This chapter should be cited as follows:
Kihara AB, Koigi MK, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.417783

The Continuous Textbook of Women’s Medicine Series – Gynecology Module

Volume 1

Female genital mutilation

Volume Editor: Professor Anne-Beatrice Kihara, University of Nairobi, Kenya,
President-elect. The International Federation of Gynecology and Obestetrics FIGO
President, African Federation of Obstetricians and Gynecologists (AFOG)

Chapter

The Epidemiology of Female Genital Mutilation/Cutting

First published: July 2022

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INTRODUCTION

Female Genital Mutilation/Cutting (FGM/C) refers to all procedures that involve the partial or total removal of the external genitalia or other injury to the female genital organs for non-medical reasons.¹ The World Health Organization (WHO) classifies FGM/C into four types² as shown in Box 1. In addition to this, the four subtypes of FGM have been included in the 11th Edition of the International Classification of Diseases (ICD-11).³

HISTORICAL BACKGROUND

Historically, FGM/C is thought to date back to the Pharaonic times. However, the practice is prevalent among animists, Catholics, Jews, Muslims, Protestants, and even amongst the areligious. The first documented opposition to this practice came from medical doctors in Egypt and Kenya in the 20th Century.^4,5

A GLOBAL PERSPECTIVE

Globally, up to 200 million women/girls have undergone FGM/C, while a further 3.6 million girls risk being cut annually.⁶ FGM/C is prevalent in 30 countries in Africa and several countries in Asia and the Middle East. The practice has also been reported among certain ethnic groups in Central and South America.⁷ The rise in international migration has increased the number of girls and women in first world countries who have either undergone or are at risk of undergoing the practice.^8,9,10,11 The modal prevalence of FGM/C among women of reproductive age (15–49 years old) are reported in Somalia (98%), Guinea (97%), and Djibouti (93%). On the other hand, amongst those under 14, the modal prevalence is reported in Gambia (56%), Mauritania (54%), and Indonesia (~50%).¹² Despite overall declines in rates of FGM/C, high rates of population growth in practicing countries means that the number of affected women and girls will likely increase by 2030. The global prevalence of FGM is shown in Figure 1.

CROSS-BORDER PRACTICE OF FGM/C

Data on FGM/C in high-income diaspora countries, including the United States of America (USA), Canada, Australia, New Zealand, Japan, and the European Union (EU), were mostly obtained using indirect estimates.^8,9,10,11 In the EU, up to half a million women and girls were estimated to be living with FGM/C based on secondary exploratory analysis from the 2011 EU census that highlighted age-specific FGM/C prevalence rates in immigrants’ home countries. In the USA, a similar number of women and girls were estimated to be living with FGM/C. This was deduced by extrapolative application of country-specific prevalence of FGM/C to the estimated number of women and girls living in the USA or with a parent born in that country.^8,10,14 Although there has been a progressive but gradual overall decline in the global prevalence of FGM/C, the rate of decline has been uneven and some countries have elicited no progress.¹⁵

Presently, FGM/C has permeated various parts of the world due to migration. This has resulted in the perpetuation of this deeply embedded traditional practice in the diaspora, making it a global problem.^9,16 Some of the factors that have contributed towards the persistence and perpetuation of this practice include the following: intermarriage; affordability; quality of FGM/C services; fear of arrest; and lack of proximity to circumcisers in the native countries.¹⁷ As this practice is largely considered harmful and illegal, it is usually undertaken in secret, with the perpetrators either being aided by relatives or are themselves closely related to the victims.^16,18 In this context, there exists a veritable paucity of data on this aspect, especially in areas where the practice is considered illegal.¹⁶ Insufficient data, in and of itself, constitutes a major problem in the prioritization and protection of those at risk of this harmful practice.^9,16

Several challenges have been identified in the attempt to mitigate cross-border FGM/C, including the following:¹⁸

• The socio-economic benefits accrued by the families, traditional healers, and excisers;
• Change in tactics in conducting the practice, e.g., performing the cut during delivery by a traditional birth attendant;
• Strong social bonds that make reporting difficult, as some of the perpetrators are relatives;
• Cross-border movements as seen in pastoralist communities;
• Dual citizenship;
• Poor surveillance across borders, thereby enabling rapid escape of the perpetrators;
• Limited access to basic services, including schools, health facilities, police stations, and courts amongst most practicing communities. Therefore, there are concurrent problems of insufficient education, access to medical care, and paucity of facilities to ensure prosecution of cases;
• Hiatuses of data on cross-border practices lead to a failure to appreciate the true magnitude of the problem;
• Insufficient allocation of resources.

