Nazia Mirza was eight years old when she was taken to a makeshift medical clinic in Houston to have her genitals cut, she says. Mirza, now 36, has a punctured memory of the day. She recalls sitting with her mother and sister inside a car that took her to a private residence. Inside, she said she waited with a cluster of girls who looked to be around her age as she heard muffled screams coming from inside an adjoining room. When Mirza asked about the sounds, she remembers her mother told her not to worry. It was “just something that girls do.”

Female genital mutilation was criminalized in the U.S. in 1996, and in 2013, the Obama administration outlawed taking a girl overseas for the procedure. But until these arrests in Michigan, the law had never been tested, and its enforcement was minimal.

For most of her life, Mirza had kept quiet. FGM is seldom talked about in the U.S., where it has long been considered an almost entirely foreign practice. But in June 2017, months after two Detroit-area doctors and an office manager were charged with performing FGM on up to nine girls, Mirza spoke out publicly for the first time. “I knew that nobody, not many people at all, are going to speak out about this,” she told VICE recently.

“It was really painful. I was like, ‘What is going on? What is this?’”

It was not until years later that Mirza recognized what she had experienced as female genital mutilation (referred to more colloquially as “genital cutting”), a ritual practice known as “FGM” that hails from various countries in Asia, Africa, and the Middle East. The United Nations and the World Health Organization consider FGM a human rights violation, defined as “all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.” Depending on the severity of the procedure, it can have serious health consequences, sometimes causing life-long pain.

“It was really quick,” she says, speaking rapidly with a slight Texan twang. “It was really painful. I was like, ‘What is going on? What is this?’” At the time, Mirza was not yet menstruating, but she was instructed to wear a pad out of the clinic, she says. While the soreness and confusion of the next few days remain a blur, Mirza lives with the resulting scar to this day. For much of her life, she says, it left her embarrassed, confused, and afraid of sexual contact.

Soon after, Mirza entered the room, which had a narrow bed covered with a plastic sheet, she says, “like what you would see inside a doctor’s office.” As she laid down, she says two older women on either side of her held down her arms and legs while another woman removed her underwear. After that, she remembers screaming as one of the women made an incision on her clitoris, using nothing to numb the pain.

In a surprising turn, the case was then revived this year in May, after the House of Representatives announced that it would ask an appeals court to reconsider Friedman’s decision. “The Trump Administration’s sudden refusal to…defend a long-standing federal statute criminalizing this horrific act disrespects the health and futures of vulnerable women and girls,” House Speaker Nancy Pelosi said in a statement in May.

Citing that case, Friedman ruled that Congress had “overstepped its bounds” by regulating FGM. On his advisement, the FGM charges against Nagarwala, the Attars, and five others involved were dropped. Five months later, the Justice Department announced that it would not appeal Friedman’s ruling, as it had originally said it would.

“Once again, the House is called upon to defend the constitutionality of a duly enacted law and to protect people’s lives.”

At the time, an FGM conviction carried up to a five-year prison sentence in the U.S. In November 2018, however, Judge Bernard Friedman, a Reagan-appointed district judge in Michigan, ruled that as the law was written, it was unconstitutional. In the 1990’s, Congress had sometimes leaned liberally and categorized certain activities as “interstate commerce” in order to count them among federal crimes. That was the case for the law prohibiting FGM. Years later, the Supreme Court started to curb the government’s ability to draft such laws, as it did in 2000 when it ruled that violence against women was not an economic activity.

Nine days earlier, Nagarwala, a Washington, D.C.-born emergency physician, was stopped as she boarded a flight to Kenya. She would spend almost seven months in jail, post a $4.5 million unsecured bond (believed to be the largest in Detroit’s history), and live under house arrest for 14 months. Four mothers who allegedly brought their daughters to Nagarwala for the procedure were also charged with violating the FGM law. All of the defendants, like Mirza, belonged to the Dawoodi Bohra community, a small Shiite Muslim sect whose traditional home is in western India.

There, outside of Burhani Medical Clinic, a one-story office on an otherwise unremarkable stretch of suburbia, the FBI secretly planted a camera after receiving a tip that something was amiss, according to court documents. On April 21, 2017, agents stormed Burhani Medical Clinic and arrested Dr. Fakhruddin and Farida Attar, a husband and wife in their early fifties who were the clinic’s owner and office manager. The couple was charged with helping Jumana Nagarwala, a Detroit-area doctor who allegedly performed FGM on up to nine girls over a three-year period. Two of the procedures took place in the couple’s clinic, prosecutors said.

