Definition & Prevalence
Female Genital Mutilation/Cutting ("FGM/C") is the long-standing harmful practice of partial or total removal of external female genitalia for non-medical reasons.[1] FGM/C has many long- and short-term negative consequences to the health of women and girls, with no health benefits.[2] Globally, it is estimated that 200 million girls and women alive today have undergone FGM/C.[3] Additionally, 3 million girls are at risk of being subjected to FGM/C each year, with a majority being cut before they turn fifteen.[4]
Geographically, the practice is most prevalent in Sub-Saharan Africa.[5] In the most-practiced countries in this region, over 95% of girls ages fifteen to forty-nine have experienced FGM/C. [6] However, FGM/C can and does occur all over the world, and growing migration means that an increased number of girls and women in North America, Europe, and Australia are at risk of being subjected to FGM/C or have already been subjected to it.[7]
While FGM/C is more prevalent in low-to-middle income countries (LMICs)[8], it is important to recognize that the practice transcends geographic and socioeconomic boundaries.[9] This includes the United States, where the women and girls most at risk of being subjected to FGM/C procedures live in and around large metropolitan areas. For example, in the tristate area surrounding New York City, over 65,000 women are at risk of FGM/C, 21,000 of whom are under the age of eighteen.[10]
Over the last three decades, there has been an overall decline in the rate of FGM/C.[11] It is estimated that the global prevalence of FGM/C has dropped by 25% since 2000.[12] In Africa specifically, in 1980 about 50% of girls in Africa between fifteen and nineteen years old had been subjected to FGM/C. Now, that rate for the same group is about 33%.[13] Despite this decrease in rate, the number of girls at risk of FGM/C each year is expected to rise to 4.6 million by 2030 because of population growth in areas with the most concentrated FGM/C occurrence[14] (Some researchers believe that this estimate is understated.[15]). By 2030, more than one third of all births worldwide will be in the thirty countries where FGM/C is most prevalent.[16]
There are four main types of FGM/C[17]:
Some FGM/C necessitates further procedures. For example, a woman who has experienced Type III infibulation may be "deinfibulated". This process involves cutting open of the sealed vaginal opening (essentially reversing the infibulation) in order to allow sexual intercourse, to allow for childbirth, or as a necessary step for improving the woman's health. This process is often mediocre in its results, despite being expensive and potentially risky.[18]
The practical details of FGM/C vary across cultures and geography. Exactly when FGM/C occurs in a woman's life is largely a function of cultural tradition. For example, while Somali girls are usually subjected to FGM/C right before puberty, the Afar practice FGM/C in the weeks following birth[19] and 85% of Yemeni girls are subjected to FGM/C within the first seven days of life.[20] In countries where data is available, a majority of girls are subjected to FGM/C before they turn five.[21] The FGM/C procedure is often undergone alone, but some cultures do practice group FGM/C (and in some cases use the same instruments on more than forty women and girls at a time).[22] The procedure is often performed as a ceremonial rite of passage, including music, gifts, and food.[23] The girls have varying levels of awareness about what will happen to them when they go into the procedure.[24]
The tools used to conduct the procedure also vary greatly, and include clippers, scissors, knives, and hot objects.[25] When infibulation is done, thorns or stiches may be used to hold the labia minora together to narrow the vaginal opening, and the legs may be bound together for up to forty days.[26] Despite the painful nature of the procedure, it is not common for traditional practitioners to take steps to manage or reduce pain.[27] It is important to note that the practice is commonly viewed as an expression of tradition and culture, so the people performing the procedure do not believe that they are doing harm to the girls.[28]
While the practice of FGM/C has traditional roots, there has been a dramatic increase in the proportion of FGM/C conducted with the involvement of health professionals (as opposed to untrained traditional practitioners or family members).[29] This might involve the healthcare provider doing the cutting, or alternatively involve a medical professional administering anesthesia and painkillers, while the FGM/C itself is still done by the traditional practitioner.[30] In one study, 74% of survivors of FGM/C reported being cut by a traditional practitioner, while 26% reported being cut by a health professional.[31] However, at least one other study found evidence that suggests that up to 80% of FGM/C now taking place is performed with the involvement of medical professionals.[32] This "medicalization" of the practice could normalize it, especially since medical professionals are often viewed with deference and respect in society.[33]
Some proponents of FGM/C medicalization argue that the medicalized practice is safer than traditional FGM/C, and that the trend of medicalization might be associated with changing norms which signal a possibility for future abandonment of the practice.[34] For example, one study found a shift to less severe nicking/pricking forms of FGM/C in countries where medicalized FGM/C is expanding.[35] While data is limited and it is unclear if there is a causal link, proponents of medicalization see promise in the shift to less harmful forms of FGM/C. [36] Others consider any form of FGM/C, including the medicalized form, as a violation of the "do not harm" principle of medical care.[37] These anti-medicalization advocates would note that there is little to no evidence that medicalization reduces the harm to girls or associated future health risks.[38] "Medicalizing the practice of FGM does not eliminate the danger it poses to women as it still removes and damages healthy and normal tissue and interferes with the natural functions of a girl’s body."[39] Further, there is additional risk that the institutionalization of FGM/C might legitimize it, leading to a decreased rate of abandonment.[40]
In general, gender norms and the associated imbalances in power and societal status are primary drivers of violence against women and girls, including FGM/C.[41] Specific to FGM/C, many believe that FGM/C is necessary to ensure premarital virginity of women and girls, as well as post-marital fidelity. Under this belief, FGM/C is supposed to reduce libido, thus helping the woman resist extramarital acts. Additionally, if the woman has been infibulated (Type III FGM/C), there fear of pain will discourage extramarital sexual relations.[42]
Gender norms in cultures that practice FGM/C also often view FGM/C as a necessary component of preparing a girl for adulthood and marriage.[43] This belief is reinforced by cultural expectations of feminine modesty, as well as the belief that girls must have body parts that are considered "unclean, unfeminine, or male" removed in order to be beautiful.[44]
In countries where FGM/C is widely practiced and even nearly-universal, FGM/C has become a social convention that creates a fear of rejection if one has not been cut.[45] Often in these communities, the structures of power and authority (including community leaders, religious figures, and medical professionals) encourage the practice.[46] This long-standing tradition of FGM/C is often viewed as an integral part of the community's culture that must be continued and perpetuated.[47]
In many communities with prevalent FGM/C, the practice is tied to traditional religious beliefs. Many practitioners believe that FGM/C has religious support (though opponents will note that no religious script prescribes it).[48] Some of the religious underpinnings may stem from cutting being mentioned in some hadiths (the recorded practices and sayings of the Prophet Mohamed).[49] It is important to note that while religion is a contributing factor in many cultures that practice FGM/C, the range of religions practiced in these communities is wide. In one study, Christianity was the most common religion among those who practice FGM/C.[50]
It is important to understand the role of economic factors in FGM/C, especially in light of the high rates of poverty in many of the prevalent FGM/C countries. Practitioners rely on FGM/C as an occupation, and thus have an economic incentive to continue the practice.[51] Additionally, FGM/C can be a prerequisite for marriage (and the associated economic benefits) and for the right to inherit.[52] These factors provide women and girls, their families, and practitioners with economic incentives to continue the practice.
