Each year, millions of girls around the world — some just babies, others as old as 15 — are at risk of undergoing the potentially dangerous procedure of having their genitalia partially or totally removed, often against their will. They are given little or no pain medication and no explanation, and are forbidden to speak about what happened.
The procedure — known as female genital mutilation/cutting (FGM/C) — is internationally recognized as a serious violation of human rights and a form of gender-based violence and child abuse. It has no known health benefits and can cause acute and chronic physical and mental health problems. It is illegal in 51 countries, including the United States.
Yet FGM/C is still occurring at an alarming rate across the globe. Approximately 200 million women and girls have already been subjected to this crime, and an estimated 3.9 million girls are at risk of undergoing the procedure each year. If current levels of the practice continue, prevalence numbers are projected to increase over the next 10 years.
“FGM/C occurs in countries on nearly every continent,” said Marieke Brock, researcher in the Federal Research Division of the Library of Congress, during an interview. “It is a global problem that transcends religion, socioeconomic status, and geography.”
The United States is no exception. One estimate holds that as many as half a million girls and women in this country could have suffered or are at risk of suffering FGM/C. Most were born in countries where FGM/C is rooted in cultural beliefs or live with a parent born in a country where it is practiced.
From a criminal justice perspective, the burden of preventing FGM/C falls primarily to law enforcement. This can present significant challenges for officers, as affected women and girls are often difficult to identify and may not come into contact with law enforcement. Also, women who had the procedure when they were young may not even recognize that they have been subjected to FGM/C. The practice is deeply rooted in cultural traditions and beliefs, and departing from the norm can lead to condemnation, harassment, and even ostracism from the community. Consequently, women and girls at risk may not seek help.
To support law enforcement’s ability to understand FGM/C, the National Institute of Justice (NIJ) partnered with Brock and her colleagues at the Library of Congress on a report that examines acts of gender-based violence in the United States that are rooted in cultural practices: FGM/C, honor violence, and forced marriage. The report offers a snapshot of all three practices in this country, noting, in particular, significant challenges in collecting accurate prevalence data on FGM/C. It also explores the cultural beliefs that reinforce these practices and existing responses across the federal government.
“The goal is to help law enforcement and other professionals working with these women develop a sound knowledge base,” said Brock. “Ultimately, it will take good data, strong partnerships, and collaboration across fields to mount an effective response to FGM/C.”
An Incomplete Picture of FGM/C in the United States and Abroad
According to UNICEF, FGM/C mostly occurs in the eastern, northeastern, and western regions of Africa, and in some countries in Asia and the Middle East. It also occurs among certain immigrant communities in North America (including the United States) and Europe.
To determine how prevalent the practice is around the world, researchers use large-scale national surveys of women. Some groups, however, claim that this method is problematic because it includes only countries where there are available data from these large-scale surveys. A joint report by Equality Now, End FGM European Network, and the U.S. End FGM/C Network states: “The current, already worrying numbers are a woeful under-representation since they do not take into account numerous countries where nationwide data on FGM/C prevalence is not available.” The result, the joint report says, is an incomplete global picture of FGM/C.
The NIJ-Library of Congress report raises additional concerns around current FGM/C prevalence numbers. Brock, lead researcher for the report, writes that prevalence varies considerably between regions and, subsequently, national estimates obscure the variation in different parts of a country. For instance, in Senegal, the national prevalence rate for FGM/C is 26%. But when this figure is broken down by region, the rates vary from as low as 1% in Diourbel to as high as 92% in Kedougou.
Prevalence data for the United States prove equally problematic. The best estimate, provided by the Centers for Disease Control and Prevention in 2012, holds that 513,000 women and girls in the United States could have suffered or may be at risk of suffering FGM/C or its consequences. However, this estimate is based on the national prevalence rates reported for immigrants’ countries of origin — and, as noted in the NIJ-Library of Congress report, incidence can vary considerably by geographic area, ethnicity, and other factors. This figure also assumes that people will behave the same way in the United States as they would at home, the report explains, discounting assimilation, differences in education and other socioeconomic factors, and U.S. laws that ban the practice.
“We really don’t have data on the number of women and girls who have undergone FGM/C in this country,” said Brock. “It is extremely difficult to collect this type of data. For one, the practice is against the law. If you ask people about it, they fear they will implicate themselves if they talk about it.”
“We also need to understand that for women who have undergone this procedure, this is their version of womanhood,” she added. “Researchers who go into these communities and try to measure how prevalent FGM/C is need to recognize the complex sensitivities around this practice and how we talk about it.”
