Female genital mutilation (FGM) comprises all procedures that involve the partial or total removal of external genitalia or other injury to the female genital organs for non-medical reasons. The procedure has no known health benefits. Moreover, the removal of or damage to healthy genital tissue interferes with the natural functioning of the body and may cause several immediate and long-term health consequences. Girls and women who have undergone FGM are therefore at risk of suffering from its complications throughout their lives. In addition, FGM violates a series of well-established human rights principles, including the principles of equality and non-discrimination on the basis of sex, the right to life when the procedure results in death, and the right to freedom from torture or cruel, inhuman or degrading treatment or punishment, as well as the rights of the child.
The practice – prevalent in 30 countries in Africa and in a few countries in Asia and the Middle East – is now present across the globe due to international migration. Health-care providers in all countries may therefore face the need to provide health care to this population. Unfortunately, health workers are often unaware of the many negative health consequences of FGM and many remain inadequately trained to recognize and treat them properly.
Recognizing the persistence of FGM despite concerted efforts to eradicate or abandon the practice in some affected communities, and acknowledging the 200 million girls and women living with or at risk of suffering the associated negative health consequences, these guidelines aim to provide up-to-date, evidence-informed recommendations on the management of health complications from FGM. This document also intends to provide standards that may serve as the basis for developing local and national guidelines and health-care provider training programmes.
Target audience
These guidelines are intended primarily for health-care professionals involved in the care of girls and women who have been subjected to any form of FGM. This document also provides guidance for policy-makers, health-care managers and others in charge of planning, developing and implementing national and local health-care protocols and policies. The information contained in this document will also be useful for designing job aids and pre- and in-service professional training curricula in the areas of medicine, nursing, midwifery and public health for health-care providers caring for girls and women living with FGM.
Guideline development methods
This document was developed using standard operating procedures in accordance with the process described in the WHO handbook for guideline development, second edition.1 In summary, the process involved: (i) identification of critical research questions and outcomes; (ii) commissioning of experts to conduct systematic reviews; (iii) retrieval of up-to-date evidence; (iv) quality assessment and synthesis of the evidence; (v) formulation of recommendations; and (vi) planning for the dissemination, implementation, impact evaluation and updating of the guidelines. The scientific evidence that informed the recommendations and best practice statements was synthesized using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods.2 For each priority research question, evidence profiles were prepared from existing or commissioned systematic reviews. Values and preferences of clients and health-care providers were assessed using evidence from qualitative reviews on the context and conditions of interventions used to manage health complications of FGM.3 The recommendations and best practice statements were developed using a consensus-based approach by the Guideline Development Group (GDG), an international group of experts in the field of FGM, during a meeting at the World Health Organization (WHO) headquarters in Geneva on 1–2 September 2015.
Guidance: recommendations and best practice statements
The guideline development process led to the adoption of three statements of “guiding principles”, five recommendations and eight best practice statements, covering the use of deinfibulation, mental health, female sexual health, and information and education (see Guidance summary tables). For each recommendation and best practice statement the quality of the evidence was graded as “very low”, “low”, “moderate” or “high”, based on the GRADE methods. When no evidence was identified for a recommendation or best practice statement, or only indirect evidence was available, this was indicated in the summary of the evidence.
Recommendations were considered as “strong” (two recommendations) or “conditional” (three recommendations), based on the available evidence, as well as considerations of the balance between benefits and harms, women's and health-care providers' preferences, human and other resource implications, priority of the problem, equity and human rights issues, and acceptability and feasibility of the proposed intervention. Where there was a need for guidance, but no relevant research evidence was available, recommendations and best practice statements were agreed if they were supported by the public health or medical practice expertise of the members of the GDG. In order to ensure each recommendation and best practice statement could be understood and used as it was intended, the GDG offered further clarifications as needed, which are noted below the relevant recommendations and best practice statements where they are presented in full within the text of these guidelines.
