Towards the elimination of FGM by 2030: A statistical assessment.

In 2015, UN member states committed to eliminate female genital mutilation (FGM) by 2030 as part of the Sustainable Development Agenda. To reach this goal, interventions need to be targeted and guided by the best available evidence. To date, however, estimates of the number of girls and women affected by FGM and their trends over time and geographic space have been limited by the availability, specificity and quality of population-level data. We present new estimates based on all publicly available nationally representative surveys collected since the 1990s that contain both information on FGM status and on the age at which FGM occurred. Using survival analysis, we generate estimates of FGM risk by single year of age for all countries with available data, and for rural and urban areas separately. The likelihood of experiencing FGM has decreased at the global level, but progress has been starkly uneven between countries. The available data indicate no progress in reducing FGM risk in Gambia, Guinea-Bissau, Mali and Guinea. In addition, rural and urban areas have diverged over the last two decades, with FGM declining more rapidly in urban areas. We describe limitations in the availability and quality of data on FGM occurrence and age-at-FGM. Based on current trends, the SDG goal of eliminating FGM by 2030 is out of reach, and the pace at which the practice is being abandoned would need to accelerate to eliminate FGM by 2030. The heterogeneity in trends between countries and rural vs urban areas offers an opportunity to contrast countries where FGM is in rapid decline and explore potential policy lessons and programmatic implications for countries where the practice of FGM appears to remain entrenched.

Female Genital Mutilation/Cutting in Mali and Mauritania: Understanding Trends and Evaluating Policies.

Despite international commitments to end female genital mutilation/cutting (FGM/C), very little is known about the effectiveness of national policies in contributing to the abandonment of this harmful practice. To help address this gap in knowledge, we apply a quasi-experimental research design to study two west African countries, Mali and Mauritania. These countries have marked similarities with respect to practices of FGM/C, but differing legal contexts. A law banning FGM/C was introduced in Mauritania in 2005; in Mali, there is no legal ban on FGM/C. We use nationally representative survey data to reconstruct trends in FGM/C prevalence in both countries, from 1997 to 2011, and then use a difference-in-difference method to evaluate the impact of the 2005 law in Mauritania. FGM/C prevalence in Mauritania began to decline slowly for girls born in the early 2000s, with the decline accelerating for girls born after 2005. However, a similar trend is observable in Mali, where no equivalent law has been passed. Additional statistical analysis confirms that the 2005 law did not have a significant impact on reducing FGM/C prevalence in Mauritania. These findings suggest that legal change alone is insufficient for behavioral change with regard to FGM/C. This study demonstrates how it is possible to evaluate national policies using readily available survey data in resource-poor settings.

Exploring barriers to seeking health care among Kenyan Somali women with female genital mutilation: a qualitative study.

BACKGROUND: Female genital mutilation/cutting (FGM/C) is a cultural practice associated with health consequences, women rights and deprivation of dignity. Despite FGM/C-related health consequences, circumcised women may encounter additional challenges while seeking interventions for reproductive health problems. Experiences of women/girls while accessing health services for reproductive health problems including FGM/C-related complications in poor, remote and hard to reach areas is poorly understood. We sought to explore barriers to care seeking among Somali women with complications related to FGM/C in public health facilities in Kenya. METHODS: We drew on qualitative data collected from purposively selected women aged 15-49 years living with FGM/C, their partners, community leaders, and health providers in Nairobi and Garissa Counties. Data were collected using in-depth interviews (n = 10), key informant interviews (n = 23) and 20 focus group discussions. Data were transcribed and analyzed thematically using NVivo version 12. RESULTS: Barriers were grouped into four thematic categories. Structural barriers to care-seeking, notably high cost of care, distance from health facilities, and lack of a referral system. Concerns regarding perceived quality of care also presented a barrier. Women questioned health professionals' and health facilities' capacity to offer culturally-sensitive FGM/C-specific care, plus ensuring confidentiality and privacy. Women faced socio-cultural barriers while seeking care particularly cultural taboos against discussing matters related to sexual health with male clinicians. Additionally, fear of legal sanctions given the anti-FGM/C law deterred women with FGM/C-related complications from seeking healthcare. CONCLUSION: Structural, socio-cultural, quality of service, and legal factors limit health seeking for reproductive health problems including FGM/C-related complications. Strengthening health system should consider integration of FGM/C-related interventions with existing maternal child health services for cost effectiveness, efficiency and quality care. The interventions should address health-related financial, physical and communication barriers, while ensuring culturally-sensitive and confidential care.

