CAIRO (AP) — She remembers it all: How female relatives held her down when she was 11, legs spread and genitals exposed. The fear that stiffened her body. The stranger in black holding the scissors. And the pain.

Like so many others, the 34-year-old Egyptian woman has lived with the psychological and physical repercussions of that day, when she was subjected to a practice many activists call “mutilation.”

For N.S., who asked to be identified only by her initials to discuss the sensitive topic, the trauma continuing into adulthood was accompanied by a desire to reclaim control over her health and body.

“I had a feeling of being incomplete and that I will never feel happy because of this,” she said. “It’s a horrible feeling.”

A global target aims to eradicate the deeply entrenched practice by 2030, and protect the next generations of girls, though campaigners acknowledge the difficulties in achieving that. The United Nations has designated an International Day of Zero Tolerance for Female Genital Mutilation, or FGM, observed every Feb. 6.

Meanwhile, some women living with the consequences have embarked on deeply personal journeys to heal. They search for answers, sometimes scouring the Internet, amid treatment gaps in many countries, or shame and possible related sexual complications.

Prevalent in parts of Africa, the Middle East and Asia, cutting has been performed in communities of different cultures and faiths. It can be viewed as a rite of passage or linked to beliefs about chastity or femininity and cleanliness, and be fueled from generation-to-generation by social pressure.

“It’s an entrenched social norm and really deeply rooted in cultural beliefs and sometimes in religious beliefs,” said Nafissatou Diop, an official with the United Nations Population Fund. “So to be able to make any change, people need to be convinced that this is not threatening their culture.”

It’s estimated that at least 200 million women and girls are living with the aftermath of the practice, which can include partial or total removal of their external female genitalia and can cause excessive bleeding and even death. Long term, it can lead to urinary tract infections, menstrual problems, pain, decreased sexual satisfaction and childbirth complications, as well as depression, low self-esteem and post-traumatic stress disorder.

Some faith leaders have worked to eliminate the practice, while others condone it. In Egypt, where genital cutting has been widespread but illegal since 2008, top Islamic authorities condemn the practice. In online edicts or television appearances, they cite medical evidence of its harms and say it’s a custom with no sound religious basis. Still, there’s opposition to the bans in Egypt and elsewhere.

Besides resistance from some religious leaders and other “traditional gatekeepers,” Diop said the campaign to change minds is hindered by limited funding, lack of political will from some governments and a perception that ending cutting reflects a “Western-led agenda.”

Meanwhile, some women suffering the aftereffects post anonymously online in the quest for healing. They express feelings of distress, discomfort in their own skin, embarrassment or fears that being cut could stop them from getting married or condemn their marriages to failure. Some want information on medical procedures.

Some considering medical interventions have found specialized treatment, including in the United States and Europe, where opposition to the practice is longstanding. But in many countries, options can be scarce or too costly.

“There are so many treatment gaps in a lot of countries where FGM is really widely practiced,” said Christina Pallitto, a scientist leading the work on FGM at the World Health Organization. “A lot of health care providers receive no training at all.”

N.S. turned to a private clinic in Egypt, Restore FGM, that opened in 2020 and has promoted treatments on Instagram and other social media.

Dr. Reham Awwad, a plastic surgeon and clinic co-founder, said many patients’ initial visits are emotional. “One of the first things they’ll say is, ‘I’ve never spoken about this to anybody,'” she said.

The clinic, which also attracts clients from Sudan and elsewhere, offers surgical and non-surgical therapies. Psychological therapy is recommended, but many don’t pursue it, Awwad said.

N.S. has struggled with anger at her parents and low self-confidence. She’s wrestled with sensitive questions: Will sex hurt? Will cutting lead to sexual problems in a marriage? What about pregnancy and childbirth? She struggled with pain and difficulty reaching orgasm.

At Restore FGM, she opted for “reconstruction” surgery to remove scar tissue, expose uncut parts of the clitoris and make that more accessible. But some experts view the procedure with caution.

Surgeons who back it say it can improve function and appearance, and reduce pain. Others, including the WHO, call for more research and say there isn’t adequate evidence to assess benefits, possible complications or long-term outcomes.

“We don’t have a recommendation in favor of that at this moment because of the lack of evidence on the safety and the efficacy,” said WHO’s Pallitto. “Any woman who has clitoral reconstruction should be offered sexual health counseling in conjunction with it.” Neither the procedure nor such counseling is widely available in high prevalence countries, she added.

It’s been more than a year since N.S. underwent the surgery. After treatment for post-surgery bruising, she’s feeling better. “I no longer feel pain,” she said. “Sensation has also improved a lot.”

But her journey isn’t over. “I still need to work on accepting myself, accepting that this has happened to me and that it has been treated,” she said. “The operation on its own is not enough. … I don’t feel like I am completely over the trauma and I still struggle with the idea of physical touch.”

She wants to pursue psychological therapy but says she can’t afford it and worries about finding someone she can trust with such intimate details.

Basma Kamel recalled bleeding badly days after getting cut — at the hands of a doctor — when she was 9. For a long time, the 30-year-old Egyptian couldn’t trust her mother. Eventually, she concluded her mother didn’t know better and didn’t mean to hurt her. But feelings of being “different” lingered.

After moving from Egypt to England, she started looking for answers and turned to an FGM clinic and charity group for talk therapy. She’s made progress, but her self-acceptance work is ongoing.

“The goal is to find peace with myself and accept my body and accept that I am a normal person,” she said. “Even if I have, like, a missing part from my body, I’m still a normal woman.”

Dr. Jasmine Abdulcadir, a gynecologist at Geneva University Hospitals, treats women, mostly from East and West Africa, who underwent genital cutting.

The women have options for medical intervention, including a procedure to re-open a narrowed vaginal opening to help with everything from urination and menstruation to natural childbirth.

Clitoral reconstruction surgery also is an option. Abdulcadir said the procedure for that includes meeting with a psychologist, who is also a trauma-trained sex therapist, and making sure patients are prepared if the surgery ends up being mentally triggering.

She said some patients said they felt “born again” post-surgery, which she attributes to her practice’s holistic approach.

“What is very important is that you are not just focusing on the clitoris,” Abdulcadir said. “It’s really the health of the person.”

N.S. has yet to tell her family about her surgery. One day she might; she especially wants to tell her sister who was cut the same day she was.

But she does speak up when she can.

She threatened to call the police on learning some relatives were considering genital cutting for their daughters even though the practice is outlawed in Egypt.

“I didn’t want anyone else to be tormented like I was,” she said. “Someone must put their foot down and say: ‘Enough.'”

___

Deepti Hajela in New York contributed.

___

Associated Press religion coverage receives support through the AP’s collaboration with The Conversation US, with funding from Lilly Endowment Inc. The AP is solely responsible for this content.

Copyright © The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Follow @ktar923