation - Dr. Marci Bowers performed surgery in Trinidad, Colo. in May 2009


Photos: Kristen Ashburn / Contact for Newsweek
Sila, a patient at Mt. San Rafael Hospital in Trinidad Colorado, prepares for her clitoroplastal reversal surgery (left). The surgery, (center) performed by Dr. Marci Bowers, reverses the effect of female genital mutilation and attempts to rebuild the clitoris, eliminate pain and restore pleasure. After the surgery, (right) Sila and Dr. Bowers embrace.


By Eve Conant | Newsweek Web Exclusive
Oct 20, 2009

One day, when Sila Folow was an 8-year-old girl living in Mali, four elderly women held her down on the dirt floor of an outhouse and, in keeping with local tradition, used a sharp blade to cut out her clitoris and most of her labia. Her grandmother and other villagers held a celebration. Sila, bleeding and in terrible pain, could not walk for weeks. Like millions of other African girls who are forced to undergo female genital mutilation—a ritual many women say is intended to ensure that they grow up to become sexually passive wives who will not stray from their husbands—Sila never recovered. She eventually moved to New York, married, and had two children. But she was reluctant to have sex with her husband. It hurt, and the scarring made it impossible for her to feel pleasure.

This May, Sila, now 38 years old, underwent a simple but profound operation to undo the past. She traveled to Trinidad, Colorado, where Dr. Marci Bowers, a gynecological and pelvic surgeon, has recently begun to perform "clitoralplasty" or "female circumcision reversals" on African women. A relatively new procedure, it reshapes the anatomy and, in 80 percent of patients, restores pleasurable sensation. "I want my womanhood back," Sila told Bowers when she first spoke to the surgeon about the operation. "I just want to know it's there. To have the feeling that I can fight against this culture."

As she awaited the anesthesiologist on the morning of the surgery, Sila—attractive, fun-loving, and talkative—was uncharacteristically quiet in her thin blue gown and hospital socks. She took a final phone call from her husband and mother, and set aside the romance novel she had brought to the hospital as a little joke. It was titled Good Girl Gone Bad.

The doctors wheeled her to the operating room, anesthetized her and got to work. Dr. Bowers cut away the thick scar tissue that had formed over Sila's wound and had obscured the remains of her clitoris. She then scraped away layers of a black, sooty material—the decades-old remnants of the ash poultice the local women had used to stop the bleeding. It had caused a low-grade infection that still hadn't healed—one reason Sila was always in pain. "They really got her good," Bowers said, shaking her head behind her surgical mask. Bowers used a cauterizing tool to quickly stop a sudden rush of blood. "That's arterial blood flowing there," she said. "You can see why so many girls have died after circumcisions." The root of the clitoris, which extends several centimeters beneath the surface of a woman's skin,is much larger than most people—and for many years scientists—ever suspected. Bowers exposed the remaining flesh of the organ and drew it out, securing it in place with delicate stitches that eventually dissolve. Finally, Bowers also did some cosmetic work to restore the appearance of Sila's labia.

A little less than an hour after it began, the surgery was complete. Two days after that, Sila was on her way home. In most cases, it takes three to six months to begin to tell if the operation was a success. However, the extent of Sila's injury was so severe—her reconstruction took twice as long as the average 30 minutes due to the level of scarring and the depth of the cut—it may take longer before she knows if the surgery worked. Still, "You should be able to feel something; there was two centimeters of scar tissue over the area," Bowers told Sila right after the operation.

"Just knowing it's out and I'm clean, I feel great," Sila said, still groggy from the anesthesia. She says she looks forward to the day when she can "have a romance with my husband."

Sila's operation was only the fourth time Dr. Bowers had done the procedure, but she has more than twenty years of experience in reconstructive surgery. Bowers learned the procedure in Europe by observing Dr. Pierre Foldes, a French urologist and surgeon who pioneered the technique after years of humanitarian work in Africa. He has received death threats from radical Islamists for his work as a surgeon and for his other efforts to reduce violence against women, he says. But he continues to train doctors and to perform the surgery. Foldes—reached by telephone outside Paris—tells NEWSWEEK that more than 3,000 women have come to him, largely because in France, , genital reconstruction surgery is covered by national health insurance. (In the United States insurance companies are still mostly unfamiliar with the surgery—only one of Bowers's patients has so far gotten full medical coverage for the procedure; others are still fighting with their insurance companies or have paid out of their own pockets.. Bowers performs the surgery free of charge, and the hospital caps its fees at $1,700. "As Dr. Foldes has said, you cannot charge money to reverse a crime against humanity," she says. "Sexuality is a right."

Bowers speaks from personal experience. She was born male and underwent "gender reassignment" surgery to become a woman 11 years ago. She now specializes in sex-change operations; she has performed some 700 of them, and is one of the leading gender-reassignment specialists in the U.S. The small Colorado town where her clinic is located has long been known as the sex-change capital of the world thanks to work of Dr. Stanley Biber , a pioneering surgeon in the 70s whose practice she took over. Asked if she is worried about the death threats that have followed Foldes, Bowers doesn't flinch. "I've jumped through enough fires and over enough barbed-wire fences in my life by now. I do not fear for my safety."

