Protecting girls and women from harmful practices affecting their health: Are we making progress?☆

2.1. Prevalence and consequences of FGM 

In these early decades, hard data about the true extent of FGM were lacking, making it sometimes difficult to sustain advocacy for action. During the late 1990s, however, WHO estimated that between 100 and 140 million girls and women worldwide had been subjected to FGM [5], most of whom were living in 28 countries in Africa and a few countries in Asia and the Middle East, and these figures have been widely used since. Despite the increased international and national attention, the prevalence of FGM overall has declined very little. Estimates based on the most recent prevalence data indicate that 91.5 million girls and women older than 9 years in Africa are currently living with the consequences of female genital mutilation [6]. In some countries, such as Burkina Faso and Senegal, considerable progress has been made in reducing the prevalence of the practice, but in others such as Egypt and Sudan, the declines are extremely slow [7], [8]. There are still an estimated 3 million girls in Africa at risk of undergoing FGM every year [7]. And while good prevalence data have yet to be compiled, it is clear that migration has increased the number of girls and women living outside their country of origin—particularly in western Europe and North America—who have undergone FGM or who may be at risk of being subjected to the practice [9]. The health consequences of FGM have been well documented [9]. The immediate complications, especially hemorrhage and infection, can cause death, and the late complications whether physical or psychological may cause suffering to women throughout their lives.

Perhaps most worrying is the apparent trend toward the practice being carried out by trained health personnel, as opposed to traditional circumcisers. Surveys in some countries indicate that at least one-third of women whose daughters underwent FGM had the procedure carried out by a trained health professional [10]. And a comparative analysis of Demographic and Health Surveys shows a very clear and sometimes substantial increase in the medicalization of FGM in some countries [11]. In addition, female genital mutilation in the form of reinfibulation has been documented as being performed as a routine procedure after childbirth in some countries [12], [13], [14]. Among groups that have immigrated to Europe and North America, reports indicate that reinfibulation is occasionally performed even where it is prohibited by law [15].

Over the past decade, strongly-established evidence now confirms that women who undergo genital mutilation have significantly increased risks for adverse events during childbirth. In a 6-country study conducted by WHO, higher incidences of cesarean delivery and postpartum hemorrhage were found in women who had type I, II and III genital mutilation compared with those who had not undergone the practice, and the risk increased with the severity of the procedure [16]. A new finding was that babies born to mothers who had undergone genital mutilation were 15%–55% more likely to die immediately after birth (depending on the type of FGM) than those born to mothers without FGM. It was estimated that, at the study sites, an additional 1–2 babies per 100 deliveries die as a result of FGM.

2.2. Recognition of girls' and women's rights to protection 

While progress on declining prevalence is slow, significant progress has been made in the recognition of FGM as a violation of human rights. Since the 1980s, harmful practices including FGM have increasingly been recognized as a violation of a series of well-established human rights principles, norms, and standards, including the principles of equality and nondiscrimination on the basis of sex, the right to life when the procedure results in death, and the right to freedom from torture and cruel, inhuman or degrading treatment or punishment. It has also become widely acknowledged that FGM is also considered to be a violation of a person's right to the highest attainable standard of health, since 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.

Regional human rights treaties such as the African Charter on the Rights and Welfare of the Child [17], and the African Charter on Human and People's Rights and its Protocol on the Rights of Women in Africa [18] have elaborated on states' legal obligations to eliminate the practice, and constitutional and national human rights guarantees have been established specifically in this regard. These, together with the international human rights treaties and consensus documents, have provided the basis for action for states and many organizations at both national and international level.

An important marker of progress in the recognition of girls' and women's rights regarding FGM is adoption by the Economic and Social Council of the UN [19], and the World Health Assembly of resolutions specifically focusing on FGM [20], in both of which the affirmation of girls' and women's human rights is extremely strong. The latter was inspired by an interagency statement on eliminating female genital mutilation, released in February 2008 and signed by heads of 10 UN agencies [9].

