Like many people, I find FGM deeply upsetting. Like many people, I feel intense discomfort – emotional and physical – when merely reading about it. Like many people, I can’t begin to imagine what the girls and women subjected to FGM experience and live through.

A literature review published in Nursing Times in 2013, sheds important light on this last point:

  • They experience significant negative psychological effects, with frequent emotional distress, anxiety and fear;
  • They report feelings of isolation, loneliness and resentment towards family members who were present at the time they underwent the procedure;
  • They are profoundly affected physically – many live with fear of the scars opening; many behave and move differently after the procedure;
  • Their sexual quality of life is significantly reduced;
  • They very seldom have any access to any form of psychological support.

The same article sets out a comprehensive overview of the effects of FGM, from immediate to longer term effects, and from psychological to gynaecological and obstetric complications.

Screen Shot 2014-02-06 at 21.27.43

It is a major issue globally. The WHO estimates that up to 140 million women and girls have undergone FGM worldwide, and 3 millions are at risk each year in Africa alone. This makes for a massive potential healthcare burden, with many associated medical, social and economic implications. For more data on FGM globally, see the Guardian’s interactive summary of the landmark 2013 UNICEF report.

Research published in the Lancet helpfully highlights some key lessons about what works, and what doesn’t, in reducing FGM. To quote directly:

Female genital mutilation, also known as female genital cutting, is a deeply rooted cultural practice in more than 28 African countries, parts of the Middle East, and pockets of Asia… Support for the practice in communities is broad-based. Mothers, mothers-in-law, fathers, and religious and community leaders defend the practice on the basis of a girl’s future role as wife and mother. Reasons cited for support include its role as a rite of passage into womanhood, marriageability, curbing sexual desire, and protecting virginity. It is not condoned by any major religion but often has socioreligious significance. Despite its cultural entrenchment, a gradual reduction is occurring in a number of countries, even without targeted interventions. The challenge is to identify successful approaches to accelerate the decline.

A number of interventions aimed at changing community norms and reducing female genital mutilation, do seem to have been proved reasonably effective. They include:

  • Sensitising communities about female genital mutilation by local leaders and by empowering girls – see for example this case study of work done among the Maasai of Kenya and Tanzania
  • Providing culturally appropriate alternative rites of passage for girls to substitute for mutilation  – see this PATH review, again from Kenya 
  • Employing Positive Deviance approaches, identifying  women and men who oppose the practice despite prevailing norms and using them to raise awareness of the issue and advocate for change – see this review from CDPA in Egypt
  • Including FGM issues in basic education programmes for women that address hygiene, human rights, literacy, community problem-solving, and health. In Sengal, Burkina and Kenya, an important focus has been working toward “public declarations” opposing female genital mutilation – see a study on a Senegal initiative
  • Highlighting the potential damage to the fertility of girls is also a potentially powerful tool against FGM

There are also some approaches that have been flagged as partial, incomplete, or often not working as intended:

  • Trying to stop providers of FGM to stop the procedure with alternative livelihoods have not worked, because they have not addressed  demand from communities
  • As the UK is discovering, laws criminalising female genital mutilation, while important policy statements, are not sufficient because they also do not address demand
  • Use of trained medical personnel to perform the procedure can in some contexts lead to support by the medical establishment, and can perpetuate the practice
  • Attention to the adverse health consequences can merely push communities to undertake less severe cutting, rather than ceasing the practice

Underpinning all of this is a major qualification: there is an urgent need for more and better research and evaluation of FGM interventions. In a 2009 systematic review of FGM practices looking at 3667 articles, only 6 met the acceptance criteria for inclusion in the review (yes, that is six out of over three thousand six hundred, no typo!) This clearly needs to improve if FGM interventions are going to become more effective at addressing the issue (see excellent comment from Michael O’Donnell below, and my response).

The evidence that does exist suggests that the optimal approach for tackling FGM needs to be both systemic and adaptive, and work with a range of stakeholders from communities, health professionals, and policymakers. As the Lancet piece suggests:

Like all efforts to change broad social norms, the most effective approach to eradicating female genital mutilation seems to be multifaceted, intervening at many strategic points throughout society, and promoting a different norm publicly….  multiple strategic approaches with various different messages [will] collectively tip the weight of public opinion…”

Full disclosure: the lead author of the Nursing Times is my cousin, Kate Harris, who wrote the first version while she was still an undergraduate.

Addendum: Check out this PRB info graphic and website (apologies for original misattribution!).

fgmc-infographic

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Join the conversation! 5 Comments

  1. Hi Ben – great article. But there seems to be a slight contradiction at one point: if only 6 out of 3667 articles on a complex issue like FGM met the criteria for inclusion in that systematic review (presumably because they needed to use experimental research methods), is that a reflection of poor evidence, or an inappropriately high standard of evidence when you’re trying to learn about a complex issue that you acknowledge is best addressed by “systemic and adaptive” approaches? RCTs can be fab, but your article shows that we can also gain vital insights through other types of evidence.

    Reply
  2. Thanks for this very useful comment Michael. I am no advocate of RCTs as a gold standard for all kinds of interventions, as I hope my previous writings make clear! But my reading of the systematic review was that there were a number of factors which they called for in high quality studies: (1) to be randomized, or at a minimum, to secure similar distribution of prognostic factors in the intervention and comparison groups (2) to be long-term to ensure viability and reliable assessment of changes in prevalence (3) to take into account
    regional, ethnic and sociodemographic variation in the practice of FGM/C (4) to focus on
    prevalence, behaviours, and intentions (5) to be cross-disciplinary, if possible through international collaborative initiatives. Wouldn’t these quality criteria all apply to a solid and evidence-based “systemic and adaptive” approach?

    Reply
    • Perhaps I am just too pessimistic about what we can realistically expect to generate in terms of evidence, though I’d like to think I’m pragmatic about the ability to discern good enough lessons from a wider selection of slightly less “high-quality” evidence. (Though I also wonder about the practical feasibility and ethics of trying to survey a control group in relation to FGM…)

      Reply
  3. Hi Ben–I’m with the Population Reference Bureau (PRB) and I thank you for sharing our FGM/C infographic! But, it’s not actually by WHO as you’ve attributed–it’s by PRB. You can also view the infographic and find out more by visiting PRB’s website at: http://www.prb.org/Publications/Media-Guides/2014/infographic-fgm.aspx. Sincerely, Tyjen Tsai

    Reply
  4. Flattered that you seem (?) to be inspired by the image for my blog’s STOP FGM category, Ben: http://hilaryburrage.com/fgm/. I agree absolutely that the systematic review of interventions and data is critical – which I why I’m trying very hard also to emphasise the economic (micro- and macro-) analyses > http://hilaryburrage.com/2014/02/06/the-global-economics-of-female-genital-mutilation-fgm/ (etc). Plenty still to be done, as you and Michael say. Would be pleased to discuss further with either / both of you…

    Reply

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About Ben Ramalingam

I am a researcher and writer specialising on international development and humanitarian issues. I am currently working on a number of consulting and advisory assignments for international agencies. I am also writing a book on complexity sciences and international aid which will be published by Oxford University Press. I hold Senior Research Associate and Visiting Fellow positions at the Institute of Development Studies, the Overseas Development Institute, and the London School of Economics.

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Campaigns, Gender, Healthcare, Influence, Public Policy, Reports and Studies, Research