Secrecy around genital mutilation in America means that there is little data about the practice, and even fewer related arrests. That made it all the more surprising when the first FGM case of its kind sprouted from the small Michigan city of Livonia, a tidy commuter town with the city motto “families first.” Just 97,000 people live there, 91 percent of them white.

Caught in a political tug of war, for the community involved, the case has resurrected some controversial questions: Is a blanket ban on FGM in the U.S. the best way to end a practice quietly enacted by mothers against their own children? Like male circumcision, should a version of FGM fall under religious freedom? And would a regulated, medicalized form of the practice actually be harmless?

Like other FGM survivors, Mirza said she was glad the Michigan case brought awareness to the fact that genital mutilation does happen in the U.S. In the end, though, the ruling was not in their favor. In November 2018, a federal judge struck down the FGM ban for a reason that had virtually nothing to do with the case. His move launched it into an ongoing constitutional battle between the House of Representatives and the Trump administration.

In 2017, a study published by Sahiyo, an anti-FGM advocacy group in the U.S., found that 80 percent of the nearly 400 Bohra women surveyed around the world had experienced genital cutting. A similar study from 2015 conducted by WeSpeakOut, a Bohra anti-FGM organization in India, said 75 percent of its participants had reported that their daughters, aged seven or below, had had their genitals cut. Asked whether they wanted female genital cutting to continue, over 80 percent of those surveyed by Sahiyo said they did not.

Worldwide, a 2016 U.N. report estimated that at least 200 million women and girls have undergone genital mutilation. The Dawoodi Bohras, thought to number between 1 and 2 million people, are just one of many ethnic and religious groups who perform FGM rituals. Today, they live in 450 communities spread across some 40 countries, according to Jonah Blank, author of Mullahs on the Mainframe: Islam and Modernity Among the Daudi Bohras.

The escalation, researchers said, was “wholly a result” of increased immigration (not a spike in the practice) from countries where FGM is practiced. In 2012, women and girls from three countries alone—Egypt, Somalia, and Ethiopia—accounted for half of all potential victims in the U.S.

While it’s unclear how many women and girls in the U.S. have experienced female genital mutilation, the Centers for Disease Control and Prevention estimated in 2016 that around 560,000 females had undergone or were at-risk of FGM, either in the U.S. or before arriving. That number is three times the estimated figure in 1990. (Though “at risk” is an expansive term, describing all women and girls who are from, or who have at least one parent from, a country where FGM is practiced).

“Once again, the House is called upon to defend the constitutionality of a duly enacted law and to protect people’s lives.”

Muhammad, a 32-year-old software engineer in San Francisco whose name has been changed to protect his identity, said that the Michigan case had inflamed doubts he had about the practice after becoming a parent. A practicing Bohra from the port city of Surat in Gujarat, India, Muhammad is married to a Bohra woman and is the father of a two-and-a-half-year-old daughter.

Outside the clergy, a significant number of Bohras reject this position, Blank added, as do clergy in most other Muslim communities. In many Islamic countries, the practice continues as more of a cultural rite than a religious one, scholars say. In the U.S., it’s difficult to say how important FGM remains to immigrants and first or second-generation Americans within the Bohra community and beyond.

“My religious authorities said [_khatna_] is a good thing to do [for] health and spirituality. If it was good, why are we taking girls into a very dark room and doing it in this fashion?”

Some Bohras, like Samina Kanchwala, from the Mumbai-based group Dawoodi Bohra Women for Religious Freedom, view this interpretation as an example of the faith’s commitment to gender equality. “Ours is the only community that talks about [the] practices in one breath and has no gender bias at all,” Kanchwala told me. The group advocates for the right to practice female genital cutting in India, where no law against the practice exists but women’s rights groups have long fought for it to be outlawed.

According to Blank, the position of the Bohra clergy is that, since the time of the prophet, FGM, known as khatna, has been practiced on women. Whenever circumcision is referred to in the Quran and the hadiths (the collection of the prophet’s sayings), he said, the clergy says it applies to both genders. For both boys and girls, Bohras claim khatna is performed for health and cleanliness reasons, although the World Health Organization maintains that there are no health benefits from any form of female genital cutting. On boys, khatna is similar to the common, medicalized procedure of circumcision practiced by Jews.

