When Marie was two years old, a woman in her village in Africa cut off her clitoris and labia. Now 34 and living thousands of miles away in New York, she is still suffering.
“I have so many problems, with my husband, with sex, with childbirth,” she told NBC News, withholding her real name to protect her identity. “The consequences on my life are all negative, both physically and psychologically."
The practice of Female Genital Mutilation is common across much of Africa, where it is believed to ensure sexual purity before marriage. But Marie says FGM is also “very common” in some communities in America.
“The pressure to get daughters cut is great,” she said.
According to the Centers for Disease Control and Prevention, at least 150,000 to 200,000 girls in the U.S. are at risk of being forced to undergo cutting. The CDC says “at risk” because there are no actual records of the practice, only estimates – and old estimates at that. Its latest data date to 1997, the year after it was banned in the U.S.
But citing anecdotal evidence from health professionals and frontline workers, experts who work with victims and their communities say FGM is on the rise.
"It is hard to believe this is the real number because of how much [FGM-practicing] communities are growing, especially in the last two or three years," said Mariama Diallo, African community specialist at Sanctuary for Families, a New York-based non-profit dedicated to helping domestic violence and trafficking victims. Her organization could only extrapolate using census data when it issued a report on the growing problem last year.
Immigration to the U.S. from countries in Africa quadrupled between 1990 and 2011 from 360,000 to 1.6 million according to a recent report released by New York City’s planning department.
“The numbers need to be updated – but this needs funding and no one is interested,” said Dr. Nawal Nour, founder of the African Women’s Health Practice at Boston’s Brigham and Women’s Hospital.
Lack of Prosecutions
There are different degrees of FGM, the most severe form being the narrowing of the vaginal opening by repositioning the labia and stitching up the opening, sometimes leaving a hole the size of a matchstick for the passing of urine and menstrual flow.
The cutting is often carried out without anesthetic on girls between infancy and the age of eight. Victims can suffer numerous physical and mental health problems: severe abdominal pain, vaginal and pelvic infections, pain during sex, complications during childbirth.
In Phoenix, Arizona, a staggering 98 percent of Somali women being treated at the Refugee Women’s Health Clinic have been circumcised, founder Dr. Crista Johnson said. She estimates the Somali community is at least 12,000-strong.
Johnson has supported such victims all over the country – from Washington,D.C., to Michigan to California – and says the spike in immigration from such communities has been astonishing in recent years.
“The number has easily quadrupled because of migration patterns,” she added.
So with such numbers, why has there only been one successful prosecution in the U.S.?
“People won't report against their families,” Marie said. Since the mutilation is usually organized by the child’s mother or grandmother and supported by the father, many cases go unreported, case workers say.
“Even if there is protection from the government, it is difficult for a victim to disclose it through fear of retaliation from their family, and fear of losing their family,” she said.
Still, experts believe the law is a useful deterrent. Johnson says there is a sense of resignation among the families that they must abide by U.S. laws. Nour agreed, saying: “Parents are afraid to do anything that will get them deported.”
For Americans on the outside of communities where it is practiced, FGM is such an unknown that many medical workers, law enforcement and child protection officers are not informed on how to proceed when confronted with it.
“This has been such a taboo topic, we [haven’t been able to] take it out from under the table. We need to make it something that can be discussed,” said Shelby Quast, senior policy adviser of Equality Now, an international women’s rights NGO.
“There has to be a huge shift so that we identify this as a form of violence against girls – and not something that's protected as a cultural and religious tradition,” she said.
Support for victims is also comparatively poor in the U.S., health workers say. Nour in Boston and Johnson in Arizona run the only two clinics dedicated to supporting FGM victims in the U.S.
Comparatively the U.K. – with only a fifth of the population of the U.S. – has 15 specialist clinics. British midwife Comfort Momoh, who runs one such operation, recently visited the U.S. to research American facilities.
Coming from Europe, where campaigners are making strides in turning FGM into a mainstream issue, Momoh was shocked to see “no proper coordination and hardly anywhere for girls to go for support,” she said. “The situation is well, well behind the U.K.”
Campaigners say reaching out to practicing communities and educating them about the risks and consequences is critical to ending FGM.
"If the police are called and told a child is at risk, what will the policeman do if he does not know what FGM is? We need to tell them about it, tell them it's a violation,” Diallo said. "Every single professional needs to know they have an obligation: doctors, nurses, school teachers.... Everyone has to see it as their responsibility to protect children."
'Shame and a Prison Term'
In France, which is also home to significant communities which traditionally practice FGM, experts say enforcing the law and outreach to practicing communities must go together.
In stark comparison to the single American case, there have been over 100 successful prosecutions in France, with prison sentences for those found guilty of cutting or of allowing their daughters to be cut.
There, FGM is prosecuted using existing child protection laws – there is no specific anti-FGM legislation.
“There was no need for a special law that would amount to pointing the finger towards immigrants,” said French lawyer Linda Weil-Curiel, who has spent years bringing cases against suspected perpetrators to court.
“We had enough legal provisions in the penal code to prosecute and punish the 'mutilation of minors,' and the penal code is applicable to everyone on French soil, without discrimination.”
She believes these prosecutions helped reduce the practice. “The large publicity in the media of the trials sent a clear message to the families: This is what you are going to get – shame and a prison term – if you do not respect the law.”
There are no further prosecutions on the horizon in America – although there has been some progress.
Legislation was strengthened in January 2013 with a federal law making “vacation cutting” illegal – when girls are taken during their school vacations to countries where FGM is widely practiced to be cut there.
"They have passed the law. Now they need to enforce it," Diallo said.
But for Marie it's too late. "My organs were removed for my whole life, I can't change it; psychologically that is very difficult," she said. "But I don't want my kids to undergo the same fate as me."
Petra Cahill and Jamieson Lesko of NBC News contributed to this report.