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 (1). Although it is internationally recognized as a violation of human rights and legislation to prohibit the procedure has been put in place in many countries, to date the practice is still being reported in 30 countries in Africa and in a few countries in Asia and the Middle East (1, 2). Some forms of FGM have also been reported in other countries, including among certain ethnic groups in Central and South America (1). The rise in international migration has also increased the number of girls and women living in the various diaspora populations, including in Europe and North America, who have undergone or may undergo the practice (3, 4).
It is estimated that over 200 million girls and women worldwide are living with the effects of FGM (2), and despite efforts to eradicate the practice, every year some 3 million girls and women are at risk of FGM and are therefore exposed to the potential negative health consequences of this harmful practice (4).
The World Health Organization (WHO), as part of its core mandate to provide assistance to Member States in achieving the goal of the highest attainable standard of health for all, issued in 2008 an interagency statement on eliminating FGM. The statement describes, among other things, the negative implications of the practice for the health and, very importantly, for the human rights of girls and women, and declared vigorous support for its abandonment (1). The aspiration to alleviate the associated adverse health conditions and to restore violated human rights constitutes the cornerstone of these guidelines.
1.1. Types of FGM
WHO classifies FGM into four types (1), as shown in Box 1.1. The first image shows unaltered female genitalia for comparison.
Types of FGM. Re-infibulation The procedure to narrow the vaginal opening in a woman after she has been deinfibulated (i.e. after childbirth); also known as re-suturing
1.2. Reasons why FGM is performed
FGM is practised for a variety of sociocultural reasons, varying from one region and ethnic group to another. The primary reason is that it is part of the history and cultural tradition of the community. In many cultures, it constitutes a rite of passage to adulthood and is also performed in order to confer a sense of ethnic and gender identity within the community. In many contexts, social acceptance is a primary reason for continuing the practice. Other reasons include safeguarding virginity before marriage, promoting marriageability (i.e. increasing a girl's chances of finding a husband), ensuring fidelity after marriage, preventing rape, providing a source of income for circumcisers, as well as aesthetic reasons (cleanliness and beauty) (5). Some communities believe that FGM is a religious requirement, although it is not mentioned in major religious texts such as the Koran or the Bible. In fact, FGM predates Islam and is not practised in many Muslim countries, while it is performed in some Christian communities (5).
Whatever the reason provided, FGM reflects deep-rooted inequality between the sexes. This aspect, and the fact that FGM is an embedded sociocultural practice, has made its complete elimination extremely challenging. As such, efforts to prevent and thus eventually eradicate FGM worldwide must continue, in addition to acknowledging and assisting the existing population of girls and women already living with its consequences whose health needs are currently not fully met.
1.3. Health risks from FGM
FGM has no known health benefits, and those girls and women who have undergone the procedure are at great risk of suffering from its complications throughout their lives. The procedure is painful and traumatic (1), and is often performed under unsterile conditions by a traditional practitioner who has little knowledge of female anatomy or how to manage possible adverse events (6). 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 genitourinary health consequences (6–8) (see Box 1.2). The evidence indicates that there might be a greater risk of immediate harms with type III FGM, relative to types I and II, and that these events tend to be considerably under-reported (6).
Regarding the obstetric risks associated with FGM, a WHO study group that conducted an analysis on FGM in 2006 concluded that women living with FGM are significantly more likely than those who have not had FGM to have adverse obstetric outcomes, and that this risk seems to be greater with more extensive forms of the procedure (9). These adverse outcomes may also affect the health of the newborn (10) (see Box 1.2).
For many girls and women, undergoing FGM can be a traumatic experience that may leave a lasting psychological mark and cause a number of mental health problems (11, 12) (see Box 1.2).
Given that some types of FGM involve the removal of sexually sensitive structures, including the clitoral glans and part of the labia minora, some women report reduction of sexual response and diminished sexual satisfaction. In addition, scarring of the vulvar area may result in pain, including during sexual intercourse (6, 11) (see Box 1.2).
In addition to these health risks, a number of procedures and day-to-day activities may be hindered due to anatomical distortions, including gynaecological examinations, cytology testing, post-abortion evacuation of the uterus, intrauterine device (IUD) placement and tampon usage, especially in the case of type III FGM.
Providing exact data regarding the direct health impacts of FGM has been a challenging task due to the small sample sizes and methodological limitations of the available studies. Despite these limitations, over the past decade or so, evidence of the direct health impacts of FGM has accrued, enabling recent systematic reviews and meta-analyses to provide summaries of these health impacts. Box 1.2 contains a summary of all health risks related to FGM.
