Harvard Public Health Review
Fall 2004

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Gentle Diplomat

For someone who recently won a half-million-dollar MacArthur Foundation "genius" fellowship, HSPH alum Nawal Nour, MPH '99, isn't at all intimidating. Intelligent, yes. Creative, focused, tenacious--yes, as the foundation requires. But not a person who inspires awe.

That's part of Nour's plan. She aims to end female genital cutting, or "circumcision," by taking a gentle, diplomatic tack. While others have denounced the practice as "genital mutilation," Nour is neither angry nor righteous. Instead, she speaks in the measured tones of an understanding physician, advising a patient to act in her own best interests.

"We don't want to go in with a heavy-handed agenda," she explains. "I do ultimately want to stop female circumcision. But fundamentally, I want to help women live healthy lives."

About 130 million women have undergone genital cutting, mostly in Africa, where it is practiced in 28 nations, and in Asia, particularly in the southern half of the Arabian peninsula, along the Persian Gulf, and in Muslim-dominated regions of India, Malaysia, and Indonesia. Performed on girls ages 5 to 12, this coming-of-age ritual dates back thousands of years--some Egyptian mummies show evidence of circumcision--but its origins are unknown. As practiced in diverse cultures and religions, the custom varies greatly. In Ethiopia, the clitoris is excised. But in Somalia, northern Sudan, and Djibouti, nearly all of a girl's external genital tissue is removed, including the clitoris, inner labia, and most of the outer labia. What's left is sewn shut, leaving a tiny opening for the passage of urine and menstrual blood.

Particularly in rural areas, the procedure is carried out by women in the family using an unsterile knife or razor, and no anesthesia. Many girls endure complications ranging from hemorrhaging to infection to urinary problems. Often they grow up to face traumatic deliveries or, ironically, infertility. One study of 4,000 women in Khartoum found that 80 percent reported sexual difficulties.

Despite its risks, this deeply rooted tradition has proven difficult to stop. Proponents believe it not only insures a girl's chastity but also improves hygiene and, for her future husband, sexual pleasure; in short, it makes her marriageable. In countries where marriage is a woman's route to economic security, research shows that families--particularly mothers--have powerful incentives to perpetuate genital cutting. Horrific though it may be to outsiders, for them it is an act of duty intended to secure a daughter's future.

"They're afraid to stop it,'' Nour says. "They want to know, 'Can you guarantee that my daughter will be married?' ''
Born in the Sudan and raised in Egypt and London, Nour says her parents opposed circumcision. Having grown up surrounded by family and friends who supported the practice, she understands that circumcised women do not consider themselves mutilated. Their scars reflect accepted standards of beauty.

Nour seems to gracefully bridge contrasting worlds. Dressed in a pinstripe pantsuit, she looks every inch the American doctor. Meanwhile, her roots are evident in the polished wood carvings of pregnant women that decorate her small office at Boston's Brigham and Women's Hospital. A 1994 graduate of Harvard Medical School as well as HSPH, Nour spends most of her workweek in a conventional obstetrics and gynecology practice.

But soon after finishing her residency, word spread within Boston's growing African immigrant community of an African woman doctor who understood them. Nour developed a following and, in 1999, she opened the African Women's Health Practice at Brigham and Women's. She developed a surgical procedure to reopen circumcised patients, alleviating many medical problems and easing childbirth. She began holding seminars around the country for African immigrants and their health providers on circumcision and other women's health issues. She also wrote guidelines to help physicians treat women effectively and with sensitivity. As African immigrant populations swelled in the U.S., caregivers began waking up to an issue that affects an estimated 168,000 women.

Now Nour is looking to Africa and Asia, where genital cutting remains common. Using her no-strings- attached MacArthur award to study others' approaches to changing the practice, she will then ally herself with the most effective groups. Skeptical of those activists who stage protests and lecture national leaders about the evils of a practice they've grown up with, Nour calls instead for one-on-one persuasion.

"The better way is to have a respect-ful dialogue," she says. "Individual conversations may do a better job of changing attitudes."

One barrier to this is that many Muslim communities practice female circumcision, even though it is not man-dated by the Koran. Given politicians' fear of being accused of attacking Islam, Nour believes religious leaders must be engaged in bringing about change.

What's also needed, Nour says, is to get political leaders to enforce existing laws against female circumcision, and to pass new ones. In societies grappling with poverty, AIDS, and other woes or crises, enforcing such legislation isn't a priority. Greater efforts must be made to raise the profile of the practice among those who wield power.

Finally, grassroots education is key. Medical workers should talk with patients about the health problems caused by circumcision while simultan-eously educating community members, Nour says: "You can say to a patient, 'This is what's happened to you, and you feel pain. Do you really want this to happen to your daughter?' "

Non-governmental organizations should take an indirect approach to avoid making people feel patronized or pressured. "You can't just say, 'We're here to talk to you about female circumcision. We're here to stop it,' '' Nour says. "Better to say, 'Let's talk about how to be healthy, let's talk about women's needs for mammography and birth control and also, by the way, female circumcision is an issue. How do you feel about it? Here are the complications it can cause.' "

Nour is particularly enthusiastic about a nonprofit Senegalese group called Tostan, whose members lead year-long education programs on literacy, health, and human rights issues, including female circumcision. According to the group, more than a thousand villages have voluntarily agreed to eliminate the practice.

"I want to collaborate with organizations that are already doing great work,'' says Nour. "My role is to find ways of influencing people, be they leaders or health providers or the women themselves."

Karen Rafinski is a freelance medical and science writer based in Cambridge, Mass. She is a former Knight Science Journalism Fellow and reporter for the Miami Herald.

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