Involuntary Sterilization Among HIV-positive Garifuna Women from Honduras Seeking Asylum in the United States: Two Case Reports

Voluntary sterilization is one of the most widely used forms of contraception by women worldwide; however, involuntary sterilization is considered a violation of multiple human rights and grounds for asylum in the United States. Women have been disproportionately affected by this practice. We report two cases of involuntary sterilization in HIV-positive Garifuna women from Honduras who sought asylum in America and were medically evaluated at the request of their attorneys. Key lessons can be drawn from these cases with regard to the importance of medical evaluations in establishing persecution. These include the need for a detailed account of the events surrounding sterilization, radiologic proof of tubal blockage if at all possible, and confirmation of significant and enduring mental distress as a result of the involuntary sterilization. Immigration attorneys and medical evaluators need to be attuned to the possibility of a history of involuntary sterilization among at risk women seeking asylum in the United States

Depression, Anxiety, Post-traumatic Stress Disorder and a History of Pervasive Gender-Based Violence Among Women Asylum Seekers Who Have Undergone Female Genital Mutilation/Cutting: A Retrospective Case Review

We sought to evaluate the frequency of anxiety, depression, PTSD, and any experiences of violence in women who had undergone Female Genital Mutilation/Cutting (FGM/C) and were seeking asylum in the United States. We undertook a retrospective qualitative descriptive study of FGM/C cases seen in an asylum clinic over a 2-year period. Standardized questionnaires provided quantitative scores for anxiety, depression and PTSD. Clients’ personal and physician medical affidavits were analyzed for experiences of violence. Of the 13 cases, anxiety and depression were exhibited by 92 and 100% of women, while all seven women screened for PTSD had symptoms. Qualitative analysis revealed extensive violence perpetrated against these women, demonstrating that FGM/C is only part of the trauma experienced. The high level of mental health disorders and endured violence has implications for providers working with FGM/C survivors and indicates the need for accessible mental health services and trauma-informed care

Public Health Research Priorities to Address Female Genital Mutilation or Cutting in the United States

Female genital mutilation or cut- ting (FGM/C), an age-old tradition that is still widely practiced around the world, is gaining recognition as an important public health issue in the United States. Increasingly, because of migration, women and girls affected by FGM/C have become members of host communities where the practice is not culturally acceptable. According to recent conservative estimates, more than 513 000 immigrant women and girls living in the United States have undergone or are at risk for FGM/C, a significant increase from the 1990 estimate of 168 000. The arrests of physicians in Michigan in 2017 for performing FGM/C on minors underscores the fact that cutting is happening in the United States. We have identified numerous gaps in our understanding of the magnitude of the problem in the United States and in the avail- ability of scientific data informing a variety of interventions (preventive, clinical, educational, le- gal). We catalog these major gaps and propose a research agenda that can help public health experts, researchers, clinicians, and other stakeholders to establish priorities as we confront FGM/C as an important health issue affecting hundreds of thousands of women and girls in the United States

Impact of Forensic Medical Evaluations on Immigration Relief Grant Rates and Correlates of Outcomes in the United States.

The purpose of this study was to investigate the impact of forensic medical evaluations on grant rates for applicants seeking immigration relief in the United States (U.S.) and to identify significant correlates of grant success. We conducted a retrospective analysis of 2584 cases initiated by Physicians for Human Rights between 2008-2018 that included forensic medical evaluations, and found that 81.6% of applicants for various forms of immigration relief were granted relief, as compared to the national asylum grant rate of 42.4%. Among the study’s cohort, the majority (73.7%) of positive outcomes were grants of asylum. A multivariable regression analysis revealed that age, continent of origin, history of sexual or gender-based violence, gang violence, LGB sexual orientation, and being detained by the U.S. government at the time of evaluation request were statistically associated with case outcomes. Forensic physical evaluation was more strongly associated with a positive outcome than forensic psychological evaluation. Our findings strengthen and expand prior evidence that forensic medical evaluations can have a substantial positive impact on an applicant’s immigration relief claim. Given the growing applicant pool in the U.S., there is an urgent need for more trained clinicians to conduct forensic medical evaluations as well as to educate adjudicators, immigration lawyers, and policy makers about the nature of the life-altering events that applicants for immigration relief experience

FGM/C Complications

Chapter sections: 6.1. Acute 6.2. Long Term 6.3. Acute and Long Term 6.4. Surgical Treatments of Complications of FGM/C 6.5. Defibulation Reference </p

Pictures Without FGM/C

This chapter will help the physician: - To make a vulvar examination (Figs. 3.1 and 3.2) - To provide a referential for surgeons undertaking procedures (Figs. 3.3, 3.4, and 3.5) - To recognize anatomical variations (Figs. 3.6, 3.7, 3.8, 3.9, 3.10, and 3.11). - To identify “ambiguous” genitals or mucocolpos (Figs. 3.12 and 3.13) - To identify dermatological conditions (Figs. 3.14, 3.15, 3.16, 3.17, 3.18, 3.19, and 3.20) - To identify urethral lesions (Figs. 3.21 and 3.22) - To identify genital trauma (Fig. 3.1 of chapter “Pictures with Potential Differential Diagnosis of FGM/C”) - To make differential diagnosis of FGM/C (Figs. 3.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9, 3.10, 3.11 of chapter “Pictures with Potential Differential Diagnosis of FGM/C”, and Fig. 3.1 of chapter “Pictures with FGM/C”)</p

Pictures with FGM/C

Chapter Sections: 5.1. FGM/C Type I 5.2. FGM/C Type II 5.3. FGM/C Type III 5.4. FGM/C Type IV References </p

Assessing the Infant/Child/Young Person with Suspected FGM/C

Femawle Genital Mutilation/Cutting (FGM/C) comprises all procedures that involve partial or total removal of the external female genitalia or injury to the female genital organs that are medically unnecessary (i.e. performed primarily for cultural or religious reasons), especially when done without the consent of the affected person. Such procedures are usually carried out in infancy or childhood and, most often before the age of 15. Although some pictorial and training tools are available, existing literature focuses primarily on adults. The signs of FGM/C particularly in prepubertal girls, can be subtle and depend on the type as well as on the experience of the examiner. The health care provider (HCP) should be trained to be familiar with, and able to identify a wide range of both modified and unmodified genitalia, as well as findings that may superficially look like FGM/C but actually reflect the normal range of genital anatomy. Knowledge of FGM/C types and subtypes, as well as complications and differential diagnoses of physical findings, are critical. We present a reference guide and atlas containing iconographic material of both the pre- and post-pubertal external female genital area with and without genital cutting/alteration. Our purpose is to facilitate training of health care professionals in making accurate diagnoses, providing appropriate clinical management, ensuring culturally informed/sensitive patient–provider communication, and accurate recording and reporting to child welfare/law enforcement agencies, where required. Chapter sections: 1.1. How Does the Child First Present? 1.2. Clinical Setting 1.3. Taking the History 1.4. The Examination 1.5. When FGM/C Is Confirmed 1.6. When FGM/C Is Not Identified 1.7. Conclusion References </p