Debating medicalization of Female Genital Mutilation/Cutting (FGM/C): learning from (policy) experiences across countries.

BACKGROUND: Although Female Genital Mutilation/Cutting (FGM/C) is internationally considered a harmful practice, it is increasingly being medicalized allegedly to reduce its negative health effects, and is thus suggested as a harm reduction strategy in response to these perceived health risks. In many countries where FGM/C is traditionally practiced, the prevalence rates of medicalization are increasing, and in countries of migration, such as the United Kingdom, the United States of America or Sweden, court cases or the repeated issuing of statements in favor of presumed minimal forms of FGM/C to replace more invasive forms, has raised the debate between the medical harm reduction arguments and the human rights approach. MAIN BODY: The purpose of this paper is to discuss the arguments associated with the medicalization of FGM/C, a trend that could undermine the achievement of Sustainable Development Goal 5.3. The paper uses four country case studies, Egypt, Indonesia, Kenya and UK, to discuss the reasons for engaging in medicalized forms of FGM/C, or not, and explores the ongoing public discourse in those countries concerning harm reduction versus human rights, and the contradiction between medical ethics, national criminal justice systems and international conventions. The discussion is structured around four key hotly contested ethical dilemmas. Firstly, that the WHO definition of medicalized FGM/C is too narrow allowing medicalized FGM to be justified by many healthcare professionals as a form of harm reduction which contradicts the medical oath of do no harm. Secondly, that medicalized FGM/C is a human rights abuse with lifelong consequences, no matter who performs it. Thirdly, that health care professionals who perform medicalized FGM/C are sustaining cultural norms that they themselves support and are also gaining financially. Fourthly, the contradiction between protecting traditional cultural rights in legal constitutions versus human rights legislation, which criminalizes FGM/C. CONCLUSION: More research needs to be done in order to understand the complexities that are facilitating the medicalization of FGM/C as well as how policy strategies can be strengthened to have a greater de-medicalization impact. Tackling medicalization of FGM/C will accelerate the achievement of the Sustainable Development Goal of ending FGM by 2030.

Sexualised violence against children: a review of laws and policies in Kenya.

Child sexual abuse (CSA) is a major global health challenge. Extant literature shows that CSA is prevalent in Kenya. As a signatory of the United Nations Convention on the Rights of the Child and the African Charter on the Rights and Welfare of the Child, the Kenyan government is mandated to ensure that children are protected from sexual abuse through sound laws and policies. This paper reviews existing laws and policies on CSA and highlights their strengths and weaknesses. Our findings indicate that laws on child protection exist and are protective to a large extent, as harsh penalties are outlined for sexual offences. Survivors of CSA are entitled to free legal and medical services. However, there are no reparations offered to survivors in criminal proceedings. Moreover, there is no legislation on age-appropriate comprehensive sexuality education which plays an important role in cultivating positive gender norms and describing what constitutes CSA and reporting procedures. The national standard operating procedures for the management of sexual violence against children lack CSA screening procedures. There is urgent need for review of these laws and policies and development of multisectoral protocols at the national and county level, that outline roles and responsibilities for various service providers, supervisory and accountability measures and referral networks.

The Legal Framework for the Fight against Female Circumcision: From Cultural Indulgence to Human Rights Violations. The French Example.

The harmful consequences of female circumcision for women's health have been demonstrated and are regularly recalled by the World Health Organisation. Whereas in the past, the cultural dimension of the practice was emphasised, which result in impunity or absence of guilt, it is now considered by the United Nations as a violation of human rights, especially of the right to health. In 2012, the General Assembly asked States for a total ban on the practice. Despite the consensus on the punishability of female circumcision, its enforcement diverges, in particular in Western Europe. France is considered as a model in this area, that's why this study focuses on it. Yet, under French law, there is no special legislation criminalising the practice: female circumcision is punishable on grounds of mutilation. However, the French success is not complete: the prevention of such acts could be improved.

A qualitative assessment of women's perspectives and experience of female genital mutilation in Iraqi Kurdistan Region.

