Female Genital Mutilation/Cutting: Existing Federal Efforts to Increase Awareness Should Be Improved
Published: 2016-06-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: FGM/C comprises all procedures that involve partial or total removal of the external female genitalia, or other harm to the female genitals for non-medical reasons. The rationale for FGM/C often includes cultural, religious, and social factors in families and communities. In the United States, women and girls believed to be most at risk of FGM/C are those from immigrant families from countries where FGM/C is practiced.
GAO was asked to review the federal response to address FGM/C in the United States. In this report, GAO examines (1) what is known about the number of women and girls at risk of or subjected to FGM/C, (2) the protections available and actions taken to protect women and girls, and (3) the extent to which actions are taken to educate and assist immigrant communities and key stakeholders. GAO analyzed documents and spoke to officials from five relevant federal agencies; spoke with officials from local law enforcement, health care, education, and social services sectors; and assessed agency actions against federal internal control standards.
section_title: What GAO Found
paragraphs: The Centers for Disease Control and Prevention (CDC) estimated that 513,000 women and girls in the United States were at risk of or had been subjected to female genital mutilation/cutting (FGM/C) in 2012, a threefold increase from its 1990 estimate. CDC attributes this change primarily to increased immigration from countries where FGM/C is practiced, rather than an increase in the occurrence of FGM/C. Agency estimates were not able to distinguish between those who have already been subjected to FGM/C and those who are at risk.
Women and girls at risk of or who have been subjected to FGM/C in their home country may seek federal protection in the United States through different avenues of the immigration process, and GAO found that there have been few U.S. investigations and prosecutions. According to Department of Homeland Security officials, protection is most commonly provided through the asylum process, where individuals must demonstrate that they have been persecuted or fear persecution in their home country on account of protected grounds such as religion or nationality. While FGM/C is a crime under federal and many state laws, law enforcement officials identified few investigations and prosecutions related to FGM/C. Officials said that this may be due, in part, to underreporting.
Federal agencies and others provide education and assistance regarding FGM/C, but gaps exist and agencies lack documented plans for future efforts. The Department of State (State) directly provides information on FGM/C in a fact sheet only to certain types of visa recipients who apply in countries where FGM/C is practiced. State does not provide the fact sheet to nonimmigrant visa recipients as these visas are for temporary stays; however, some of these visas permit stays in the United States for multiple years. In addition, State does not directly provide the fact sheet to visa recipients who are nationals of countries where FGM/C is common, but apply at posts in other countries. Visa recipients who do not directly receive the fact sheet may be unaware of the health and U.S. legal consequences of FGM/C. Federal agencies have made efforts to increase awareness of FGM/C among stakeholder groups, including hosting roundtables and developing educational materials. However, the agencies lack documented plans for future efforts. Internal controls state that agencies should establish plans and document activities. Absent this, the federal government may be unable to ensure that its activities meet the needs of and that it communicates effectively with external parties, such as key stakeholder groups.
section_title: What GAO Recommends
paragraphs: GAO recommends that State provide information to additional visa recipients and that each federal agency document its domestic FGM/C awareness efforts. The agencies generally agreed with the recommendations; however, State disagreed with documenting its awareness efforts, noting that it is not responsible for domestic outreach and education. GAO maintains that the recommendation is valid as discussed in the report.

section_title: Letter
paragraphs: Female genital mutilation/cutting (FGM/C) comprises all procedures that  involve partial or total removal of the external female genitalia, or other  harm to the female genital organs for non-medical reasons. The rationale  for FGM/C often includes cultural, religious, and social factors within  families and communities. The United Nations Children’s Fund (UNICEF)  estimated in 2016 that over 200 million women and girls have been  subjected to FGM/C worldwide, although the exact number is unknown.  In the United States, women and girls believed to be most at risk of  FGM/C are those born to immigrant families from countries where FGM/C  is practiced, mainly in parts of Africa and the Middle East. One publication  estimated that as many as 500,000 women and girls in the United States  were at risk of or had been subjected to FGM/C as of 2013.
Federal efforts to prevent FGM/C in the United States, and to provide  assistance to women and girls who are at risk of or have been subjected  to FGM/C, encompass a range of activities and services. These activities  and services relate to law enforcement, immigration, health care,  education, and social services. At the international Girl Summit 2014, the  United States committed to several areas of domestic response to  FGM/C. For example, one domestic commitment was to provide  information on FGM/C to educators and nongovernmental organizations  that serve immigrant and refugee populations in communities throughout  the United States with large populations of girls at risk.