FGM/C May Lead to Acute and Chronic Physical and Mental Health Problems
Although prevalence data remain elusive, we do know this: FGM/C has no health benefits.
The practice involves removing and damaging healthy female genital tissue and interferes with the natural functions of a woman’s body. The World Health Organization describes four major types of FGM/C; these types are practiced at varying rates across the globe.
FGM/C can lead to acute and chronic physical and mental health problems. The risk of adverse outcomes generally increases with more severe forms of FGM/C, but all forms of FGM/C are associated with increased health risk. Immediate medical problems can include blood loss, severe pain, infection of the wound, and sometimes death. Long-term health problems can include urinary infections; fistula (an opening between the urethra and vagina that lets urine run into the vagina); infertility; painful urination, menstruation, or sexual intercourse; and a potential increase in the risk of HIV/AIDS infection.
Women who have had FGM/C may also experience sexual dysfunction, such as painful sex, lack of desire, or bleeding. In addition, they can face unique health risks during childbirth. These include prolonged labor, excessive bleeding after childbirth, higher risk for episiotomy during childbirth, and higher risk for cesarean section. Risks to the baby include low birth weight (smaller than 5 ½ pounds at birth), breathing problems at birth, and stillbirth or early death.
Women and girls can also experience severe, long-lasting mental health issues. During the procedure, girls are held down, often against their will, and they might not understand what is being done to them and why. This painful experience may lead to post-traumatic stress disorder, depression, or anxiety. Women and girls might also feel scared, psychologically scarred, embarrassed, and distressed.
A Practice Rooted in Tradition
Given the significant — and well-documented — health risks, the obvious question arises: Why is FGM/C still practiced around the world today? The answers are complex and diverse, and are deeply embedded in each community’s customs and beliefs.
FGM/C forms a critical part of the identity for women and girls in many cultures. In some communities, it signals coming of age and solidifies membership within the community. This rite of passage is supported by local authorities, including tribal or religious leaders, circumcisers, and even some medical personnel, and is often accompanied by celebrations, public recognitions, and gifts.
FGM/C is also commonly tied to marriageability. In many practicing communities, there is an expectation that men will marry only women who have had FGM/C, and so women and girls are cut in order to be suitable for marriage. As the NIJ-Library of Congress report explains, a proper marriage is often essential for economic and social security, as well as to fulfill local ideals of womanhood and femininity in many communities: “Girls may want the procedure themselves because of social pressure from their peers, and because of a fear of stigmatization and rejection if they do not follow the tradition.”
“When looking at FGM/C, it’s critical that we understand cultural norms and expectations,” said Brock. “We need to understand what a young girl is truly up against if she says, ‘I don’t want this done to me.’ The social pressures to conform, the fear of not being accepted by your community, the fear of being seen as unsuitable to marry — these are all very real.”
“And then there is this notion that helps perpetuate the practice: Mothers had this done to them, and so their daughters will have it done, and so on. The common belief is ‘This is what has been done, and we all have to do it,’” Brock explained. “The tradition is so ingrained within these communities.”
Other reasons for FGM/C may include maintaining girls’ chastity and hygiene. Some communities believe the procedure will help ensure a woman remains a virgin until marriage, and others hold that the external female genitals that are cut (the clitoris or the labia or both) are unclean.
Lastly, some groups use religion and religious duty to justify the procedure; however, no religious text actually requires cutting. In fact, the NIJ-Library of Congress report points out that religious groups are among those actively working to eliminate FGM/C.
A Complex Problem Demands a Multisector Approach
Family dynamics add an additional — and significant — layer of complexity to the issue. According to the NIJ-Library of Congress report, the extended family is typically involved in decision-making about FGM/C. Parents, especially mothers, who may be against FGM/C for their daughters, often face resistance from more conservative family members who want to see the tradition continue.
In some cases, mothers may send their daughters to visit their homelands to become better acquainted with their family and culture not knowing that, once there, an FGM/C procedure may occur. In other instances, family members abduct a daughter against her parents’ will and take her to be cut.
“Who are these parents going to turn to for help?” asked Brock. “They feel like they can’t call law enforcement. FGM/C is illegal. They fear going to jail. They fear putting family members in jail. They fear endangering their immigration status. Are they going to turn in their aunts and uncles? Not likely. More likely is they will hide what happened.”
Seeking proper medical care poses another set of concerns for women and girls who have undergone FGM/C and are living in the United States. “There are some really alarming stories of how poorly prepared our doctors are to treat women who have undergone FGM/C,” explained Brock. “Many women have had bad experiences with doctors and failed to receive proper medical care. Others may fear having a bad experience with doctors. They feel scared and ashamed.”