Through a variety of studies and initiatives aimed at ending FGM/C, many effective counter-factors have been identified. Specifically, FGM/C can be combatted by empowering women and girls. This involves activating resources that enhance female voices and create agency, especially in contexts where it has been denied or limited in the past. It includes expanded educational opportunities in order to create exposure to new ideas about equitable gender relations and to enhance female self-worth (investing in educating girls on interpersonal and life skills can also enhance her ability to establish and maintain violence-free relationships). It includes investment in non-familial social resources to reinforce equitable gender relations, build solidarity with peers, and begin building norms of nonviolence. Economic resources should also be provided to enhance women's value to their families and future spouses. Further, investment in community infrastructure that focuses on reducing inequity can create economic growth while also engaging the broader community in shifting norms.
FGM/C has no beneficial health impacts[54] and more than 85% of those who have been subjected to FGM/C have medical complications at some point in their lives as a result of the procedure.[55] These short- and long-term health complications are amplified by the limited availability of healthcare in LMICs.[56]
In the short term, these complications can include extreme pain, excessive bleeding, swelling, infections (including HIV), problems urinating, mental health problems, and shock.[57] FGM/C can also lead to death[58], which is most likely to occur with Type III FGM/C (infibulation).[59] One study estimates that 1 in every 500 FGM/C procedure results in death.[60]
Long-term complications include pain, excessive scar tissue, perinatal risks, genital infections, infection of the reproductive or urinary tracts, menstrual problems, vaginal problems, childbirth complications (including stillbirth[61]), pain when menstruating, urinating, or having sexual intercourse, and mental health issues.[62] Sexual intercourse can often only occur after dilation of the vaginal opening, which can be extremely painful (and 15% of women in one study reported that cutting was necessary before sexual penetration could be achieved).[63] Additionally, maternal mortality rates are much higher among women who have been subjected to FGM/C. [64] Girls who are not subjected to FGM/C tend to grow up to be healthier and to have healthier children.[65]
The mental health impacts of FGM/C are often underappreciated. First, the scarring of the cut area is often a source of anxiety and shame for women. [66] Further, mental health complications including depression, neuroses, psychoses, and PTSD are common.[67] These are complicated by the fact that they are often delayed in manifesting themselves, and regularly go unrecognized and untreated in LMICs.[68]
The costs of these complications is also extremely high. If all medical needs resulting from FGM/C were addressed, it would cost about $1.4 billion annually.[69] This would be about 10% of annual health expenditures in most countries, but up to 30% in countries where FGM/C is most prevalent.[70] A country-by-country calculator is available from the World Health Organization at https://srhr.org/fgmcost/cost-calculator/.
The legal landscape varies greatly by country and is further complicated by the trend of medicalization. In the United States, a 1997 federal law made it a crime to perform FGM/C on a girl under 18 or to attempt to send a girl outside of the country for FGM/C. The law was rarely used to prosecute offenders, and was declared unconstitutional by a district court in 2018.[71] The Department of Justice did not appeal the ruling.[72]
On the international level, performing FGM/C on children is considered a violation of the rights of children under the UN Convention of the Rights of Children (Art.19(1), Art.24(3)).[73]
"Laws against FGM have been passed in 26 countries in Africa and the Middle East, as well as in 33 other countries with populations from FGM-practicing countries, but girls are often transported over state or international borders to circumvent such regulations." [74] Enforcement of these laws is also not especially common. For example, in 2019 a woman in London was prosecuted for committing FGM/C on her three-year-old daughter. This was the first successful prosecution under that law, which went into effect 34 years earlier in 1985.[75] Also recently, a doctor in Egypt was arrested after a twelve-year-old girl on whom he performed FGM/C without anesthesia bled to death.[76] This arrest was unusual, despite a 2008 ban on the practice in Egypt, because enforcement of the law relies on people to self-report violations.[77]
Several countries have also passed laws establishing duties of health care providers to avert FGM/C and duties to report.[78] However, these laws implicate medical confidentiality laws that health care providers also have to follow, complicating the legal landscape. Several countries have established repercussions, ranging from fines to imprisonment, if health care providers fail to fulfill their duties to avert or report.[79] Further, legal bans can run against norms and ethical obligations within certain communities of providers who see medicalized cutting as an opportunity to prevent the procedure from being performed by an unskilled practitioner in unsanitary conditions without pain management.[80]
The practice of FGM/C also has many social consequences, several of which reinforce the causal factors. First, FGM/C perpetuates a deeply-ingrained inequality between men and women.[81] This inequality further limits access to education and economic opportunities.[82] FGM/C also severely restricts or even removes the ability for women and girls to have a say in major decisions implicating bodily autonomy and quality of life that will have lifelong impacts.[83] Additionally, polyvictimization of girls is common, especially during adolescence. FGM/C, especially in its most severe forms, is commonly practiced alongside forced sexual debut, intimate partner violence, and child marriage.[84] Often girls are victims of multiple forms of violence against women, creating a reinforcing cycle of violence.
