Ending FGM/C requires individualized approaches, says Population Council

A midwife shares her stories of childbirth at a community discussion on female genital mutilation/cutting. Photo by: Jessica Lea / DFID / CC BY

NEW YORK — When it comes to eradicating female genital mutilation and cutting there isn’t any one approach that’s guaranteed to be successful, research from the Population Council, an international research nonprofit organization, shows.

While FGM/C rates have dropped globally over the last few decades, many countries haven’t seen a change in prevalence. And there are still major knowledge gaps on how, where, and why FGM/C is practiced, as well as the effectiveness of different approaches.

“The most important thing to take forward with this work is we cannot globally apply interventions,” Jacinta Muteshi-Strachan, the project director of a six-year FMG/C project run by the Population Council, explained to Devex following a recent March event. “There’s not going to be one response to it. [It’s a question of] how it is practiced, why it is practiced, what enables change, and what kinds of individual influences there are that made those shifts happen.”

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Some of the latest progress in better understanding and eradicating FGM/C — which varies in form and tradition but generally involves partially cutting or entirely removing the external female genitalia — was on display during the Population Council event. The meeting coincided with the two-week long Commission on the Status of Women at the United Nations headquarters.

Female genital mutilation and cutting is prevalent in more than 30 countries in Africa and the Middle East as well as some Asian countries, like Indonesia, and across certain ethnic groups in Latin America, cutting across religious, cultural, and economic boundaries.

FGM/C does not have any health benefit and can result in physical harm, ranging from severe bleeding and urinary problems to complications during childbirth. It can also be detrimental to women and girls’ social, psychological, and sexual health in the long term.

Penny Mordaunt, the United Kingdom’s secretary of state for international development, spoke of the need to better financially back FGM/C prevention work, which the Department for International Development has called a “highly neglected area.” Global funding totaled $18 million in 2011, according to DFID, which is supporting the Population Council’s FGM/C project and other efforts through 2018 with 26 million British pounds, or $36.53 million.

Multiple Population Council studies on prevalence and interventions are now underway in Egypt, Ethiopia, Sudan, Somalia, Kenya, Nigeria, and Senegal, according to Muteshi-Strachan. Her six-year project launched in March 2015.

At least 200 million girls and women have undergone FGM/C, and as many as 30 million girls under the age of 15 are at continued risk, according to UNICEF. These figures are likely an underestimate, said experts at the event.

Advocacy, raising awareness, and community empowerment are the most common interventions currently practiced, according to the Population Council. Encouraging alternative rites of passage — which could mean symbolic ceremonies in which girls’ heads are shaved and they are given bracelets — can also result in better knowledge of the practice’s negative health effects.  FGM/C can often be used as a marker of adulthood, or womanhood.

Studies evaluating the community education empowerment programs undertaken by the Senegal-based NGO Tostan International, operating in six African countries, have shown an increase in awareness of FGM/C consequences and a reduction in the proportion of people who see FGM/C as a necessity.

Another intervention that often results in progress is strengthening local health systems. The medicalization of FGM/C, meaning health care professionals carry out the practice, is still common in some countries. In Egypt and Sudan, 38 and 67 percent of all cases, respectively, are carried out in medical settings.

Research shows that medicalization appears to be increasing in Egypt, based off studies that tracked generational shifts between mothers and their daughters. 

“In Egypt, women say they look to doctors to help them decide, so that is telling us something,” Muteshi-Strachan said. “They look to them and ask, ‘Can I cut my daughter, is it time?’ So that responsibility is being put on medical doctors.”

In some cases, a health care provider refusing to perform FGM/C could be rejected by the community. “What that says is we need to be looking at the demand and supply sides,” Muteshi-Strachan said.

Self-reported government health data from 25 countries, analyzed by the Population Council, show that traditional practitioners performed 74 percent of the procedures while medical professionals conducted the other 26 percent. A clear relationship between medicalization and the support or lack thereof for the continuation of FGM/C hasn’t been identified, but further research on this link is needed at local levels.

Still, the quality of the available evidence studying the effectiveness and impact of FGM/C interventions is generally “moderate to low,” according to the Population Council.

Better understanding trends within countries could help guide responses, said Muteshi-Strachan.

Data is typically collected at a national level, but differing prevalence trends on a more local level within countries can mean this broader set of information comes with some level of inconsistency. Subnational data is key.

For example, Kenya has a national prevalence of about 21 percent, down from 37.5 in 1998. But in a northeast corner of the country these rates among women aged 15 to 41 topped 80 percent in 2014 — while less than 10 percent of girls and women in the west of the country experience FGM/C.

“Yes, it is good to have national prevalence data but it is equally and more important that we are looking at where are the hotspots,” Muteshi-Strachan said.

There has been a global push over the past two decades to end FGM/C. UNICEF and the U.N. Population Fund launched a joint program on abandoning FGM/C in 2007, and five years later the U.N. General Assembly adopted a resolution on the elimination of the practice.

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An executive order banning female genital mutilation on girls under 18 was recently signed in Liberia during the last days of the Sirleaf administration. While a step in the right direction toward banning the practice, women's rights advocates tell Devex the looseness of the bill will hamper enforcement efforts.

Since 1996, 35 countries have passed laws banning FGM/C, according to the World Health Organization. Liberia joined these ranks in January — temporarily, at least — with a one-year ban.

But one effect of outlawing FGM/C can be to drive the practice underground, Muteshi-Stracha says.

Two-thirds of all women who have undergone FGM/C live in four of the countries — Egypt, Ethiopia, Nigeria, and Sudan — that have laws against FGM/C, pointing to the limited impact laws and penalization can have.

“Are people going to actually tell you they are cutting their daughters when punitive measures come out of the law? So you may not know if it’s happening,” Muteshi-Strachan said.  

In southern Senegal, knowledge of the law banning FGM/C has resulted in families limiting the number of people involved with deciding to cut a girl, according to the Population Council. That means a father might only find out about the act after it is done, Muteshi-Strachan says.

In 15 of the 29 countries that have public data, there is no clear evidence of change, while in 14 countries the practice appears to be declining, according to the Population Council.

“It is important to have the policy because that is the script we all read, but for it to happen there must be alignment of resources next to it, and that part is often missing,” Muteshi-Strachan said. “It depends on global financing, donor funding. It may be a good thing to also see states themselves make the financial commitments.”

Burkina Faso is one country where a 1996 law against the practice has resulted in a sharp decline in FGM/C. There, 89 percent of women aged 45-49 have been cut, but only 13 percent of 5- to 9-year-olds have experienced FGM/C. This means the law may have prevented close to 240,000 girls from being cut, according to the Center for Global Development. Other influences, like the public support of religious and community leaders and politicians in ending FGM/C, have also been cited.

“The thing is we [need to] think through what might happen, having laws in contexts we understand. What do people do with the law, how is this practiced?” said Muteshi-Strachan, speaking of the general impact laws can have.

The Population Council is aiming to release their studies on the effects of FGM/C legislation at the end of this year.

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  • Lieberman amy

    Amy Lieberman

    Amy Lieberman is the New York Correspondent for Devex. She covers the United Nations and reports on global development and politics. Amy previously worked as a freelance reporter, covering the environment, human rights, immigration, and health across the U.S. and in more than 10 countries, including Colombia, Mexico, Nepal, and Cambodia. Her coverage has appeared in the Guardian, the Atlantic, Slate, and the Los Angeles Times. A native New Yorker, Amy received her master’s degree in politics and government from Columbia’s School of Journalism.