According to Brock, the result is an intricate web that is hard to navigate — for affected women and girls and for those trying to help them.
For example, a woman who has experienced FGM/C may go for regular checkups with a primary care provider or gynecologist, seek prenatal care while pregnant, visit a school nurse, or go to the emergency room. Health providers need to know what clues to look for and how to talk to these women in a culturally competent, nonjudgmental manner. The care these women and girls initially receive when disclosing their experience may determine their willingness to seek medical care in the future. Health providers also need to know the types of services to which they could refer affected women and girls.
Educators — teachers, counselors, and school nurses — come into regular contact with young women and girls who may be at a particularly high risk for FGM/C, making them a first line of defense. However, like healthcare professionals, educators need to know which clues to look for and how to intervene without further endangering these women and girls.
Social service organizations provide potentially critical support directly to women and girls who have experienced FGM/C. Some groups also work with policymakers to help improve protections and access to services. People working in this sector must be familiar with practicing cultures and the unique circumstances of FGM/C.
Finally, a woman who has been subjected to FGM/C may go directly to those in the criminal justice sector for help, or someone may seek help on her behalf. Law enforcement and other criminal justice professionals need to know what signs to look for and the best practices to follow to effectively engage with these women.
“Cross-collaboration among all of these groups — health providers, educators, social services, and law enforcement — is absolutely critical,” said Brock.
At the federal level, a coordinated response to FGM/C would involve multiple agencies, each with their own mission and focus but with overlapping responsibilities, according to Brock and her colleagues. The NIJ-Library of Congress report lists the efforts of some federal agencies. For example, the U.S. Department of Health and Human Services awarded $6 million in grant funding to eight organizations to address gaps and problems in FGM/C-related healthcare services for women and girls in the United States. The funds could also be used to prevent FGM/C of women and girls living in this country who are at risk for having the procedure conducted here or abroad.
NIJ’s sister agency, the Office of Juvenile Justice and Delinquency Prevention, provided training on FGM/C to members of the law enforcement community to raise awareness and understanding of the physical, psychological, and emotional effects of FGM/C. The training also provided tools and resources to help law enforcement identify and prevent FGM/C in at-risk girls.
In fall 2020, the Office for Victims of Crime awarded nearly $1.8 million to increase education, detection, and local partner engagement, and more than $1.1 million to provide targeted technical assistance to front-line providers on how to identify and serve women and girls who have experienced FGM/C and those at risk. These awards will help raise awareness of the danger of FGM/C to women and girls, as well as support organizations — including domestic violence and child abuse service providers — and first responders that may encounter affected women and girls.
These federal efforts are a first step in addressing this complex crime. A unified strategy would also require collaboration with national and local organizations working to combat FGM/C and other forms of gender-based violence in the field. The NIJ-Library of Congress report lists several of these groups, including the U.S. End FGM/C Network and the Honor Our Bodies, Educate Our Community, Respect Our Heritage (HER) Initiative, although there are many more.
Strong partnerships among these various stakeholders — along with solid prevalence data and increased understanding — are all key elements to mounting an effective and coordinated response to FGM/C.
For More Information
Read the NIJ-Library of Congress report on female genital mutilation/cutting, honor-based violence, and forced marriage.
About This Article
This article was published as part of NIJ Journal issue number 283.
Sidebar: Honor Violence and Forced Marriage
The NIJ-Library of Congress report examines two other alarming forms of gender-based violence in the United States that are rooted in cultural practices: honor-based violence and forced marriage. The report notes that as with female genital mutilation/cutting, research on honor crimes and forced marriage in this country is scant; consequently, empirical data on both are lacking. At this time, the United States has no federal or state laws addressing honor-based violence as a crime distinct from other types of assault, abuse, or homicide. There is also no federal law addressing forced marriage. Although several states do have criminal laws on forced marriage, these laws are problematic, the report explains, as they fail to address the complicated dynamics of forced marriage, hold the perpetrators involved accountable, and empower authorities to intervene before the marriage takes place. For more on honor-based violence and forced marriage, read the full report at https://www.ojp.gov/pdffiles1/nij/252841.pdf.
Sidebar: Laws Prohibiting Female Genital Mutilation in the United States
FGM/C is against the law in the United States. The federal government “opposes FGM/C, no matter the type, degree, or severity, and no matter what the motivation for performing it.” It is considered “a serious human rights abuse, and a form of gender-based violence and child abuse.”