Presented with the question of consent, Samina Kanchwala from the Dawoodi Bohra Women for Religious Freedom argued that, just as with male circumcision, the decision to cut a girl child should fall within a parent’s rights. By caring for a child, a parent makes decisions that have lasting impacts on a person’s life, she said, and female genital cutting is just one of these choices. “Parents are responsible for the physical, emotional, and spiritual growth of [a] child,” she said, adding that while male circumcision is widely accepted, there is no medical consensus on its benefits to health.

Muhammad moved to the U. S. in 2014. He is in the country on an H-1B guest worker visa, a program increasingly in flux as the Trump administration modifies it. If his visa is not renewed in the future, he and his family would likely return to India, he said, where he would defer to tradition. “If we go back to India, the only best thing I can do is make sure that my daughter goes to a hospital and they use local anesthesia,” he said. If he stays in the U.S., he said he would let his daughter decide for herself when she turns 18.

“We are taught in Gujarat that many things in life you do for your religious authorities,” he said. “My religious authorities said [ _khatna_] is a good thing to do [for] health and spirituality. If it was good, why are we taking girls into a very dark room and doing it in this fashion?”

To Mirza, these arguments are familiar, having grown up in the Bohra community, but she harbors little sympathy for them. Similarly, human rights groups around the world, including the World Health Organization, deem FGM a violation of the rights of children.

Mirza, who left the Bohra community after high school, said she wishes her mother and other women in favor of the practice considered the consequences of cutting a young girl in the name of tradition.

“I do wish [they] would really think, ‘How could something like this be ok?’” she said.

In April 2017, Nagarwala’s attorney, Shannon Smith, said that her client admitted to scraping “a sesame-seed amount of mucous membrane” from the clitoral hoods of the two victims cited in the criminal complaint. She argued, though, that the “ritual nick” was a “protected religious procedure” and that what her client performed did not meet the definition of genital mutilation.

The unverified argument falls in line with a contentious debate over what even qualifies as FGM and whether sanctioning the least harmful versions of the procedure (including what’s known as the “ritual nick”) could actually protect girls at-risk of FGM from more invasive cutting in countries where the practice is illegal.

Studies by anti-FGM groups and anecdotal information from Bohra women who have detailed their experiences suggest there is little uniformity in how girls are cut. The W.H.O. broadly categorizes four types of FGM, which describe a sweeping range of procedures performed on female genitalia: clitoridectomy (removing some or all of the clitoris), excision (cutting and/or removing the clitoris and inner vaginal lips), infibulation (sealing the vagina by cutting the clitoris, inner and outer vaginal lips and sewing them together), as well as any other alteration to the genital area for non-medical reasons. That includes a pinprick or “ritual nick” of the clitoris that does not remove skin or tissue.

“Mothers will find a way to cut their daughter.”

Like the many types of FGM, health complications from these procedures vary, based on severity and factors such as what tools are used and where the procedure takes place. Immediately after a girl is cut, short-term health risks include severe pain, bleeding, genital tissue swelling, and infections. According to the WHO, women and girls who experience more severe forms of genital cutting, like clitoridectomy, excision, or infibulation, can suffer from chronic genital infections, painful or irregular menses, excessive scar tissue, pain during sex, complications during childbirth and even death. Anxiety, PTSD, and depression are also common.

Kanchwala and a handful of other Bohras I spoke with in support of khatna claim the practice bears no resemblance to the WHO’s definition of FGM. The WHO and rights groups insist, however, that even a pinprick counts. Among Bohras (both in support of and against khatna), other practicing communities, and U.S. medical professionals, the lack of uniformity in the way women are cut has been used to justify both the complete ban on all genital cutting practices as well as the medicalization of less severe procedures.

In 1996, a group of Somali mothers living in Seattle approached doctors at Harborview Medical Center, a public hospital long known for its cultural sensitivity with patients. The women repeatedly asked that doctors at the hospital "circumcise" their daughters. The doctors said they considered offering a less invasive form of the procedure as an alternative to other often-brutal forms of genital cutting, such as infibulation, which is prevalent in Somalia, where 98 percent of women are still cut.