Studies have shown that communities that confront FGM/C and work to decrease its prevalence reap benefits. Girls who are not subjected to FGM/C tend to be more educated, which leads to higher income and greater empowerment.[85] These benefits aggregate up to the community level.
Many international organizations, including the UN, the WHO, and UNICEF, have developed initiatives and responses to combat FGM/C. The WHO issued its first UN policy statement on FGM/C in 1997.[86] Across these initiatives, organizations are focused on shifting the underlying attitudes that legitimize the practice. This includes working at all levels of society (individual, societal, institutional), including engagement with faith leaders and men and boys.[87]
FGM/C is internationally recognized as a violation of human rights and as an extreme form of gender discrimination. [88] Human Rights Council Resolution 38/6 reiterated this, calling it an abuse of women and violation of their human rights while simultaneously posing a serious threat to their well-being.[89] UN General Assembly Resolution 71/168 again reaffirmed that FGM/C was a harmful practice, and established an international understanding that FGM/C stems from negative norms, customs, and stereotypes that have severe negative impacts on the human rights, physical health, and mental health of women and girls.[90] Specifically, FGM/C violates the rights to physical integrity, to health security, to be free from torture and inhumane treatment, and the right to life (when the practice results in death).[91] Further, the UN's Commission on the Status of Women has urged governments and other implicated stakeholders to eliminate FGM/C and other practices that disproportionately harm women and girls.[92]
The UN has incorporated elimination of FGM/C into its Sustainable Development Goals, with a target of abandoning the practice by 2030. The implicated goals are Development Goal 5.2 (elimination of all forms of violence against women and girls) and Development Goal 5.3 (elimination of harmful practices). [93] Additionally, the Nairobi Summit of the International Conference on Population and Development committed to ending FGM/C in ten years, placing it in-line with the Sustainable Development Goals.[94]
Over the last forty years, many efforts have combined the resources of national governments, international organizations, and community organizations.[95] Several UN funds and organizations (including a UN trust fund specifically designated to support the elimination of violence against women) strive to provide survivors of FGM/C with medical and psychological resources through grassroots organizations.[96] While those initiatives aim to aid those who have been subjected to FGM/C, most initiatives focus on ending the practice. The trend in UN initiatives is toward creating locally-relevant, rights-based, holistic strategies that are integrated into the national policies and economies of individual states.[97] Similarly, the Spotlight Initiative has been building programs that are strategically coordinated across institutional and legal frameworks as part of an effort to address the intersectionality of FGM/C with other forms of violence against women.[98] Deep integration and coordination across levels of society and government are necessary to ensure that those women who are most at risk (i.e. those who encounter intersecting forms of discrimination, such as refugees, migrant women, young girls, women in rural and remote communities) are not left behind.[99] However, achieving the level of integration required to enact such systemic change has been challenging.[100]
The United Nations Population Fund and UNICEF joint program established to work toward the abandonment of FGM/C is the largest in the world, and works with governments and non-governmental leaders to create policies and laws to prohibit the practice of FGM/C. [101] This program also supports outreach to help transform the social norms that underpin FGM/C, as well as provides treatment (both mental and physical) for women and girls who have been subjected to FGM/C. [102] The program has had success, and girls in countries that are served by the program are 33% less likely to be subjected to FGM/C than they were in 1997.[103] The average cost per prevented case is $95[104], which is much lower than the costs of FGM/C to the health system and economies of implicated countries.
In order to address the trend of medicalization, the UN Human Rights Council passed Resolution 38/6 to call upon the international community and individual states to halt the medicalization of FGM/C[105], reinforcing the UN's stance that FGM/C is a human rights violation and proclaiming that medicalization doesn't cure its human rights defects.[106] Similarly, the Committee on the Elimination of Discrimination Against Women issued General Recommendation No. 35, which calls upon countries to stop the medicalization of FGM/C.[107]
Medical licensing bodies, as well as professional health care associations, have joined in these efforts to condemn FGM/C medicalization.[108] Additionally, the WHO launched a clinical handbook in 2018, which aims to improve the knowledge and skills of medical professionals to empower them to prevent FGM/C and manage complications that may arise.[109] There has also been a push to adopt medical codes and medical school curricula that integrate FGM/C issues directly.[110] These initiatives that engage directly with healthcare providers reflect the key role providers can play in preventing FGM/C through education of parents and patients, especially in light of the epistemic deference and social stature healthcare professionals enjoy in most cultures.[111]
Other successful initiatives include awareness campaigns (February 6, 2019 was the International Day of Zero Tolerance for Female Genital Mutilation[112]), community mobilization, education expansion, and initiatives to increase economic empowerment.[113] There have also been efforts to create alternative rites of passage (to replace FGM/C rituals with nonviolent rituals) and to train FGM/C practitioners for new vocations ("drop the knife" programs).[114] Many of these include intersections with other women's movements, like #MeToo.[115] Overall, the campaigns and initiatives to have showed promising results. Data from UNICEF released in 2016 showed that 67% of women and 63% of men in countries with relatively high prevalence of FGM/C oppose continuation of FGM/C practices, however this varies widely across and even within countries.[116]