In the United States, the federal response to FGM/C requires the efforts  of multiple federal agencies. The Department of Homeland Security  (DHS), the Department of Justice (DOJ), and the Department of State  (State) share responsibility for the U.S. immigration system. In addition,  DHS and State share responsibility for providing information on the health  and legal consequences of FGM/C to certain visa recipients. DHS and  DOJ share responsibility for federal FGM/C investigations and  prosecutions. The Department of Health and Human Services (HHS) is  responsible for public health research, guidelines, and programs, as well  as for issuing grants that address public health issues. The Department of  Education (Education) disseminates information and performs outreach to  education professionals.
You asked us to review the federal response to address FGM/C  domestically and abroad for women and girls at risk of or who have ever  been subjected to the practice. The first report focused on U.S. efforts  abroad. This is the second of the two reports responding to your request,  and in this report we focus on the federal government’s domestic efforts  to combat FGM/C. In this report, we examine  1.  what is known about the number of women and girls in the United  States at risk of or who have been subjected to FGM/C;  2.  the protections available and actions taken, if any, by federal and  selected state and local agencies to protect women and girls in the  United States at risk of or who have been subjected to FGM/C; and  3.  the extent to which federal agencies and others have taken action to  educate and assist immigrant communities and key stakeholders  about FGM/C.
To examine what is known about the number of women and girls in the  United States at risk of or who have been subjected to FGM/C, we  collected and reviewed documentation from HHS’s Centers for Disease  Control and Prevention (CDC), including the agency’s estimates on the  prevalence of FGM/C among women and girls in the United States for  1990 and 2012. We also collected and reviewed documentation related to  efforts to measure FGM/C prevalence in the United Kingdom to inform  our understanding of alternate methods to estimate prevalence. We  reviewed journal articles and reports related to prevalence from the  United States and other countries, as well as publications from  nongovernmental organizations and medical associations. In addition, we  interviewed officials at CDC and government officials from the United  Kingdom about their efforts to measure prevalence.
To examine protections available and the actions taken to protect women  and girls at risk of or who have been subjected to FGM/C, we reviewed  agency documentation and interviewed officials from the agencies  responsible for managing relevant immigration processes. Specifically  related to the asylum process, we selected a generalizable sample of  DHS case files from fiscal years 2014 and 2015 involving women from  countries with known prevalence of FGM/C who filed affirmatively with  DHS’s U.S. Citizenship and Immigration Services (USCIS) and whose  asylum applications were granted. We reviewed these case files to  assess whether FGM/C was a basis for the asylum determination. In  order to determine the reliability of the data we used to select the case  files, we reviewed relevant documentation on the database, conferred  with knowledgeable officials, and reviewed the data for any obvious errors  or abnormalities. We determined that the data were sufficiently reliable for  the purposes of our reporting objectives. We spoke with DHS and DOJ  officials who are responsible for investigating and prosecuting FGM/C- related crimes and adjudicating immigration proceedings involving women  who are at risk of or have been subjected to FGM/C. We then interviewed  officials from two relevant nongovernmental organizations that provide  legal support to immigrant women. To understand the actions taken on  the local level to protect women and girls who are at risk of or have been  subjected to FGM/C, we met with officials from law enforcement and child  protective services agencies from selected local communities with large  populations of immigrants from countries with known prevalence of  FGM/C. To identify these communities, we used data from multiple  sources, including the most recent UNICEF data on FGM/C prevalence at  the time of our selection, as well as U.S. Census Bureau population data.  Using these data, we identified the following communities: Los Angeles,  California; Minneapolis, Minnesota; New York City, New York/Newark,  New Jersey; and Washington, D.C.