Bowers expects that the restoration technique she performed on Sila "will explode" in popularity as word gets out to the thousands of other circumcised African women who live in the United States. (Female genital mutilation is practiced in both Christian and Muslim communities and has been performed on some 100 to 130 million women worldwide, and some of those women may have been mutilated here in the U.S.). Since Sila, Bowers has performed four additional surgeries with two more scheduled for this month A California nurse, Ngozi, who was circumcised as a newborn in Nigeria and also had her labia entirely cut away, came to Bowers in August. She is already feeling results, she tells NEWSWEEK. "Before, I would look at my textbook and look at myself and they were two different things. I wasn't even human." Bowers performed not only the clitoral operation but also plastic surgery to create labia for Ngozi, 34. "Now when I look at myself I feel like a woman." Says Ngozi, who says she has even experienced orgasms for the first time in her life. "It's beautiful, I just love it, it feels like you're melting. Before it irritated me when my husband tried to touch me, now I reach out to him."

But here and even in Europe, many women fear being ostracized by their immigrant communities if they undergo the operation. Sila, whom NEWSWEEK followed before, during and after her operation, has the same concerns. She asked that her full name not be used for this article—Sila is her nickname—because she worries friends and family in America and Africa will once again treat her as an outcast. Sila knows about the stigma uncircumcised girls suffer in some African communities. Her mother, who was 14 when she gave birth to her, was vehemently opposed to female circumcision and for years refused to subject Sila to the procedure. In Mali, where nine out of 10 girls are forced to undergo the ritual, Sila stood out. Her cousins and friends had all been circumcised, many as infants. They teased her for being unclean and wouldn't let her eat at the same table with them. When Sila was 8, her mother moved to the United States, leaving her grandmother to raise her. The grandmother soon arranged for Sila to be made "normal." But the women who performed the circumcision the first time weren't satisfied with their work. Three weeks later, they held her down and cut her again. (In one way, Sila says, she was lucky. Some African girls are subjected to an even more extreme and dangerous ritual called an infibulation, which involves sewing up the vagina, leaving only a small opening for urine and menstrual blood.)

In 1989, when Sila was a teenager, her mother invited her to come live with her in the United States. She went to high school and college, and became a U.S. citizen. Dating was awkward. When she'd meet a young man, says Sila, "I'd think, he's cute, but if he knows he will run away. I would go out with them but when it came time for bed I'd say, 'Bye!' " She married an African man at age 20. Her husband was understanding. "He had lived in the U.S. a long time," she says. "He thinks the circumcisions are wrong." But her avoidance of intimacy strained their relationship. An avid reader, Sila devoured American romance novels with a tinge of jealousy and confusion, "I'd think, I wish I had that."

Last year she was reading a book with a character who'd had a sex change and wondered if she could change herself too—not into a man, but into a "real" woman. If a man can be made to feel like a woman, she thought, maybe they could fix me?

She surfed the Internet and discovered Foldes. She arranged an appointment, but the cost of the trip was high and French health care wouldn't cover an American patient. She found a small nonprofit organization on the web called Clitoraid, which had helped to fund Dr. Bowers's training in France. The organization has unusual backers: it is run primarily by volunteers of the provocative French Raelian movement—the pleasure-promoting "UFO religion" whose members believe life on Earth was created by a race of advanced aliens and who emphasize human sexuality. Clitoraid, however, reaches out to women of all religions and focuses solely on connecting women with trained surgeons in order to "create real, long-lasting changes for women who have been forced to experience clitoral excision or genital mutilation against their will" according to its mission statement. It has been the primary source of referrals to Dr. Bowers and has provided some financial aid to some of her patients, In late May, Sila flew to Colorado for the surgery. Like many of Bowers's patients, she stayed at a guesthouse for people awaiting sex-change operations. She was charged just $35 per night, less than half the usual rate.

Sila had spoken with two of Bowers's first three patients. Mariam—she agreed to give only her first name—was circumcised as an infant in Mauritania and now lives in Virginia. She spoke with NEWSWEEK seven weeks after her surgery and was still healing, but had begun to recover some sensation. "When I cross my legs or sit in a certain way, I feel something," she says. "It's kind of exciting. You keep wanting to do it." She is still haggling to have her hospital stay covered by insurance. "I've gone through this hell, why are they going to say this is cosmetic?" she says. "They don't even know what they're talking about. If a person is missing something, it's not cosmetic."

After the surgery, Sila showed anger for the first time at the women who cut her as a child. "They were so mean, so mean to me," she said as she rested on the couch in the guesthouse. "I want to go back and"—she made a shooting motion—"t-t-t with a gun." But she quickly reverted to her cheerful self. "Even if I feel something just one time, it will all be worth it." She knows she'll be criticized by fellow immigrants who may read this story, but hopes that eventually those who practice female circumcision will come to recognize it for what it is—a primitive and barbaric act. "They'll call me an infidel now, but later they will say it is a good thing," she says.

The night before her operation Sila could barely sit still, much less sleep. It was, she wrote in her journal, her last night "as an incomplete woman." At one point, she took a call from her mother. In African culture, says Sila, "usually you don't talk about things like this with your mother." But when she told her mother that she was going to have the operation, her mom was envious. "Oh, I'm too old to do it," she told her daughter. That was how Sila learned that her mother, too, had been circumcised. And now her mom hopes to be one of Dr. Bowers's next patients.