Multiple international and nongovernmental organizations advocate for the criminalization of FGM/C and push for investigation and prosecution of perpetrators.[117] This would harness criminal law's expressivist rationale of signaling that the practice is not acceptable, and the utilitarian rationale of providing deterrence. However, there is recognition that this criminalization and the development of related legal norms must be community-driven and part of a broader strategy that addresses the cultural context and social norms in order to maximize enforceability and buy-in.[118] As of 2018, more than forty countries had banned FGM/C, with at least six countries prescribing specific elevated penalties for medical personnel who perform FGM/C procedures.[119] This includes twenty-five of the African Union's members.[120] Mandatory reporting laws are also common. Developed countries have also pursued criminalization, though not universally. In the U.S., for example, fifteen states have no laws against FGM.[121] While the trend is toward expanded criminalization of the practice, enforcement and implementation of such laws are still major barriers, especially in light of the sensitive and secretive nature of the practice.[122] There is some evidence that criminalization does have deterrent effect, as the expanding number of countries with laws against FGM/C has led to a recent increase in cross-border FGM/C, where families transport women and girls to countries without legal prohibitions to have the procedure done before returning home.[123]
There are some concerns with unintended consequences of criminalization. First, it might push the practice underground, increasing the risks to women and girls.[124] It might also provide opportunities to further victimize women who have been subjected to FGM/C. In one case, three women who had been subjected to FGM/C were jailed under mandatory reporting laws because they did not report their own FGM/C procedure.[125] Children may also be exposed to unsafe and unstable conditions if their parents are jailed for FGM/C offenses.[126] Additionally, harsh sentences might not have the desired deterrent effect because overly-harsh sentences could disincentivize reporting, especially in cultures where family members play an larger role in FGM/C ritual.[127] There is also concern that mandatory reporting laws for healthcare providers could discourage women and girls from seeking medical treatment for fear that doing so could expose themselves or their families to criminal liability.[128]
In addition to international efforts, there are several initiatives at the regional and local levels that are aimed at using the levers of domestic and foreign policy to combat FGM/C. The Protocol to the African Charter on Human and People's Rights on the Rights of Women in Africa Article 5(b) explicitly requires that member states ban all forms of FGM/C, including those forms that are (para-)medicalized.[129] Additionally, the African Union Initiative "Saleema" was created to accelerate the abandonment of FGM/C through transforming social norms, expanding enforcement of anti-FGM/C legislation (including combating cross-border FGM/C), increasing engagement with local civil and community groups, advocating for domestic financial resource apportionment for anti-FGM/C initiatives, and investing in data and reporting.[130]
Some of the actions of individual states have been met with success. Burkina Faso has been effective at reducing medicalized FGM/C through a combination of community initiatives, legal frameworks, and large penalties.[131] Sudan has achieved a decrease in medicalized FGM/C through an accountability framework aimed at midwives.[132] Egypt has found success by supporting Doctors Against Female Genital Mutilation, an initiative created by Egyptian healthcare professionals to raise awareness of FGM/C issues with medical students.[133]
There are local and regional factors working against progress, especially in Africa and Asia. For example, a current trend of reactionary pushback against the expansion of women's rights in places like India and Sudan threatens progress of anti-FGM/C initiatives in those countries.[134] There is also concern that shifting legal landscapes can lead to anticipatory behavior. In Sudan, large numbers of women and girls are being subjected to FGM/C as Sudanese citizens prepare for the anticipated adoption of anti-FGM/C legislation.[135]
There are also technology barriers to overcome, especially in tracking and reporting FGM/C in rural and remote areas. To that end, some countries have focused on creating technological solutions to help enable progress of FGM/C goals. For example, Tanzania uses "Crowd2Map", which employs open-source technology to create improved maps of rural areas of Tanzania so that initiatives at the domestic and international levels have better access to remote villages in order to locate at-risk girls and move them to safe houses during Tanzania's traditional cutting season.[136] These technological initiatives demonstrate how efforts to combat FGM/C, economic development, and technology can intersect.
Many developed countries also employ domestic and foreign policy tools to encourage the abandonment of FGM/C. It has been the official policy of USAID and the US government to support the elimination of FGM/C since the 1990s.[137] In Europe, many countries have employed extraterritoriality provisions in order enforce their laws against FGM/C, even if the procedure itself does not occur within their boundaries.[138] Several other countries have utilized protection orders in order to minimize the risk that girls are transported to another country to be subjected to FGM/C.[139] It should be noted that this strategy does create concerns of discriminatorily targeting specific communities with these protection orders.[140]
With the broad array of initiatives across every level of international society, there are many learnings about the effectiveness of efforts to end FGM/C. First, there is a wide gap of scientific study and available data on the impacts of intervention programs, especially in LMICs as compared to high-income countries.[141] Addressing this gap can help expand understanding of initiative efficacy, and lead to increased development and investment in the most effective programs.
From data that is available, it is clear that the deep transformation of social norms that is needed to truly eliminate FGM/C requires sustained action at all levels of global society, including schools, communities, religious establishments[142], national governments, and international organizations.[143] The most successful programs have included both individual-level interventions and multi-level interventions, though the most successful programs also focused on a limited number of components (as opposed to attempting on taking on too many components and diluting resources).[144] The most promising initiatives have included agency-enhancing skill building, strengthened social networks, increased engagement with the community, and exposure to female role models outside of the family.[145]
Finally, the commitment must be fully funded. In one study of prevalent FGM/C countries, 24 out of 30 countries studied had a plan of action at the national level for reducing FGM/C.[146] However, these plans were not consistently implemented or funded.[147] In order to maximize the efficacy of these programs, consistent full funding and implementation will be required.
[1] World Health Organization, "Female Genital Mutilation: An Overview", accessed Jul. 16, 2020, https://www.who.int/health-topics/female-genital-mutilation#tab=tab_1.
[2] Ibid..
[3] World Health Organization, "The Economic Cost of Female Genital Mutilation", accessed Jul. 16, 2020, https://www.who.int/news-room/detail/06-02-2020-economic-cost-of-female-genital-mutilation; USAID, "International Day of Zero Tolerance for Female Genital Mutilation/Cutting," accessed Jul. 16, 2020, https://www.usaid.gov/what-we-do/gender-equality-and-womens-empowerment/international-day-zero-tolerance-fgmc.