Based on the above-mentioned legally-binding international, regional, and national laws and other consensus documents, states have an obligation to grant special protection for children and take appropriate measures to eliminate harmful social and cultural practices affecting the welfare, dignity, normal growth, and development of the child [21], [17], [18]. In particular, states have an obligation to eliminate those customs and practices that are prejudicial to the health or life of the child and are discriminatory to the child on the grounds of sex or other status. Faced with the human rights arguments, those who wish to legitimize the practice of FGM or other harmful traditional practices often argue that FGM is part of the culture and tradition of the society in which women live, that women gain benefits from going through the practice, and that any restriction on carrying out FGM would be a violation of girls' and women's rights related to participating in cultural life and freedom of thought and religious freedom. However, it has been established at international, regional, and national levels that the primary consideration of the best interests of the child with regard to any action affecting their health and well-being is a basic human rights principle [21], [17], [18]. On the basis of this principle, it has been legally established that the apparent benefits to be gained from FGM—that it will make the girl more "marriageable" or keep her "virginal" for instance—do not outweigh the risks involved, and thus the procedure cannot be defended as it is not in the best interests of the child [9]. Furthermore, religious freedom and freedom of expression cannot be justified if they are used to defend practices that violate the fundamental rights of individuals, especially children [22], [23].

A companion principle in human rights is that the evolving capacity of the child in decision-making about procedures that affect them has to be taken into account. It has been argued that girls who undergo FGM are deprived of making an independent decision about an intervention that has a harmful and lasting effect on them. Even in cases where there is an apparent agreement or desire by girls to undergo the procedure, in reality it is the result of social pressure and community expectations and stems from the girls' aspiration to be accepted as full members of the community. A girl's decision to undergo female genital mutilation cannot be called free, informed or free of coercion [9].

2.3. Obligations and actions to eliminate harmful practices against women and girls 

All states in the world have ratified at least one international treaty, and most states have ratified many treaties including regional treaties. By doing so, and by putting constitutional guarantees in place, states have committed themselves to take targeted steps to realize human rights of all, with attention to those who are in an especially vulnerable position, such as women and girls. They thus have legal obligations to take all appropriate and effective regulatory, remedial, administrative, budgetary, educational, and other measures to eliminate FGM and other harmful practices to the maximum extent of their available resources.

Over the past decade in particular, many states where FGM is practiced have taken such regulatory and remedial measures which have included elaborating specific laws on FGM, amending the criminal code and child protection law, and developing regulations on preventing and eliminating the medicalization of the practice. Many have recognized, however, that the use of law is only one component of a multidisciplinary approach to stopping the practice of FGM and that outreach efforts by civil society, governments, and other players aimed at changing perceptions and attitudes regarding FGM should accompany legislation on FGM [24], [25].

There are a few places where FGM has been abandoned on a large scale. Where this has happened, it has resulted from a process of social change in which a significant number of families within a community make a collective, coordinated choice to abandon the practice so that no single girl or family is disadvantaged by the decision [26]. Often this has been done through educational activities geared to empowerment undertaken by community-based organizations, in which information about health, hygiene, nutrition, and women's rights more broadly leads to discussion of FGM and what should and can be done about it [27]. Experience has shown that only if the decision is widespread within the practicing community will it be sustained and thus bring about a new social norm that does not harm girls or violate their rights. Community-led action is therefore essential.

Accountability for eliminating FGM ultimately rests with a government, but many other actors also have responsibilities. Thus, for instance, it is the duty of the ministry of health to prevent and eliminate the medicalization of the practice, including the practice of reinfibulation, through regulatory and other measures. At the same time, health care professional associations have an obligation to ensure that neither private nor public providers perform FGM, and health professionals individually carry a special responsibility [9]. At the very least, they have a key role in caring for girls and women who have suffered the consequences of FGM, but they also have an obligation to educate and inform their patients—and the wider community—about their sexual and reproductive health, their natural body functions, and the harmful consequences of FGM. Critical in the pathway to elimination of FGM is the total refusal on the part of any healthcare worker to perform FGM for whatever reason. Any performance of FGM by medical personnel is likely to wrongly legitimize the practice as medically sound or beneficial for girls' health [28]. Given the worrying trend toward medicalization in some parts, this is an area where intensive action is needed in order for progress to be made.

The health sector has the responsibility to conduct research and develop strategies to address FGM as agreed in the African Union's Maputo Plan of Action on Sexual and Reproductive Health Rights [29], but high quality, ethical research in this area is also the responsibility of universities and other academic institutions.

Where domestic capacity is not sufficient for effective response to the practice, other states have an obligation to provide support and assistance—including through the UN and other international agencies—to the country whose population is affected by the practice. Beside the financial support, other measures, such as the issuing of residence permits and protection for the victims of this practice and recognizing the right to asylum of women and girls at risk of being subjected to FGM, should be taken [30].