Input from peer reviewers and a range of stakeholders, including colleagues working directly with girls and women living with FGM, was also sought and helped to further clarify the wording of the recommendations and best practice statements. Important knowledge gaps that need to be addressed through primary research were identified and included in the document.
The recommendations and best practice statements on the management of health complications from FGM are summarized in the . They will be reviewed and updated following identification of new evidence.
Guidance summary
Guiding principles
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Girls and women living with female genital mutilation (FGM) have experienced a harmful practice and should be provided quality health care. All stakeholders – at the community, national, regional and international level – should initiate or continue actions directed towards primary prevention of FGM. Medicalization of FGM (i.e. performance of FGM by health-care providers) is never acceptable because this violates medical ethics since (i) FGM is a harmful practice; (ii) medicalization perpetuates FGM; and (iii) the risks of the procedure outweigh any perceived benefit.
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Summary of the recommendations (R) and best practice statements (BP)
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| DEINFIBULATION |
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- R-1.
Deinfibulation is recommended for preventing and treating obstetric complications in women living with type III FGM (strong recommendation; very low-quality evidence). - R-2.
Either antepartum or intrapartum deinfibulation is recommended to facilitate childbirth in women living with type III FGM (conditional recommendation; very low-quality evidence). - R-3.
Deinfibulation is recommended for preventing and treating urologic complications – specifically recurrent urinary tract infections and urinary retention – in girls and women living with type III FGM (strong recommendation; no direct evidence). - BP-1.
Girls and women who are candidates for deinfibulation should receive adequate preoperative briefing (Best practice statement). - BP-2.
Girls and women undergoing deinfibulation should be offered local anaesthesia (Best practice statement).
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| MENTAL HEALTH |
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- R-4.
Cognitive behavioural therapy (CBT) should be considered for girls and women living with FGM who are experiencing symptoms consistent with anxiety disorders, depression or post-traumatic stress disorder (PTSD) (conditional recommendation; no direct evidence). - BP-3.
Psychological support should be available for girls and women who will receive or have received any surgical intervention to correct health complications of FGM (Best practice statement).
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| FEMALE SEXUAL HEALTH |
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- R-5.
Sexual counselling is recommended for preventing or treating female sexual dysfunction among women living with FGM (conditional recommendation; no direct evidence).
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| INFORMATION AND EDUCATION |
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- BP-4.
Information, education and communication (IEC)4 interventions regarding FGM and women's health should be provided to girls and women living with any type of FGM (Best practice statement). - BP-5.
Health education5 information on deinfibulation should be provided to girls and women living with type III FGM (Best practice statement). - BP-6.
Health-care providers have the responsibility to convey accurate and clear information, using language and methods that can be readily understood by clients (Best practice statement). - BP-7.
Information regarding different types of FGM and the associated respective immediate and long-term health risks should be provided to health-care providers who care for girls and women living with FGM (Best practice statement). - BP-8.
Information about FGM delivered to health workers should clearly convey the message that medicalization is unacceptable (Best practice statement).
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- 4
WHO defines information, education and communication (IEC) interventions as “a public health approach aiming at changing or reinforcing health-related behaviours in a target audience, concerning a specific problem and within a pre-defined period of time, through communication methods and principles”. Source:
Information, education and communication – lessons from the past; perspectives for the future. Geneva: World Health Organization; 2001. .
- 5
Health education is the provision of accurate, truthful information so that a person can become knowledgeable about the subject and make an informed choice. Source:
Training modules for the syndromic management of sexually transmitted infections: educating and counselling the patient. Geneva: World Health Organization; 2007. .
- 1
WHO handbook for guideline development. 2nd ed. Geneva: World Health Organization; 2014. .
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- 3
The GDG issued recommendations when the available evidence and ancillary criteria supported their development. When the available evidence is of low quality or weak but the contents of the recommended statement were based upon sound judgement and supported by human rights and equity principles, public or medical practices, and judged to have little to no risk of harm to health, best practice statements were issued.