[4] World Health Organization, "Female Genital Mutilation: An Overview", accessed Jul. 16, 2020, https://www.who.int/health-topics/female-genital-mutilation#tab=tab_1.
[5] USAID, "International Day of Zero Tolerance for Female Genital Mutilation/Cutting," accessed Jul. 16, 2020, https://www.usaid.gov/what-we-do/gender-equality-and-womens-empowerment/international-day-zero-tolerance-fgmc.
[6] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[7] World Health Organization, "Female Genital Mutilation: A Global Concern", accessed Jul. 16, 2020, https://www.who.int/health-topics/female-genital-mutilation#tab=tab_2; Elliot Klein, Elizabeth Helzner, Michelle Shayowitz, Stephan Kohlhoff, and Tamar A. Smith-Norowitz, Female Genital Mutilation: Health Consequences and Complications- A Short Literature Review, Obstetrics and Gynecology International, Jul. 2018, https://doi.org/10.1155/2018/7365715.
[8] Kathryn M. Yount, Kathleen H. Krause, and Stephanie S. Miedema, Preventing Gender-Based Violence Victimization in Adolescent Girls in Lower-Income Countries: Systemic Review of Reviews, 192 Social Science & Medicine 1–13 (2017).
[9] Spotlight Initiative, "Five Myths About Female Genital Mutilation", accessed Jul. 15, 2020, http://www.spotlightinitiative.org/news/five-myths-about-female-genital-mutilation.
[10] Elliot Klein, Elizabeth Helzner, Michelle Shayowitz, Stephan Kohlhoff, and Tamar A. Smith-Norowitz, Female Genital Mutilation: Health Consequences and Complications- A Short Literature Review, Obstetrics and Gynecology International, Jul. 2018, https://doi.org/10.1155/2018/7365715.
[11] World Health Organization, "Female Genital Mutilation: A Global Concern", accessed Jul. 16, 2020, https://www.who.int/health-topics/female-genital-mutilation#tab=tab_2.
[12] Press Release, UNICEF, A Race Against Trends (Feb. 6, 2018). Also available online at https://www.unicefusa.org/press/releases/race-against-trends/33980.
[13] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[14] World Health Organization, "Female Genital Mutilation: An Overview", accessed Jul. 16, 2020, https://www.who.int/health-topics/female-genital-mutilation#tab=tab_1.
[15] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[16] Press Release, UNICEF, A Race Against Trends (Feb. 6, 2018). Also available online at https://www.unicefusa.org/press/releases/race-against-trends/33980.
[17] World Health Organization, "Types of Female Genital Mutilation", accessed Jul. 16, 2020, https://www.who.int/sexual-and-reproductive-health/types-of-female-genital-mutilation.
[18] Elliot Klein, Elizabeth Helzner, Michelle Shayowitz, Stephan Kohlhoff, and Tamar A. Smith-Norowitz, Female Genital Mutilation: Health Consequences and Complications- A Short Literature Review, Obstetrics and Gynecology International, Jul. 2018, https://doi.org/10.1155/2018/7365715.
[19] UNICEF, "After Losing a Daughter to FGM, a Mother in Djibouti Renews Her Fight," accessed Jul. 16, 2020, https://www.unicefusa.org/stories/after-losing-daughter-fgm-mother-djibouti-renews-her-fight/35898.
[20] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[21] USAID, "International Day of Zero Tolerance for Female Genital Mutilation/Cutting," accessed Jul. 16, 2020, https://www.usaid.gov/what-we-do/gender-equality-and-womens-empowerment/international-day-zero-tolerance-fgmc.
[22] Elliot Klein, Elizabeth Helzner, Michelle Shayowitz, Stephan Kohlhoff, and Tamar A. Smith-Norowitz, Female Genital Mutilation: Health Consequences and Complications- A Short Literature Review, Obstetrics and Gynecology International, Jul. 2018, https://doi.org/10.1155/2018/7365715.
[23] Ibid..
[24] Ibid..
[25] Ibid..
[26] Ibid..
[27] Ibid..
[28] Ibid..
[29] World Health Organization, "Female Genital Mutilation: A Public Health Approach", accessed Jul. 16, 2020, https://www.who.int/health-topics/female-genital-mutilation#tab=tab_3; USAID, "USAID Guidance on Female Genital Mutilation/Cutting (FGM/C)," accessed Jul. 16, 2020, https://www.usaid.gov/sites/default/files/documents/1870/205maa.pdf.
[30] Samuel Kimani and Bettina Shell-Duncan, Medicalized Female Genital Mutilation/Cutting: Contention Practices and Persistent Debates, 10 Current Sexual Health Reports 25–34 (Feb. 2018). Also available at https://doi.org/10.1007/s11930-018-0140-y.
[31] Samuel Kimani and Bettina Shell-Duncan, Medicalized Female Genital Mutilation/Cutting: Contention Practices and Persistent Debates, 10 Current Sexual Health Reports 25–34 (Feb. 2018). Also available at https://doi.org/10.1007/s11930-018-0140-y; Press Release, UNICEF, Approximately 1 in 4 FGM Survivors Were Cut by a Health Care Provider (Feb. 6, 2020). Also available online at https://www.unicefusa.org/press/releases/approximately-1-4-fgm-survivors-were-cut-health-care-provider-%E2%80%93-unicef/36967.
[32] UNICEF, "Female Genital Mutilation Is an Extreme Form of Violence Against Girls," accessed Jul. 16, 2020, https://www.unicefusa.org/stories/female-genital-mutilation-extreme-form-violence-against-girls/36956.
[33] World Health Organization, "Female Genital Mutilation: A Public Health Approach", accessed Jul. 16, 2020, https://www.who.int/health-topics/female-genital-mutilation#tab=tab_3; USAID, "USAID Guidance on Female Genital Mutilation/Cutting (FGM/C)," accessed Jul. 16, 2020, https://www.usaid.gov/sites/default/files/documents/1870/205maa.pdf.