BACKGROUND: Female genital mutilation (FGM) is prevalent in Iraqi Kurdistan Region, but there is a lack of adequate knowledge about how the practice is perceived by the women population who are the direct victims of the practice. This study aimed to assess the knowledge, beliefs, and attitude of a sample of Kurdish women of FGM and identify the main enabling factors for performing this practice and the barriers to ending it. METHODS: This qualitative study was based on six focus groups involving a sample of 51 women. We used a topic guide to lead discussions, which included questions on women's perspectives of different aspects of FGM such as the reasons for practicing it, the positive and negative consequences, the continuation of the practice and tackling this problem in the community. Content analysis was used for the qualitative analysis of the data. RESULTS: The women had poor knowledge about different aspects of FGM particularly concerning the procedure and the consequences. The mutilated participants revealed the devastating experience of the pain and the psychological effects they have experienced. Reducing sexual desire, having halal (permissible by Allah) hands, and religious requirement were the main reasons for practicing FGM. Reduction in women's sexual desire and the related social problems with the husband were the main problems identified to be associated with FGM. Most women did not support the continuation of FGM practice, but some women still think that FGM should be left to the people's preference. The participants identified raising people's awareness, active involvement of religious leaders in prevention efforts and the issuance and enforcement of legislation against FGM as the primary measures to reduce FGM practice. CONCLUSION: Passing through FGM at childhood is an overwhelming experience with long-term effects for women. There is still a significant segment among the women population that do not oppose the continuations of FGM and need religious and scientific evidence against FGM. Some reasons for practicing FGM are deeply embedded in the culture and traditions, and there is a need for extensive efforts to raise the awareness of the population and change their thoughts and behavior about FGM.

The prevention of female genital mutilation in England: what can be done?

BACKGROUND: Female genital mutilation (FGM) is a global public health issue. Women in the UK are at risk of FGM and its adverse health consequences but little is known about its practice. Since 1985 it has been a criminal offence to perform FGM in the UK and further legislation has tightened the law but FGM continues. METHODS: Four community researchers from the Kenyan, Nigerian, Somalian and Sudanese communities in Oxford conducted focus groups and interviews with 53 people to understand the communities' beliefs about how best to prevent FGM. RESULTS: Participants believed that the current UK legislation alone was not sufficient to tackle FGM and might in fact be counterproductive by alienating communities through its perceived imposition. They felt that there had been insufficient consultation with affected communities, awareness raising and education about the legislation. Community-led solutions were the most effective way to tackle FGM. CONCLUSIONS: FGM adversely affects communities globally. In the UK, researchers from affected communities gathered data demonstrating the feasibility and importance of involving communities in FGM prevention work. Further research is needed to understand how best to prevent FGM in affected communities and, very importantly, to examine the impact of the UK legislation relating to FGM.

Qualitative evaluation of the Saleema campaign to eliminate female genital mutilation and cutting in Sudan.

BACKGROUND: Female genital mutilation and cutting (FGM/C, herein FGM) is a widespread and harmful practice. The Government developed a national campaign in Sudan, called Saleema, to change social norms discouraging FGM. Saleema translates to being "whole", healthy in body and mind, unharmed, intact, pristine, and untouched, in a God-given condition. An interim evaluation was conducted using focus groups among Sudanese adults. The primary aim was to explore perceptions of the Saleema poster exemplars and to assess if the desired themes were being communicated. Secondary aims were to understand more about participants' information sources, values, and suggestions for the campaign broadly. METHODS: The Saleema campaign evaluation included four focus groups from each of the 18 states in Sudan (72 total). Participants were presented with three poster stimuli from the Saleema campaign and asked about the content and their reactions. Themes were coded inductively by concepts that arose through content in the transcripts. Codes were also reviewed in conjunction with themes from the broader Saleema evaluation framework. RESULTS: Participants reported the most common source of information or admiration was from local leaders who are responsive to a community, media-based outlets, and discussions among community members. Participants held high value for education, community solidarity, and/or religious devotion. Participants had positive opinions of Saleema and responded positively to the branding elements in the posters and the campaign as a whole. The most common suggestion was continued awareness. Advocacy, training, and posters were suggested to highlight the harms of FGM through leaders or in community settings. Individuals suggested that these activities target older women and individuals in rural villages. There was also a burgeoning theme of targeting youth for support of the campaign. DISCUSSION: The results of this focus group analysis demonstrate support for future Saleema campaign efforts promoting awareness and community engagement. The campaign could capitalize on partnerships with young people and those who are respected in the community (e.g., religious leaders) or continue promoting common values aligning with the support of education and community solidarity. Continuing campaign efforts have promise to decrease the harms of FGM in Sudan.