In 1996, Congress passed the Federal Prohibition of Female Genital Mutilation Act, making it illegal to perform the procedure on girls younger than 18 in the United States. Congress amended this law in 2013 to criminalize the act of knowingly transporting a girl out of the country for FGM/C, often referred to as “vacation cutting.”
In April 2017, in U.S. v. Nagarwala, the first case to be prosecuted under these laws, the U.S. Department of Justice indicted two Detroit-area doctors and one co-conspirator, alleging participation in a scheme to perform FGM/C on minors, transportation of those minors across state lines, and obstruction of justice. Dr. Jumana Nagarwala, Dr. Fakhruddin Attar, and Attar’s wife Farida were accused of performing FGM/C procedures on at least six girls, between the ages of 6 and 8, in Attar’s medical office in Livonia, Michigan. Two of the girls had traveled from Minnesota for the procedure. A federal judge in Detroit ruled that the federal law was unconstitutional and dismissed several charges against the doctors.
In January 2021, the STOP FGM Act of 2020 was signed into law, clarifying the criminalization of FGM. It gives federal authorities the power to prosecute those who carry out or conspire to carry out FGM and increases the maximum prison sentence from five to 10 years. The same month, the U.S. Department of Justice charged a Texas woman with transporting a minor from the United States to a foreign country for the purpose of FGM.
Currently, 39 states have anti-FGM/C laws in place.
Sidebar: Defining Female Genital Mutilation
Female genital mutilation/cutting is the cultural practice of partially or totally removing the external genitalia of women and girls for nonmedical reasons.
The World Health Organization describes four major types of female genital mutilation:
- Type 1: The partial or total removal of the clitoris, and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris). This is often called “clitoridectomy.”
- Type 2: The partial or total removal of the clitoris and the labia minora (the inner folds of the vulva), with or without excision of the labia majora (the outer folds of the vulva). This is often called “excision.”
- Type 3: The narrowing of the vaginal opening through the creation of a covering seal, which is formed by cutting and repositioning the labia minora or labia majora, sometimes through stitching, with or without removal of the clitoris. This is often referred to as “infibulation.”
- Type 4: All other harmful procedures to the female genitalia for nonmedical purposes (e.g., pricking, piercing, incising, scraping, or cauterizing the genital area).
[note 1] Equality Now, End FGM European Network, and U.S. End FGM/C Network, Female Genital Mutilation/Cutting: A Call for a Global Response (New York: Equality Now; Brussels: End FGM European Network; New York: U.S. End FGM/C Network, 2020); and U.S. Department of Justice, “Fact Sheet on Female Genital Mutilation or Cutting (FGM/C),” Washington, DC: U.S. Department of Justice, 2015.
[note 4] According to the United Nations Population Fund, if FGM continues to be practiced at current levels, the current estimates of 3.9 million girls mutilated each year will rise to 4.6 million by 2030 and 68 million girls will be subjected to FGM by 2030. United Nations Population Fund, “Bending the Curve”; and United Nations Children’s Fund, “Female Genital Mutilation.”
[note 5] Howard Goldberg et al., “Female Genital Mutilation/Cutting in the United States: Updated Estimates of Women and Girls at Risk, 2012,” Public Health Reports 131 no. 2 (2016): 340-347.
[note 6] Some recent reports also suggest that the practice may occur among conservative religious communities, even though no religious text requires FGM/C. See Equality Now, End FGM European Network, and U.S. End FGM/C Network, Female Genital Mutilation/Cutting.
[note 7] Marieke Brock and Emma Buckthal, “Historical Overview of U.S. Policy and Legislative Responses to Honor-Based Violence, Forced Marriage, and Female Genital Mutilation/Cutting,” Washington, DC: U.S. Department of Justice, National Institute of Justice, 2018, NCJ 252841.
[note 9] Brock and Buckthal, “Historical Overview of U.S. Policy and Legislative Responses.”
[note 10] Goldberg et al., “Female Genital Mutilation/Cutting in the United States.”
[note 13] Rigmor C. Berg et al., “Effects of Female Genital Cutting on Physical Health Outcomes: A Systematic Review and Meta-Analysis,” BMJ Open 4 no. 11 (2014): e006316.
[note 14] Researchers do not know how many girls die because of FGM/C. Few records are kept, and deaths that may have been caused by FGM/C are often not reported as related to FGM/C. UNICEF Innocenti Research Centre, “Changing a Harmful Social Convention: Female Genital Mutilation/Cutting,” Innocenti Digest (Florence, Italy: UNICEF Innocenti Research Centre, United Nations Children’s Fund, 2005).