Although there is evidence showing that these adverse health outcomes are associated with FGM, and that many communities have started to acknowledge this association, in reality health-care providers are still often unaware of the many negative health consequences and remain inadequately trained to recognize and treat them properly.
1.4. FGM and human rights
Recognizing the persistence of FGM despite concerted efforts to eradicate or abandon the practice in some affected communities, and recognizing the increased need for clear guidance on the treatment and care of women who have undergone FGM, WHO has developed these guidelines to include a focus on human rights and gender inequality (13).
In December 2012, the Member States of the United Nations (UN) agreed in UN General Assembly resolution 67/146 to intensify efforts to eliminate FGM, as a practice that is “an irreparable, irreversible abuse that impacts negatively on the human rights of women and girls” (14).
For the past several decades, a diverse group of scholars, advocates, legislators and health-care practitioners have offered differing views and ideas about how to best respond to this UN resolution. One consistent and powerful theme in these conversations is a call for common recognition of FGM as a denial of girls' and women's ability to fully exercise their human rights and to be free from discrimination, violence and inequality.
FGM violates a series of well-established human rights principles, norms and standards, 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 (see Box 1.3). As it interferes with healthy genital tissue in the absence of medical necessity and can lead to severe consequences for a woman's physical and mental health, FGM is also a violation of a person's right to the highest attainable standard of health (1).
Human rights violated by the practice of FGM.
A variety of human rights treaties and agreements have also pronounced FGM to be a manifestation of violence against girls and women, and a practice that sustains unequal gender norms and stereotypes that contravene human rights. Human rights treaty monitoring bodies have consistently made clear that harmful practices like FGM constitute a form of discrimination based on sex, gender, age and other grounds (19). Several regional human rights agreements also take up the issue, especially the Protocol on the Rights of Women in Africa (“the Maputo Protocol”), which mandates legal prohibition of harmful practices such as FGM (20). For a comprehensive list of international and regional human rights treaties and consensus documents providing protection and containing safeguards against FGM, please see Annex 1.
The UN Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) and the UN Convention on the Rights of the Child (CRC) further called for an end to the practice, as have a variety of other UN human rights treaty bodies (19). They have clarified that states' “obligations to respect, fulfil and protect” the rights of girls and women require that they take action to ensure that girls and women can live free from harmful practices, such as FGM.
The obligation to respect requires states to refrain from interfering directly or indirectly with the enjoyment of rights. In the case of FGM, it may require states to ensure that the health system is not used to perform this practice, as is the case with medicalization of FGM. The obligation to fulfil requires states to take appropriate legislative, administrative, budgetary, judicial and other actions to prevent and eliminate FGM. Finally, the obligation to protect requires states to ensure that third parties do not violate the rights of girls and women and that protective measures are in place, such as health, legal and social services. This means that states must set in place systems and structures to support “women and children who are victims of harmful practices” by ensuring access to “immediate support services, including medical, psychological and legal services”, as well as emergency medical services (19).
The right to health means that states must generate conditions in which everyone can be as healthy as possible. Despite some progress, governments face persistent challenges in meeting their international obligations within their national laws and policies related to FGM. These range from failing to fully implement and enforce existing laws, failing to foresee and address unintended consequences of laws and policies, and taking misguided actions that may increase the practice, such as the medicalization of FGM (see section 1.5), which is often instituted as a harm-reduction measure (13). Health interventions targeted at women suffering from FGM-related complications can contribute, from within the health system, to the safeguarding and restoration of a number of health-related human rights. In order to achieve this, appropriate evidence-based clinical guidance accompanied by adequate training of health-care providers is a key requirement. While the promotion and protection of human rights is ultimately the responsibility of governments, it is clear that health-care providers have a critical role to play in ensuring that efforts to eradicate FGM and provide care for women living with FGM are accomplished with the utmost attention and consideration of girls' and women's human rights (13).
1.5. Medicalization of FGM
The medicalization of FGM refers to situations in which the procedure (including re-infibulation) is practised by any category of health-care provider, whether in a public or a private clinic, at home or elsewhere, at any point in time in a woman's life. This definition was first adopted by WHO in 1997 (21), and reaffirmed in 2008 by 10 UN agencies in the interagency statement, Eliminating female genital mutilation (1). The interagency statement strongly emphasizes that regardless of whether FGM is carried out by traditional or medical personnel, it represents a harmful and unethical practice, with no benefits whatsoever, which should not be performed under any circumstances.