SOCIAL ASPECTS OF FGM/C

Although intent to perform FGM/C still exists in various communities, evidence shows that the trend is likely to reduce, especially with the emergence of anti-FGM legislation.^17,19,20 The social reasons that have been thought to perpetuate the practice of FGM/C include the following: marriageability; prevention of premarital sex and promiscuity; preventing the spread of human immunodeficiency virus (HIV) infection; social acceptance; hygiene; religious identity; cosmesis; tradition; and perception as a rite of passage.^{5,17,21,22,23,24,25,26}

The practice of FGM/C is often the herald of forced and childhood marriage, therefore exposing girls to the atrocities thereof, including the following: denial of the opportunity to pursue further formal education; intimate partner and domestic violence; and a myriad of obstetric and neonatal complications due to childhood/teenage pregnancy, including but not limited to obstructed labor, obstetric fistula, preterm birth, maternal and neonatal death.^17,23,27,28

GLOBAL TRENDS OF FGM/C

Current evidence shows that the practice is generally on the decline in most countries, with the current trend likely to continue.^29,30,31 This may be attributed to anti-FGM laws and increased knowledge of health complications associated with FGM/C,^17,18 as demonstrated by global governments’ commitments to eliminate violence against women.³² However, this has led to the controversial aspect of medicalization of FGM, with a subsequent shift from the more severe form (type III) to the less severe forms (type I or II).^17,29,33,34 Alternatively, in some instances, healthcare professionals have been asked to perform a "nick" or "prick" on the clitoris as a form of harm reduction.³⁴ However, this approach is thought to attempt to legitimize a practice that is an overt violation of human rights (ibid).

Some studies have shown that there has been a decline in FGM/C in the rural areas in some regions.²⁹ This could in part be attributed to rural–urban migration, in addition to increased access to education, technology, and awareness of the consequences of FGM/C (ibid).

MEDICALIZATION OF FGM/C

“It is the mission of the physician to safeguard the health of the people.”

World Medical Association Declaration of Helsinki, 1964

Medicalization of FGM/C represents a change that entails situations whereby licensed certified healthcare professionals of various cadres (doctors, nurses, midwives, or other health professionals) perform FGM/C either in a health facility, at home, or in a neutral place, often using surgical tools, anesthetics, and antiseptics.^35,36 It also includes re-infibulation, which refers to re-closing external genitalia of women who had been de-infibulated to allow for sexual intercourse, birth delivery and/or related gynecologic procedures by doctors or midwives.³⁵ Although these shifts are supported by community social norms passed for generations, other dynamics show emerging evidence from demographic health surveys (DHSs), multiple indicator cluster surveys (MICSs), and qualitative research suggests that some families and communities are shifting how FGM/C is practiced, to sustain rather than abandon it, mainly due to the following: perceived harm reduction, willingness of some health providers to carry out the procedure, financial incentive or social recognition.^12,37,38,39 The greatest burden of medicalized FGM/C is concentrated in Sudan (67%), Egypt (38%), Guinea (15%), Kenya (15%), and Nigeria (13%), where nurses, trained midwives, and other lower-level providers perform FGM/C; Egypt is exceptional because the cutting is mainly by doctors.^35,36,38,39 Furthermore, the risk of medicalization is higher among girls aged 0–14 years rather then those of reproductive age (15–49 years), and the trend towards medicalization may instigate institutionalization of the practice, which would encourage its perpetuation rather than its extermination.^35,36

Medical licensing authorities and professional associations have joined the United Nations’ organizations in condemning attempts to medicalize FGM/C.³⁸ The International Federation of Gynaecology and Obstetrics (FIGO) passed a resolution in 1994 in its general assembly that included a recommendation to oppose any attempt to medicalize the procedure or to allow its performance, under any circumstances, in health establishments or by health professionals (FIGO, 1994.^35,40

CONCLUSION

Female genital mutilation/cutting is a violation of human rights that has existed from the early records of human history and has escalated to become a global problem. This catastrophe is estimated to afflict over 200 million girls and women globally, and over 3 million more are at risk annually. Despite the decline that has been observed over the last few decades, the prevalence of this practice remains unacceptably high, with some areas having nearly ubiquitous performance of the procedure. This remains the case despite global initiatives and legislative sanctions, with further difficulties being instigated by the attempts at medicalization of the procedure. Overall, there is a need to increase the efforts on multiple fronts in order to protect those who are at risk.

PRACTICE RECOMMENDATIONS

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