Factors associated with the support of pricking (female genital cutting type IV) among Somali immigrants - a cross-sectional study in Sweden.

BACKGROUND: Pricking, classified as female genital cutting (FGC) type IV by the World Health Organization, is an under-researched area gaining momentum among diaspora communities. Our aim was to explore factors associated with being supportive of pricking among Somalis in Sweden. METHODS: In a cross-sectional design, attitudes and knowledge regarding FGC, and measures of socioeconomic status, acculturation, and social capital, were assessed by a 49-item questionnaire in four municipalities in Sweden. Data were collected in 2015 from 648 Somali men and women, ≥ 18 years old, of which 113 supported the continuation of pricking. Logistic regression was used for the analysis. RESULTS: Those more likely to support the continuation of pricking were older, originally from rural areas, and newly arrived in Sweden. Further, those who reported that they thought pricking was: acceptable, according to their religion (aOR: 10.59, 95% CI: 5.44-20.62); not a violation of children's rights (aOR: 2.86, 95% CI: 1.46-5.61); and did not cause long-term health complications (aOR: 5.52, 95% CI: 2.25-13.52) had higher odds of supporting pricking. Religion was strongly associated with the support of pricking among both genders. However, for men, children's rights and the definition of pricking as FGC or not were important aspects in how they viewed pricking, while, for women, health complications and respectability were important. CONCLUSIONS: Values known to be associated with FGC in general are also related to pricking. Hence, there seems to be a change in what types of FGC are supported rather than in their perceived values.

African, male attitudes on female genital mutilation: an Australian survey.

Female genital mutilation (FGM) is a traditional practice where female genital organs are altered for non-medical reasons. The custom is outlawed in Australia and associated with an array of medical consequences. Due to the recent influx of migrants from regions endemic to FGM, the practice is becoming a growing concern locally. This federal government funded study aimed to elicit the poorly understood perceptions that young, Sub-Saharan African, migrant males residing in Townsville, Australia have on FGM. Through piloted questionnaires we found that amongst the 67 participants, 23.9% believed that FGM should be allowed under Australian Law. The independent predictors of supportive attitudes in favour of FGM were having resided in Australia for five or less years (p = .016, 95% CI 0.99-8.09) and coming from a basic educational background (high school or TAFE) (p = .003, 95% CI 1.3-12.4). This study also found that participant perceptions on FGM were amenable to change through educational interventional strategies. Impact statement Female genital mutilation (FGM) is a traditional practice where female genital organs are altered for non-medical reasons. The role that males play in the continuation of this outlawed practice remains poorly understood. No research has ever been conducted in Australia looking at the perception that young, migrant males have on FGM. Several European-based studies have examined the perceptions of older, poorly educated, migrant male cohorts. Generally, these studies show that the attitudinal support for FGM and intention to practice remains relatively high amongst these cohorts. This study examined the attitudes of a young, Sub-Saharan African, migrant, male cohort residing in Australia. This adds to the literature base by establishing the perceptions and associated socio-demographic variables of this unique and influential subset of the migrant population. This directly facilitates the development of interventional strategies against FGM by highlighting those most likely to have an attitudinal support in favour of FGM. Consequentially, this 'at risk' group can be more effectively focussed on interventional programmes and be further investigated in larger scale studies.

Gender equality and human rights approaches to female genital mutilation: a review of international human rights norms and standards.