[34] Samuel Kimani and Bettina Shell-Duncan, Medicalized Female Genital Mutilation/Cutting: Contention Practices and Persistent Debates, 10 Current Sexual Health Reports 25–34 (Feb. 2018). Also available at https://doi.org/10.1007/s11930-018-0140-y.
[35] Ibid..
[36] Samuel Kimani and Bettina Shell-Duncan, Medicalized Female Genital Mutilation/Cutting: Contention Practices and Persistent Debates, 10 Current Sexual Health Reports 25–34 (Feb. 2018). Also available at https://doi.org/10.1007/s11930-018-0140-y.
[37] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[38] Ibid..
[39] Press Release, UNICEF, Approximately 1 in 4 FGM Survivors Were Cut by a Health Care Provider (Feb. 6, 2020). Also available online at https://www.unicefusa.org/press/releases/approximately-1-4-fgm-survivors-were-cut-health-care-provider-%E2%80%93-unicef/36967.
[40] Samuel Kimani and Bettina Shell-Duncan, Medicalized Female Genital Mutilation/Cutting: Contention Practices and Persistent Debates, 10 Current Sexual Health Reports 25–34 (Feb. 2018). Also available at https://doi.org/10.1007/s11930-018-0140-y.
[41] Kathryn M. Yount, Kathleen H. Krause, and Stephanie S. Miedema, Preventing Gender-Based Violence Victimization in Adolescent Girls in Lower-Income Countries: Systemic Review of Reviews, 192 Social Science & Medicine 1–13 (2017).
[42] World Health Organization, "Female Genital Mutilation Fact Sheet", accessed Jul. 16, 2020, https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation; Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[43] Ibid..
[44] World Health Organization, "Female Genital Mutilation Fact Sheet", accessed Jul. 16, 2020, https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation.
[45] Ibid..
[46] Ibid.
[47] Ibid..
[48] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[49] Samuel Kimani and Bettina Shell-Duncan, Medicalized Female Genital Mutilation/Cutting: Contention Practices and Persistent Debates, 10 Current Sexual Health Reports 25–34 (Feb. 2018). Also available at https://doi.org/10.1007/s11930-018-0140-y.
[50] Elliot Klein, Elizabeth Helzner, Michelle Shayowitz, Stephan Kohlhoff, and Tamar A. Smith-Norowitz, Female Genital Mutilation: Health Consequences and Complications- A Short Literature Review, Obstetrics and Gynecology International, Jul. 2018, https://doi.org/10.1155/2018/7365715.
[51] Samuel Kimani and Bettina Shell-Duncan, Medicalized Female Genital Mutilation/Cutting: Contention Practices and Persistent Debates, 10 Current Sexual Health Reports 25–34 (Feb. 2018). Also available at https://doi.org/10.1007/s11930-018-0140-y; Spotlight Initiative, "Five Myths About Female Genital Mutilation", accessed Jul. 15, 2020, http://www.spotlightinitiative.org/news/five-myths-about-female-genital-mutilation.
[52] Spotlight Initiative, "Five Myths About Female Genital Mutilation", accessed Jul. 15, 2020, http://www.spotlightinitiative.org/news/five-myths-about-female-genital-mutilation.
[53] Kathryn M. Yount, Kathleen H. Krause, and Stephanie S. Miedema, Preventing Gender-Based Violence Victimization in Adolescent Girls in Lower-Income Countries: Systemic Review of Reviews, 192 Social Science & Medicine 1–13 (2017).
[54] World Health Organization, "Female Genital Mutilation: An Overview", accessed Jul. 16, 2020, https://www.who.int/health-topics/female-genital-mutilation#tab=tab_1.
[55] Elliot Klein, Elizabeth Helzner, Michelle Shayowitz, Stephan Kohlhoff, and Tamar A. Smith-Norowitz, Female Genital Mutilation: Health Consequences and Complications- A Short Literature Review, Obstetrics and Gynecology International, Jul. 2018, https://doi.org/10.1155/2018/7365715.
[56] Ibid..
[57] World Health Organization, "Female Genital Mutilation Fact Sheet", accessed Jul. 16, 2020, https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation.
[58] Department of Justice, "U.S. Government Fact Sheet on Female Genital Mutilation or Cutting," accessed Jul. 16, 2020, https://www.justice.gov/sites/default/files/criminal-hrsp/legacy/2015/02/05/01-22-15fgm-notice.pdf; USAID, "USAID Guidance on Female Genital Mulilation/Cutting (FGM/C)," accessed Jul. 16, 2020, https://www.usaid.gov/sites/default/files/documents/1870/205maa.pdf.
[59] Elliot Klein, Elizabeth Helzner, Michelle Shayowitz, Stephan Kohlhoff, and Tamar A. Smith-Norowitz, Female Genital Mutilation: Health Consequences and Complications- A Short Literature Review, Obstetrics and Gynecology International, Jul. 2018, https://doi.org/10.1155/2018/7365715.
[60] Ibid..
[61] R. Elise B. Johansen, Mai Mahgoub Ziyada, Bettina Shell-Duncan, Adriana Marcusan Kaplan, and Els Leye, Health Sector Involvement in the Management of Female Genital Mutilation/Cutting in 30 Countries, BMC Health Services Research, Apr. 2018, https://doi.org/10.1186/s12913-018-3033-x.
[62] World Health Organization, "Female Genital Mutilation Hurts Women and Economies", accessed Jul. 16, 2020, https://www.who.int/news-room/detail/06-02-2020-female-genital-mutilation-hurts-women-and-economies.
[63] Elliot Klein, Elizabeth Helzner, Michelle Shayowitz, Stephan Kohlhoff, and Tamar A. Smith-Norowitz, Female Genital Mutilation: Health Consequences and Complications- A Short Literature Review, Obstetrics and Gynecology International, Jul. 2018, https://doi.org/10.1155/2018/7365715.