[note 15] Dan Reisel and Sarah M. Creighton, “Long Term Health Consequences of Female Genital Mutilation (FGM),” Maturitas 80 no. 1 (2015): 48-51; Christos Iavazzo, Thalia A. Sardi, and Ioannis D. Gkegkes, “Female Genital Mutilation and Infections: A Systematic Review of the Clinical Evidence,” Archives of Gynecology and Obstetrics 287 (2013): 1137-1149; Berg et al., “Effects of Female Genital Cutting on Physical Health Outcomes”; U.S. Department of Health and Human Services, Office on Women’s Health, “Female Genital Mutilation or Cutting”; and U.S. Department of Justice, “Fact Sheet on Female Genital Mutilation or Cutting (FGM/C).”
[note 16] Khalid Yassin, Hadeel A. Idris, and Abdel Aziem, “Characteristics of Female Sexual Dysfunctions and Obstetric Complications Related to Female Genital Mutilation in Omdurman Maternity Hospital, Sudan,” Reproductive Health 15 no. 7 (2018).
[note 17] Yassin, Idris, and Aziem, “Characteristics of Female Sexual Dysfunctions and Obstetric Complications”; U.S. Department of Health and Human Services, Office on Women’s Health, “Female Genital Mutilation or Cutting”; and Rigmor C. Berg and Vigdis Underland, “The Obstetric Consequences of Female Genital Mutilation/Cutting: A Systematic Review and Meta-Analysis,” Obstetrics and Gynecology International (2013): 496564.
[note 18] WHO Study Group on Female Genital Mutilation and Obstetric Outcome, “Female Genital Mutilation and Obstetric Outcome: WHO Collaborative Prospective Study in Six African Countries,” The Lancet 367 no. 9525: 1835-1841; and U.S. Department of Health and Human Services, Office on Women’s Health, “Female Genital Mutilation or Cutting.”
[note 19] Salma M. Abdalla and Sandro Galea, “Is Female Genital Mutilation/Cutting Associated With Adverse Mental Health Consequences? A Systematic Review of the Evidence,” BMJ Global Health 4 no. 4 (2019): e001553; and U.S. Department of Health and Human Services, Office on Women’s Health, “Female Genital Mutilation or Cutting.”
[note 20] U.S. Department of Justice, “Fact Sheet on Female Genital Mutilation or Cutting (FGM/C).”
[note 21] Brock and Buckthal, “Historical Overview of U.S. Policy and Legislative Responses.”
[note 22] Brock and Buckthal, “Historical Overview of U.S. Policy and Legislative Responses.”
[note 24] Brock and Buckthal, “Historical Overview of U.S. Policy and Legislative Responses.”
[note 25] Brock and Buckthal, “Historical Overview of U.S. Policy and Legislative Responses.”
[note 26] Brock and Buckthal, “Historical Overview of U.S. Policy and Legislative Responses.”
[note 27] Office of the Assistant Secretary for Health, “HHS Awards $6 Million To Improve Female Genital Cutting-Related Health Care Services for Women and Girls in the United States,” Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Health, Press Office, July 20, 2016.
[note 28] Office of Juvenile Justice and Delinquency Prevention, “Keeping Kids Safe: Preventing Female Genital Mutilation/Cutting in the United States,” webinar, Washington, DC: U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention, March 18, 2015.
[note 29] U.S. Department of Justice, Office for Victims of Crime, “Office for Victims of Crime Awards Nearly $3 Million to Help Victims of Female Genital Mutilation or Cutting,” October 30, 2020.
[note 30] For more information on various organizations working to combat gender-based violence, see Brock and Buckthal, “Historical Overview of U.S. Policy and Legislative Responses.”
[note 31] U.S. Department of Justice, “Fact Sheet on Female Genital Mutilation or Cutting (FGM/C).”
[note 32] Brock and Buckthal, “Historical Overview of U.S. Policy and Legislative Responses.”
[note 33] Strengthening the Opposition to Female Genital Mutilation Act of 2020, Pub. L. No 116-309, 134 Stat. 4922 (2021).
[note 34] The case is still being investigated at the time of publication. U.S. Department of Justice, Office of Public Affairs, “Texas Woman Indicted for Transporting Minor for Female Genital Mutilation,” January 13, 2021.
[note 36] Some use the phrase “female circumcision,” which is how practicing cultures refer to it, but this is disfavored in other circles for drawing an inaccurate comparison with male circumcision. Still others use “female genital cutting,” but this is also criticized as normalizing the procedure.
[note 37] World Health Organization, “Female Genital Mutilation”; and Brock and Buckthal, “Historical Overview of U.S. Policy and Legislative Responses.”