Two hundred million girls and women in the world are estimated to have undergone female genital mutilation (FGM), and another 15 million girls are at risk of experiencing it by 2020 in high prevalence countries (UNICEF, 2016. Female genital mutilation/cutting: a global concern. 2016). Despite decades of concerted efforts to eradicate or abandon the practice, and the increased need for clear guidance on the treatment and care of women who have undergone FGM, present efforts have not yet been able to effectively curb the number of women and girls subjected to this practice (UNICEF. Female genital mutilation/cutting: a statistical overview and exploration of the dynamics of change. 2013), nor are they sufficient to respond to health needs of millions of women and girls living with FGM. International efforts to address FGM have thus far focused primarily on preventing the practice, with less attention to treating associated health complications, caring for survivors, and engaging health care providers as key stakeholders. Recognizing this imperative, WHO developed guidelines on management of health complications of FGM. In this paper, based on foundational research for the development of WHO's guidelines, we situate the practice of FGM as a rights violation in the context of international and national policy and efforts, and explore the role of health providers in upholding health-related human rights of women at girls who are survivors, or who are at risk. Findings are based on a literature review of relevant international human rights treaties and UN Treaty Monitoring Bodies.

Between Moral Relativism and Moral Hypocrisy: Reframing the Debate on "FGM".

The spectrum of practices termed "Female Genital Mutilation" (or FGM) by the World Health Organization is sometimes held up as a counterexample to moral relativism. Those who advance this line of thought suggest the practices are so harmful in terms of their physical and emotional consequences, as well as so problematic in terms of their sexist or oppressive implications, that they provide sufficient, rational grounds for the assertion of a universal moral claim--namely, that all forms of FGM are wrong, regardless of the cultural context. However, others point to cultural bias and moral double standards on the part of those who espouse this argument, and have begun to question the received interpretation of the relevant empirical data on FGM as well. In this article I assess the merits of these competing perspectives. I argue that each of them involves valid moral concerns that should be taken seriously in order to move the discussion forward. In doing so, I draw on the biomedical "enhancement" literature in order to develop a novel ethical framework for evaluating FGM (and related interventions--such as female genital "cosmetic" surgery and nontherapeutic male circumcision) that takes into account the genuine harms that are at stake in these procedures, but which does not suffer from being based on cultural or moral double standards.

Key points for abolishing Female Genital Mutilation from the perspective of the men involved.

INTRODUCTION: female Genital Mutilation is internationally considered an affront on human rights and an act of violence against women and young girls. Furthermore, it hierarchises and perpetuates inequality and denies the right to bodily and psychosocial integrity of women and young girls. AIMS: to detect the key points for the abolition of Female Genital Mutilation as well as the necessary resources for its eradication. MATERIAL AND METHOD: a qualitative methodology with an ethnonursing perspective, via semi-structured interviews, held both individually and in groups, in 21 men familiar with Female Genital Mutilation. FINDINGS: through the voices of men familiar with this tradition, five key points are presented for its gradual eradication: sensitisation and awareness building, team action, abolition-promoting media, focusing action on rural areas and applying educational means before punitive ones. CONCLUSION AND PRACTICAL IMPLICATIONS: awareness-raising via the combined efforts of families, communities and governments, together with the promotion of health education programmes in demonstrating the complications derived from this practice, play a vital part in eradicating Female Genital Mutilation.

Cultural change after migration: Circumcision of girls in Western migrant communities.

This paper reviews the current knowledge on cultural change after migration in the practice of female circumcision, also named genital cutting or mutilation. Explorative studies show trends of radical change of this practice, especially the most extensive form of its kind (type III or the 'Pharaonic' type). The widespread interpretation that Islam would require circumcision of girls is questioned when, for example, Somalis meet other Muslim migrants, such as Arab Muslims, who do not circumcise their daughters. The few criminal court cases for circumcision of girls that have taken place in Western countries corroborate the conclusion that substantial change in the practice has occurred among migrants. In this literature review, an absence of reports is identified from healthcare providers who have witnessed circumcision after migration. Concurrently, a substantial knowledge exists on how to take care of already circumcised women and girls, and there is a system of recommendations in place regarding best practices for prevention. There is a great potential for healthcare providers to encourage this development towards general abandonment of circumcision of girls. The challenge for the future is how to incorporate culturally sensitive efforts of prevention on the one hand, and the examination of suspicious cases of illegal circumcision on the other. We recommend using--in a cautious way--the existing routines for identifying child abuse in general. Experiences from African contexts show that failure to generate significant change of the harmful practices/tradition may be due to the lack of multidisciplinary collaboration in different sectors of the society. In Western societies, the tendency toward abandonment of the practice could be reinforced by professionals who work toward better inclusion of men and women originally from countries where circumcision is practised.