[64] Ibid..
[65] Press Release, UNICEF, A Race Against Trends (Feb. 6, 2018). Also available online at https://www.unicefusa.org/press/releases/race-against-trends/33980.
[66] Elliot Klein, Elizabeth Helzner, Michelle Shayowitz, Stephan Kohlhoff, and Tamar A. Smith-Norowitz, Female Genital Mutilation: Health Consequences and Complications- A Short Literature Review, Obstetrics and Gynecology International, Jul. 2018, https://doi.org/10.1155/2018/7365715.
[67] Ibid..
[68] Ibid..
[69] World Health Organization, "Female Genital Mutilation Hurts Women and Economies", accessed Jul. 16, 2020, https://www.who.int/news-room/detail/06-02-2020-female-genital-mutilation-hurts-women-and-economies.
[70] Ibid..
[71] Alison Thoet, Why the U.S. Ban on Female Genital Mutilation Was Ruled Unconstitutional, PBS News Hour, Dec. 3, 2018, https://www.pbs.org/newshour/nation/why-the-u-s-ban-on-female-genital-mutilation-was-ruled-unconstitutional.
[72] Shelby Quast, UPDATE: Disappointment at the U.S. Department of Justice Decision Not to Appeal Ruling in the First Federal Genital Mutilation Case, Global Newswire, Apr. 11, 2019, https://www.globenewswire.com/news-release/2019/04/12/1803150/0/en/UPDATE-Disappointment-at-the-U-S-Department-of-Justice-decision-not-to-appeal-ruling-in-the-first-federal-genital-mutilation-case.html.
[73] USAID, "USAID Guidance on Female Genital Mulilation/Cutting (FGM/C)," accessed Jul. 16, 2020, https://www.usaid.gov/sites/default/files/documents/1870/205maa.pdf.
[74] UNICEF, "Female Genital Mutilation Is an Extreme Form of Violence Against Girls," accessed Jul. 16, 2020, https://www.unicefusa.org/stories/female-genital-mutilation-extreme-form-violence-against-girls/36956.
[75] Hannah Summers and Rebecca Ratcliff, Mother of Three-Year-Old Is Convicted of FGM in UK, The Guardian, Feb. 1, 2019, https://www.theguardian.com/society/2019/feb/01/fgm-mother-of-three-year-old-first-person-convicted-in-uk.
[76] UNICEF, "Female Genital Mutilation Is an Extreme Form of Violence Against Girls," accessed Jul. 16, 2020, https://www.unicefusa.org/stories/female-genital-mutilation-extreme-form-violence-against-girls/36956.
[77] Ruth Michaelson, FGM Doctor Arrested in Egypt After Girl, 12, Bleeds to Death, The Guardian, Feb. 3, 2020, https://www.theguardian.com/global-development/2020/feb/03/fgm-doctor-arrested-in-egypt-after-girl-12-bleeds-to-death.
[78] R. Elise B. Johansen, Mai Mahgoub Ziyada, Bettina Shell-Duncan, Adriana Marcusan Kaplan, and Els Leye, Health Sector Involvement in the Management of Female Genital Mutilation/Cutting in 30 Countries, BMC Health Services Research, Apr. 2018, https://doi.org/10.1186/s12913-018-3033-x.
[79] Duties to avert and duties to report differ between HCP and other public servants and HCP are bound by medical confidentiality.[79]
[80] Samuel Kimani and Bettina Shell-Duncan, Medicalized Female Genital Mutilation/Cutting: Contention Practices and Persistent Debates, 10 Current Sexual Health Reports 25–34 (Feb. 2018). Also available at https://doi.org/10.1007/s11930-018-0140-y.
[81] World Health Organization, "Female Genital Mutilation: An Overview", accessed Jul. 16, 2020, https://www.who.int/health-topics/female-genital-mutilation#tab=tab_1.
[82] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[83] Ibid..
[84] Kathryn M. Yount, Kathleen H. Krause, and Stephanie S. Miedema, Preventing Gender-Based Violence Victimization in Adolescent Girls in Lower-Income Countries: Systemic Review of Reviews, 192 Social Science & Medicine 1–13 (2017); Spotlight Initiative, Annex I: Description of the Action (Nov. 2018), 9. Also available at http://www.spotlightinitiative.org/sites/default/files/publication/Annex_I_Description_of_the_Action_Spotlight_Initiative_Rider_II_FINAL_1.pdf.
[85] Ibid..
[86] R. Elise B. Johansen, Mai Mahgoub Ziyada, Bettina Shell-Duncan, Adriana Marcusan Kaplan, and Els Leye, Health Sector Involvement in the Management of Female Genital Mutilation/Cutting in 30 Countries, BMC Health Services Research, Apr. 2018, https://doi.org/10.1186/s12913-018-3033-x.
[87] Report of the Secretary General on Intensifying Global Efforts for the Elimination of Female Genital Mutilation, (Jul. 27, 2018), U.N. Doc. A/73/266.
[88] World Health Organization, "Female Genital Mutilation: An Overview", accessed Jul. 16, 2020, https://www.who.int/health-topics/female-genital-mutilation#tab=tab_1.
[89] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[90] Ibid..
[91] World Health Organization, "Female Genital Mutilation: An Overview", accessed Jul. 16, 2020, https://www.who.int/health-topics/female-genital-mutilation#tab=tab_1.
[92] World Health Organization, "Female Genital Mutilation Fact Sheet", accessed Jul. 16, 2020, https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation.
[93] World Health Organization, "Female Genital Mutilation: An Overview", accessed Jul. 16, 2020, https://www.who.int/health-topics/female-genital-mutilation#tab=tab_1; Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[94] World Health Organization, "Unleashing Youth Power: A Decade of Accelerating Actions Towards Zero Female Genital Mutilation", accessed Jul. 16, 2020, https://www.who.int/news-room/detail/06-02-2020-unleashing-youth-power-a-decade-of-accelerating-actions-towards-zero-female-genital-mutilation.