To examine the extent to which cognizant federal agencies and others  have taken action to educate and assist immigrant communities and key  stakeholders about FGM/C, we reviewed documentation and interviewed  officials from several federal, state, and local agencies, as well as key  stakeholder groups. To understand the Department of State’s outreach  efforts pertaining to informing visa recipients about the consequences of  FGM/C, we obtained data on the visa processing workload for fiscal years  2012 to 2015 from two State information systems. We analyzed data on  issued visas for temporary or permanent stays in the United States to  assess State’s efforts to target FGM/C information to visa recipients. We  assessed the reliability of the data by reviewing documentation on the  information systems that contain the data, speaking with knowledgeable  agency officials, and reviewing our prior work on the systems. We  determined that the data obtained from these systems were sufficiently  reliable for the purposes of our reporting objectives. We also examined  the agencies’ decisions to target information to certain visa recipients  against the Office of Management and Budget’s Memorandum on  Updated Principles for Risk Analysis. At the federal level, we interviewed  five departments and their relevant agency components responsible for  outreach to key stakeholders on FGM/C. We also assessed agency  actions against the relevant standards for internal control in the federal  government. At the state and local level, we interviewed officials from  state and local health agencies in our selected communities, as well as  officials from local law enforcement agencies and school districts. We  also interviewed key stakeholder groups on their outreach efforts,  including health care providers who are knowledgeable about FGM/C,  and officials from three medical associations and four nongovernmental  organizations serving the immigrant community.
We conducted this performance audit from June 2015 to June 2016 in  accordance with generally accepted government auditing standards.  These standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives. For additional details on our  scope and methodology, see appendix I.
subsections: section_title: Background
paragraphs: FGM/C varies by the type of practice, by country, and by age. Women or  girls at risk of or who have been subjected to FGM/C may enter the  United States through a variety of immigration paths. Once in the United  States, certain federal and state laws exist to penalize the practice of  FGM/C.
subsections: section_title: FGM/C Types and Health Consequences
paragraphs: According to the World Health Organization, there are four major types of  FGM/C:  type I (clitoridectomy) partially or totally removes the clitoris or the skin  around it;  type II (excision) partially or totally removes the clitoris and the labia  minora, with or without removal of the labia majora;  type III (infibulation) narrows the vaginal opening by creating a seal  through cutting and sewing together the labia minora and labia  majora, with or without removal of the clitoris; and  type IV (other) includes all other harmful procedures, including  pricking, piercing, incising, scraping, and cauterizing the genital area  for non-medical purposes.
FGM/C has no health benefits and can have numerous short- and long- term adverse health consequences. Short-term consequences can  include severe pain, excessive bleeding, shock, swelling, delayed or  incomplete healing, and infections and hemorrhaging, which can lead to  death. Long-term consequences may include chronic pain and infections,  scar tissue, and chronic menstrual and urinary tract problems. In addition,  FGM/C can lead to mental health problems, sexual problems, and  obstetric complications, including increased need for Caesarean sections  during childbirth.
section_title: Countries with Known Prevalence of FGM/C
paragraphs: According to UNICEF, FGM/C has been reported to occur in all parts of  the world, but is most prevalent in western, eastern, and northeastern  regions of Africa; some countries in Asia and the Middle East; and among  certain immigrant communities in North America and Europe. UNICEF’s  prevalence data are based on nationally representative household  surveys, conducted from 2004 to 2015. There are 30 countries where  FGM/C is known to be prevalent based on rates estimated by UNICEF in  2016, which includes the addition of Indonesia for the first time as a  country with known prevalence of FGM/C. There are additional  countries, such as Colombia and India, where FGM/C is known to occur,  but prevalence has not been estimated. Figure 1 shows UNICEF data on  the percentages of women and girls between the ages of 15 and 49 who  have undergone FGM/C in the countries with known prevalence.
According to UNICEF, in most of the countries with known prevalence,  the majority of girls who are subjected to FGM/C are harmed before the  age of 5. In Somalia, Egypt, Chad, and the Central African Republic, at  least 80 percent of girls who are subjected to FGM/C are harmed  between the ages of 5 and 14. However, data show that the practice is  becoming less common in many countries found to have a high  prevalence of FGM/C. For example, while the overall prevalence rate is  87 percent for women and girls ages 15 to 49 in Egypt, the prevalence of  FGM/C among girls ages 15 to 19 has declined from 97 percent in 1985  to 70 percent in 2015. In addition, UNICEF reported in 2013 that 24  countries where FGM/C is prevalent have enacted legislation—varying in  scope—related to FGM/C. According to UNICEF, some laws ban the  practice only in government medical facilities and by medical  practitioners; other laws ban the practice anywhere.