Communities may be increasingly turning to health-care providers to perform the procedure for a combination of reasons. An important contributing factor is the fact that FGM has been addressed for years as a health issue, using what is known as the “health risk approach”. This approach has involved locally respected health experts expressing concern about the health risks of FGM, in the form of a didactic and factual delivery of messages (22). In several high-prevalence countries, this approach unfortunately did not result in individuals, families or communities abandoning the practice, but began to shift it from traditional circumcisers to modern health-care practitioners in the hope that this would reduce the risk of various complications (21, 22). This brought to light the problem that although providing information about the associated health risks of FGM is an important part of its elimination, it is not sufficient to eradicate a practice strongly based on cultural beliefs and deeply embedded in societal traditions.
As an additional side-effect of the “health risk approach” to FGM, some professional organizations and governments have increasingly supported less radical forms of cutting (e.g. the pricking of the clitoris), performed under hygienic and medically controlled conditions; such harm-reduction strategies are an attempt to reduce the risk of severe complications arising from the procedure when carried out in precarious conditions.
These circumstances – paired with the fact that a number of health-care providers still consider certain forms of FGM not to be harmful and a large proportion of them are unable or unwilling to state a clear position when confronted with crucial issues like requests for performing FGM or re-infibulation (5) – have contributed to increasing the popularity of medicalized FGM across Africa and in the Middle East. In addition, the involvement of health-care providers in performing FGM is likely to confer a sense of legitimacy on the practice and could give the impression that the procedure is good for women's health, or at least that it is harmless (21).
Efforts to stop this unintended consequence were initiated by WHO in 1979 at the first international conference on FGM, held in Khartoum, Sudan, where WHO established that it is unacceptable to suggest that performing less invasive forms of FGM within medical facilities will reduce health complications. Since then, this position has been endorsed by numerous other medical professional associations, international agencies, nongovernmental organizations (NGOs) and governments. The condemnation of medicalization of FGM was further highlighted and reiterated in the 2008 interagency statement on the elimination of FGM (1). It has been recognized that stopping the medicalization of FGM is an essential component of the holistic, human-rights-based approach towards the elimination of the practice: when communities see that health-care providers have taken a stand in favour of the abandonment of the procedure and have refrained from performing it, this will foster local debate and questioning of the practice.
On this basis, WHO has issued within these guidelines a guiding principle statement against the medicalization of FGM, aiming to stop this practice (see section 3.1). One fundamental measure needed to tackle this situation is the creation of protocols, manuals and guidelines to guide health-care providers in dealing with issues related to FGM, including what to do when faced with requests from parents or family members to perform FGM on girls, or requests from women to perform re-infibulation after delivery. Technical knowledge about how to recognize and manage complications of FGM, including suitable obstetric care and how to counsel women on FGM-related issues, must be provided in order to emphasize the health-care provider's role as a caregiver rather than a perpetrator (21). Therefore, adequate training becomes not only a preventive measure, but also an urgently needed tool for coping with the reality that millions of women have already undergone FGM and must live with its consequences.
In the course of developing these guidelines (see Methods, section 2.1), the Guideline Development Group (GDG) noted that an increasingly relevant issue related to FGM is female genital cosmetic surgery (FGCS). Although parallels may exist between FGM and FGCS procedures (which include labial reduction or vaginal tightening because of social, cultural and community norms that promote a particular aesthetic of female beauty and appropriate female bodies), critical differences are evident. FGM as described by the WHO classification (1) and referred to within this document is the result of a procedure that is performed on individuals without full informed consent, and who may face profound direct or indirect coercion to take part in these procedures, which are done in the absence of any potential medical benefit. The underlying reasons for performing FGM in the context discussed within these guidelines perpetuate deep-rooted inequality between the sexes and constitute human rights violations, as described above and noted in the 2009 UN report to the General Assembly on the Girl Child: FGM is “perpetrated without a primary intention of violence but is de facto violent in nature” (23).
Thus, although outside of the immediate scope of these guidelines, the GDG thereby differentiated FGM from FGCS. In the event that FGCS is requested by an individual who is fully autonomous and able to give consent, the individual should be given complete preoperative counselling, including a discussion of normal variation and physiological changes over the lifespan, as well as the possibility of unintended consequences of cosmetic surgery to the genital area. The lack of evidence regarding outcomes and the lack of data on the impact of subsequent changes during pregnancy or menopause should also be discussed and considered part of the informed consent process (24).
