Despite more than 40 years of discussion and debate regarding female genital mutilation/cutting (FGM/C), this topic remains controversial and emotive, and the practice continues. FGM/C is defined as ‘all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs, whether for cultural or other non-therapeutic reasons’. There are four main classifications of FGM/C :Type III, or ‘infibulation’, is the most severe form and accounts for 10% of cases. It is estimated that more than 200 million girls and women worldwide are living with the effects of FGM/C. Of these, 44 million are <15 y of age. FGM/C is practised mainly in Africa, with the highest prevalence in Somalia, Egypt, Mali and Sudan, where more than 80% of all women between 15 and 49 y of age have undergone FGM/C. However, FGM/C is also prevalent in other settings including the Middle East, India and Indonesia. The specific type of FGM/C varies within and between countries.
The 2008 World Health Assembly resolution emphasized the need for concerted action in all sectors of health, education, finance, justice and women’s affairs, with recommendations that focus on strengthening the health sector response, including guidelines, training and policies to ensure that all health professionals can provide medical care and counselling to girls and women living with FGM/C; building evidence, including generating knowledge and accurate data regarding the prevalence, types, causes and consequences of the practice; and increasing advocacy, including developing publications and advocacy tools for international, regional and local efforts to end FGM/C within a generation.
Since 1997, great efforts have been made to eradicate FGM/C through culturally sensitive research, the engagement of communities and changes in public policy. Progress to stop FGM/C has been made possible because of the establishment of international monitoring bodies, agreements on resolutions that condemn the practice, revised legal frameworks and growing political support to end FGM/C. Of the 29 countries where FGM/C is most prevalent, 24 governments have enacted laws against continuation of the practice. For example, the governments of South Africa and Zambia have banned the practice. In line with this, professional associations such as the International Federation of Obstetricians and Gynaecologists, the International Confederation of Midwives, the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives in the UK condemn the practice of FGM/C and are vocal in calling on all professional associations worldwide to oppose the practice.
As a result of international combined efforts and legal frameworks being put in place in many countries, an ever-increasing number of women and men in practising communities support eradication of the practice of FGM/C and the overall prevalence is decreasing. However, progress in the eradication of FGM/C is too slow.
Challenges include the implementation of recommendations and enforcement of the legal frameworks regarding FGM/C. For example, in Sudan, FGM/C type III was banned in 1946, but continues to be practised, and there have not been any successful prosecutions. Furthermore, there is international concern regarding an increasing trend of medically trained personnel being asked to perform FGM/C. For example, in Malaysia, FGM/C is carried out legally by health care providers in hospitals. Some health care providers consider the medicalization of FGM/C as a harm-reduction strategy and support the notion that with this approach, some of the risks associated with immediate health complications are reduced and ‘less damage’ is done. However, this practice is unacceptable, contravenes the essence of the Hippocratic Oath and is against the ethical framework of health care of ‘do no harm’.
More recently, there has been a shift in emphasis from considering FGM/C as a purely health-related issue to adopting a more holistic approach in which the role and sexual and reproductive rights of women in societies are addressed. However, some communities continue to argue that FGM/C is a traditional and cultural practice and that Western countries should not impose their ‘imperialist’ and ‘colonialist’ views on this long-standing custom. Increased media coverage and statements by ministers, religious leaders, faith-based groups, celebrities and non-governmental organizations have led to more discussion of the topic both at the international level and in countries where FGM/C is prevalent. However, there is an ongoing need for a stronger coordinated and combined approach in which societal opinion and norms are challenged, community awareness and engagement are mobilized and legal, and medical frameworks supporting eradication are in place and proactively implemented. Often as countries develop and diversify from within, cultural practices do change and there is a realization that condoning acts that contravene human rights has no place within any moral or ethical framework.
Accurate data regarding FGM/C are lacking and greater efforts should be made to address this. Finally, any campaigns or interventions that aim to eradicate FGM/C should be medium to long term (at least 5 years) and should include clear methodologies for implementation and evaluation of the effectiveness (or not) of such interventions to better inform public policy.
Call to action
The eradication of FGM/C can only be achieved through a strong and coordinated approach implemented at local, regional, national and international levels. Supportive education and targeted training are recommended to enable all stakeholders to sensitively and respectfully address this complex and long-standing practice. Health care providers have a duty of care and are in many ways uniquely positioned to support the eradication of FGM/C. It is crucial that all healthcare providers are aware of and meet the requirements of the ethical and legal frameworks that are currently in place to support the eradication of FGM/C. This includes continued promotion of community understanding and objection to FGM/C as a practice that is contrary to human rights, including the right to physical as well as reproductive and sexual health for women.
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