section_title: Immigrant Communities and Avenues to Enter or Remain in the United States
paragraphs: Immigrant communities across the United States include foreign nationals  who have entered the United States through the immigration process. In  fiscal years 2014 and 2015, nearly 30,000 women and girls from  countries with known prevalence of FGM/C obtained lawful immigration  status or protection in the United States through one or more avenues  including the visa process, the asylum system, or refugee resettlement.  The process for lawfully entering or remaining in the United States is  based on a number of factors, including the type of immigration benefit  and the applicable eligibility criteria.
subsections: section_title: Visas
paragraphs: U.S. immigration law provides for the admission of various categories of  foreign nationals into the United States, on either a temporary or  permanent basis. Those who wish to come to the United States on a  temporary basis and are not citizens or nationals of countries that  participate in the Visa Waiver Program must generally obtain a  nonimmigrant visa (NIV). NIV holders include a wide range of visitors,  such as tourists, foreign students, diplomats, and temporary workers who  are admitted for an authorized period of time and a specific purpose.  There are dozens of types of NIVs that foreign nationals can obtain by  fulfilling the requirements of a specific nonimmigrant category within their  authorized period of admission. For example, victims of certain crimes  may be eligible to obtain a “U” visa—one type of NIV—if they are a victim  of qualifying criminal activity, such as FGM/C, are helpful to law  enforcement in the investigation or prosecution of the criminal activity,  and meet certain other eligibility requirements.
The immigrant visa (IV) process allows foreign nationals to immigrate to  the United States permanently. There are also many different types of  employment- or family-based IVs that an individual can obtain. USCIS  and State’s Bureau of Consular Affairs manage the visa application  process at over 220 visa-issuing posts abroad. The process for  determining who will be issued or refused a visa comprises several steps,  often including in-person interviews. Personal interviews with consular  officers are required by law for all immigrants seeking IVs and most  nonimmigrants seeking NIVs. By law, DHS, in cooperation with State, is  required to make information on the health and legal consequences of  FGM/C available to individuals who are issued IVs or NIVs prior to or  upon entry into the United States.
section_title: Asylum System and Refugee Resettlement
paragraphs: In addition to the visa process, the asylum system and refugee  resettlement may be available to women and girls from countries with  known prevalence of FGM/C. Table 1 describes specific ways for women  and girls at risk of or previously subjected to FGM/C to obtain immigration  status or protection in the United States through the asylum system,  withholding of removal, or refugee resettlement.
section_title: Federal and State Laws on FGM/C
paragraphs: A number of federal and state laws exist to penalize the practice of  FGM/C in the United States. Since 1996, there have been specific federal  criminal penalties for performing FGM/C in the United States on anyone  under 18 years old, including fines, up to 5 years in prison, or both. In  2013, Congress amended the federal statute related to FGM/C to  criminalize the knowing transportation of a girl under 18 years old from  the United States for the purpose of performing FGM/C abroad—often  referred to as “vacation cutting.”
In addition, some states have enacted laws specifically criminalizing  FGM/C, while other states may pursue FGM/C offenses under other  related statutes, such as child abuse laws. In some instances, states  require that an occurrence of FGM/C be reported. DOJ indicates that two  states, Illinois and Tennessee, have mandatory reporting for FGM/C. All  states have mandatory reporting laws governing child abuse, which may  apply to reporting FGM/C depending on the relevant circumstances and  particular statutory requirements. Some state laws address other areas of  FGM/C, such as provisions prohibiting “vacation cutting” or provisions for  community education and outreach. According to DOJ, some states also  criminalize performing FGM/C on both adults and children.
section_title: About A Half Million Women and Girls in the United States Estimated to Be at Risk of or Have Been Subjected to FGM/C
paragraphs: CDC published a report in 2016 estimating that 513,000 women and girls  in the United States were at risk of or may have been subjected to FGM/C  in 2012. While subject to certain limitations, this represents a substantial  increase—about threefold—from CDC’s prior estimate of 168,000, which  was based on 1990 data. (See fig. 2.) CDC attributed this increase to a  sharp rise in recent decades in the U.S. population originating from  countries where FGM/C is commonly practiced, and noted that the  increase occurred despite FGM/C prevalence not increasing or seemingly  falling in many of these countries.