1.6. Objectives of the guidelines
1.6.1. Why these guidelines were developed
Following the publication of the 2008 interagency statement on elimination of FGM co-signed by WHO and nine UN partner agencies (1), the UN General Assembly resolution 67/146 of December 2012, Intensifying global efforts for the elimination of female genital mutilations, called on Member States to:
. . . protect and support women and girls who have been subjected to female genital mutilations and those at risk, including by developing social and psychological support services and care, and to take measures to improve their health, including sexual and reproductive health, in order to assist women and girls who are subjected to the practice;
and to:
. . . develop, support and implement comprehensive and integrated strategies for the prevention of female genital mutilations, including the training of social workers, medical personnel, community and religious leaders and relevant professionals, and to ensure that they provide competent, supportive services and care to women and girls who are at risk of or who have undergone female genital mutilations, and encourage them to report to the appropriate authorities cases in which they believe women or girls are at risk (14).
Since the release of the interagency statement and the resolution, significant efforts have been made to counteract FGM, through (i) research to generate further evidence to inform both policy and health interventions; (ii) working with communities on prevention strategies; (iii) advocacy; and (iv) passing of laws. The last involves enabling legislation against FGM and focuses primarily on punitive measures against practitioners and community members who perform FGM, as well as parents who support or condone it. Laws against FGM exist in more than half of the countries where FGM is a traditional practice, as well as in many of the countries with communities of immigrants from countries where FGM is practised. While legal prohibitions create an important enabling environment for abandonment efforts, and criminal prosecutions can send a strong message against the practice, if these are not combined with education and community mobilization, they risk placing health-care practitioners in the position of enforcers of punitive policies, potentially damaging their relationships with their clients and limiting their capacity to engage in rights-based and gender-equality-promoting health practices (13). A framework that includes preventive measures to promote abandonment, as well as punitive measures for those who engage in the practice, has been shown to have a positive effect when coupled with community-based work (21).
In spite of the positive signs resulting from these efforts, prevalence of the practice in many areas remains high and millions of women live today with the negative health consequences of FGM (1). In this regard, the development of pertinent, evidence-based clinical guidelines for health workers is of key importance. First and foremost, guidelines help guide clinical decision-making and ensure the delivery of standardized, quality health services to girls and women currently suffering complications of FGM.
Secondly, guidelines serve as an important basis for both pre- and in-service medical training programmes, which are urgently needed not only in countries with a high prevalence of FGM, but also in high-income countries that are home to growing diaspora communities of people who have migrated from regions where FGM is widespread. As a result, health-care providers across the globe, many of whom have received little or no formal education on the issue of FGM, may find themselves ill-prepared to make sensitive enquiries about FGM and to treat and care for girls and women with FGM-related complications (25).
Further, the development of guidelines offers a unique opportunity to systematically review the available evidence in specific areas of interest, and in this way to identify and target critical research gaps that are crucial to expanding our knowledge in any given scientific field.
Lastly, the technical knowledge conveyed within these guidelines on how to recognize and manage complications of FGM makes it clear that the procedure is inherently harmful to the health of girls and women and, what is more, that it is a violation of several human rights, including the human right to the highest attainable standard of health. This is especially relevant with regard to the efforts to stop medicalization, placing the emphasis on the role of health workers as caregivers who must not also become perpetuators of a harmful practice.
1.6.2. Purpose of these guidelines
The main purpose of these guidelines is to provide evidence-informed recommendations on the management of health complications associated with or caused by FGM.
The guidance provided covers selected topics related to FGM that were considered critically important by an international, multidisciplinary group of health-care providers, patient advocates and other stakeholders. These guidelines, therefore, do not include all reported FGM-related health conditions, but this should on no account be taken to indicate that those conditions are not also real or important.
Additionally, these guidelines, and in particular the knowledge gaps it identifies, may be used as a blueprint for the design of research protocols that could further enrich the scarce evidence currently available on the management of health conditions that may arise from FGM.
1.6.3. 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. These health-care professionals may include, among others, obstetricians and gynaecologists, surgeons, general medical practitioners, midwives, nurses and other country-specific health cadres. Health-care professionals involved in the provision of mental health care and educational interventions, such as psychiatrists, psychologists and social workers, are also part of the target audience. This document also provides guidance for policy-makers, health managers and others in charge of planning, funding and implementing pre- and in-service professional training, and for those responsible for developing training curricula in the areas of medicine, nursing, midwifery and public health.