[95] Samuel Kimani and Bettina Shell-Duncan, Medicalized Female Genital Mutilation/Cutting: Contention Practices and Persistent Debates, 10 Current Sexual Health Reports 25–34 (Feb. 2018). Also available at https://doi.org/10.1007/s11930-018-0140-y.
[96] Report of the Secretary General on Intensifying Global Efforts for the Elimination of Female Genital Mutilation, (Jul. 27, 2018), U.N. Doc. A/73/266.
[97] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[98] Spotlight Initiative, Annex I: Description of the Action (Nov. 2018), 9. Also available at http://www.spotlightinitiative.org/sites/default/files/publication/Annex_I_Description_of_the_Action_Spotlight_Initiative_Rider_II_FINAL_1.pdf.
[99] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[100] Ibid..
[101] UNICEF, "Female Genital Mutilation Is an Extreme Form of Violence Against Girls," accessed Jul. 16, 2020, https://www.unicefusa.org/stories/female-genital-mutilation-extreme-form-violence-against-girls/36956.
[102] Ibid..
[103] Ibid..
[104] Ibid..
[105] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[106] Ibid..
[107] Ibid..
[108] USAID, "USAID Guidance on Female Genital Mulilation/Cutting (FGM/C)," accessed Jul. 16, 2020, https://www.usaid.gov/sites/default/files/documents/1870/205maa.pdf.
[109] World Health Organization, "Female Genital Mutilation Fact Sheet", accessed Jul. 16, 2020, https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation.
[110] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[111] Duties to avert and duties to report differ between HCP and other public servants and HCP are bound by medical confidentiality.[111]
[112] USAID, "International Day of Zero Tolerance for Female Genital Mutilation/Cutting," accessed Jul. 16, 2020, https://www.usaid.gov/what-we-do/gender-equality-and-womens-empowerment/international-day-zero-tolerance-fgmc.
[113] Report of the Secretary General on Intensifying Global Efforts for the Elimination of Female Genital Mutilation, (Jul. 27, 2018), U.N. Doc. A/73/266.
[114] Samuel Kimani and Bettina Shell-Duncan, Medicalized Female Genital Mutilation/Cutting: Contention Practices and Persistent Debates, 10 Current Sexual Health Reports 25–34 (Feb. 2018). Also available at https://doi.org/10.1007/s11930-018-0140-y.
[115] Report of the Secretary General on Intensifying Global Efforts for the Elimination of Female Genital Mutilation, (Jul. 27, 2018), U.N. Doc. A/73/266.
[116]UNICEF, Female Genital Mutilation/Cutting: A Global Concern (2016). Also available at https://www.unicef.org/media/files/FGMC_2016_brochure_final_UNICEF_SPREAD.pdf.
[117] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[118] Ibid..
[119] Samuel Kimani and Bettina Shell-Duncan, Medicalized Female Genital Mutilation/Cutting: Contention Practices and Persistent Debates, 10 Current Sexual Health Reports 25–34 (Feb. 2018). Also available at https://doi.org/10.1007/s11930-018-0140-y.
[120] Report of the Secretary General on Intensifying Global Efforts for the Elimination of Female Genital Mutilation, (Jul. 27, 2018), U.N. Doc. A/73/266.
[121] UNICEF, "Female Genital Mutilation Is an Extreme Form of Violence Against Girls," accessed Jul. 16, 2020, https://www.unicefusa.org/stories/female-genital-mutilation-extreme-form-violence-against-girls/36956.
[122] Report of the Secretary General on Intensifying Global Efforts for the Elimination of Female Genital Mutilation, (Jul. 27, 2018), U.N. Doc. A/73/266.
[123] UNICEF, "Female Genital Mutilation Is an Extreme Form of Violence Against Girls," accessed Jul. 16, 2020, https://www.unicefusa.org/stories/female-genital-mutilation-extreme-form-violence-against-girls/36956.
[124] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[125] Ibid..
[126] Ibid..
[127] Ibid..
[128] Ibid..
[129] Ibid..
[130] Ibid..
[131] Ibid..
[132] Ibid..
[133] Ibid..
[134] Ibid..
[135] Ibid..
[136] Ibid..
[137] USAID, "International Day of Zero Tolerance for Female Genital Mutilation/Cutting," accessed Jul. 16, 2020, https://www.usaid.gov/what-we-do/gender-equality-and-womens-empowerment/international-day-zero-tolerance-fgmc.
[138] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[139] Ibid..
[140] Ibid..
[141] Kathryn M. Yount, Kathleen H. Krause, and Stephanie S. Miedema, Preventing Gender-Based Violence Victimization in Adolescent Girls in Lower-Income Countries: Systemic Review of Reviews, 192 Social Science & Medicine 1–13 (2017).
[142] Spotlight Initiative, "Five Myths About Female Genital Mutilation", accessed Jul. 15, 2020, http://www.spotlightinitiative.org/news/five-myths-about-female-genital-mutilation.
[143] Report of the Expert Group Meeting on the Elimination of Female Genital Mutilation, (Apr. 6, 2020), U.N. Doc. A/HRC/44/33.
[144] Kathryn M. Yount, Kathleen H. Krause, and Stephanie S. Miedema, Preventing Gender-Based Violence Victimization in Adolescent Girls in Lower-Income Countries: Systemic Review of Reviews, 192 Social Science & Medicine 1–13 (2017).
[145] Ibid..
[146] R. Elise B. Johansen, Mai Mahgoub Ziyada, Bettina Shell-Duncan, Adriana Marcusan Kaplan, and Els Leye, Health Sector Involvement in the Management of Female Genital Mutilation/Cutting in 30 Countries, BMC Health Services Research, Apr. 2018, https://doi.org/10.1186/s12913-018-3033-x.
[147] Ibid..