F.A. Cole was 11 when her stepmother told her to dress up for a special occasion near her hometown of Freetown, Sierra Leone.
It was, instead, a traumatic occasion, Cole recalls 34 years later. Her stepmother turned her over to a small group of women, who led her into a forest and bound and blindfolded her. Then someone put a razor blade to her genitals.
"Two or four of the women held me down. They spread my legs open and pinned me down, and then the woman who was the cutter, she sat on my chest," Cole recounts. "As she began to cut my clitoris, I began to fight and scream and wriggle under her, just looking for somebody to help me, somebody to come to my rescue."
No one came then. But the United Nations has been working to eradicate female genital mutilation. To raise awareness, the U.N. since 2003 has sponsored an International Day of Zero Tolerance for FGM to raise awareness. The annual observance was on Wednesday.
FGM has sparked a global clash between those who define it as a cultural tradition and those who say it's a dangerous ritual that should end. In Africa, the procedure is illegal in 22 countries but widespread nonetheless. In the United States, a federal ban on FGM was overturned in November, but it still is prohibited by state laws in nearly 50 percent of the country.
WATCH: Zero Tolerance for Female Genital Mutilation
Cole recalls days of excruciating pain and years of wondering why she was cut.
"When I came to America and I started doing research, and I started talking about my story, that's when I realized the damage — not just the sexual damage, but the psychological damage that was done," says Cole, who now lives in Washington and campaigns to end FGM.
The World Health Organizationidentifies three types of FGM most common in Africa. In type one, the clitoris is partially or totally removed. Type two goes further, including the labia. And type three involves removing the labia and stitching to narrow the vaginal opening.
The cultural practice can have serious medical consequences. Physicians at major U.S. medical centers and teaching hospitals worry whether American doctors are equipped — medically and culturally — to treat women who have been circumcised.
Dr.Ranit Mishori, a professor of family medicine at Georgetown University School of Medicine in Washington, recalls an experience in the second month of her residency. A woman from Djibouti, in East Africa, was in labor.
"I was getting ready to do a pelvic examination, and I put my gloves on and suddenly I realize I can't put my fingers in there because the whole area is closed off," Mishori said of the patient's vagina. "I had no idea what that meant. I called my senior physicians and they had no idea what was going on. The bottom line is a lot of doctors don't know what to expect, don't know how to handle these types of emergencies."
A call for communication and respect
That experience inspired Mishor to teach other doctors about FGM, especially as they treat more immigrants from Africa, Asia and the Middle East.
She stresses communication and cultural humility.
"We can't forget that some women are very proud [of being circumcised], because that ensures their marriageability and economic prospects," Mishori says, adding that medical personnel must learn "to ask about it in a nonjudgmental way."
Respectful questioning, she says, is "more important than how to deal with the medical complications, even though they are there. In some women, the cutting has healed. There are no scars, maybe … but the long-term effects are here and here," she adds, pointing first to her head, then her heart.
Not everyone agrees the practice should be banned.
Anthropologist Fuambai Ahmadu, who lives in Washington and also is from Sierra Leone, says she was circumcised, not mutilated. She was an adult when she chose to undergo the procedure — the most minimal type of circumcision.
Ahmadu was prepared to testify on behalf of Dr. Jumana Nagarwala, who was among eight people facing federal charges over the genital mutilations of nine girls from Michigan, Illinois and Minnesota. As the Associated Press reported, U.S. District Judge Bernard Friedman in November dismissed mutilation and conspiracy charges against the defendants, saying the 1996 law banning the practice was unconstitutional.
A rite of passage
Ahmadu says circumcision is a rite of passage into womanhood in Kono culture. She believes anti-FGM campaigners are putting African cultures under siege.
"The grand narrative of mutilation is completely inappropriate," says Ahmadu. "… It's really important that FGM campaigners understand that the messages that they're sounding out to women, they're not working, they're not effective," she says. "What they're doing is driving the practice underground."
She says some families are reacting to the pressure by bringing in their daughters for circumcision at younger ages — sometimes even as babies. She advocates that girls should have a choice in whether to undergo the procedure and that they should wait until at least age 16 to understand the cultural significance.
"This is a coming-out ceremony, where they are celebrated and they are now women," Ahmadu says.
It was no celebration for Cole, who says her circumcision made her less desirable to men in Sierra Leone.
"It was supposed to make me more marriageable, but I'm 45 and still single," she says. "So what was that?"
This report originated in VOA's English to Africa service.