To develop both estimates, CDC applied country-specific prevalence  rates of FGM/C to the estimated number of women and girls living in the  United States who were born in that country or who lived with a parent  born in that country. The 2012 estimate was based on
U.S. Census Bureau data from its 2012 American Community Survey, population-based, country-specific FGM/C prevalence estimates  compiled from national surveys (most often Demographic and Health  Surveys supported by the United States Agency for International  Development or UNICEF’s Multiple Indicator Cluster Surveys).
The most significant change in CDC’s latest methodology from that used  for its 1990 estimate was the application of different prevalence rates to  younger women and girls, specifically those aged 15 to 19. The lower  prevalence rate applied to this population reflects the reported lower risk  of FGM/C in this age range in the countries from which the women and  girls immigrated.
CDC acknowledged four specific limitations to its most recent estimate,  which are similar to those applicable to the 1990 estimate.  1.  Estimate does not account for changes in behavior upon moving  to the United States. CDC’s estimate assumes that, with regard to  FGM/C practices, people behave the same in the United States as  they would in the countries from which they came. However, there are  several reasons why the behaviors are likely to differ from those in the  countries of origin, including assimilation, differences in education and  other socioeconomic characteristics, and U.S. laws banning FGM/C.  The authors note that these differences would very likely result in  reduced risk for FGM/C. While there are no data to test this  hypothesis for a U.S.-based population, a systematic review of  FGM/C studies in Europe concluded that children born to an  immigrant family run relatively little risk of undergoing FGM/C.  2.  Estimate does not account for variation of prevalence within  countries of origin. CDC’s estimate was based on national  prevalence levels reported for the countries of origin where FGM/C is  practiced. However, in many of those countries, the prevalence of  FGM/C varies by geographic area (e.g., urban or rural), ethnic group,  and other factors including socioeconomic status. Further, the  population coming to the United States may not be representative of  the entire country of origin.  3.  Estimate does not include countries where it is known that  FGM/C is practiced, but for which there are no data. CDC only had  FGM/C prevalence estimates from countries for which such  information had been published at the time the agency’s estimates  were developed. There are several countries where FGM/C is known  to be practiced, but for which no data were then available. CDC  stated that excluding such countries from their analysis could have  resulted in an underestimate. Notably, an updated report from  UNICEF published after CDC’s most recent estimate provided data for  the first time on the number of girls subjected to FGM/C in Indonesia.  Specifically, in 2013, Indonesia collected data on the occurrence of  FGM/C in girls ages 0 to 11; the data indicate that about 49 percent of  girls in this age group have undergone FGM/C. CDC officials told us  that the Indonesia data would likely increase the U.S. estimate by  approximately 50,000 women and girls. Further, CDC noted that the  length of time since the most recent FGM/C prevalence surveys were  conducted varied by country, such that if prevalence were changing,  the country of origin data could be somewhat outdated.  4.  Estimate does not capture data for undocumented individuals.
CDC reported that it is difficult to determine the number of  undocumented individuals who have come to the United States from  countries where FGM/C is commonly practiced, or the probability that  such individuals would be captured in the U.S. population estimates.  They noted that the result is a possible underestimation of U.S.  women and girls at risk of FGM/C.
In addition, neither of CDC’s estimates distinguishes between women and  girls in the United States who have already been subjected to FGM/C and  those who are at risk, due to the lack of scientifically valid data available  on the former. In the report for the 2012 estimate, the authors said that  until scientifically valid data are collected, the approach used provides the  best available information on the potential levels of FGM/C. CDC and  others have acknowledged that collecting more scientifically valid data  would be difficult due, in part, to the cultural and legal sensitivity of the  information needed. International efforts to collect data on the actual  occurrence of FGM/C have faced similar challenges. Starting in October  2015, however, the United Kingdom began requiring health care  providers in England to report through a nationwide database any  instance of FGM/C described to them or discovered during physical  exams.
CDC and others have stated that further data on the occurrence of  FGM/C collected at the community and individual level would facilitate  prevention efforts and the provision of services to women and girls who  have been subjected to FGM/C. According to CDC officials, the agency is  currently working on the development of a strategy and methodology for a  potential future study that would provide scientifically valid data about the  actual prevalence of FGM/C in the United States. CDC began working  with a contractor at the beginning of fiscal year 2016 to design the study,  examining what has been done in the past and what methodologies may  be applicable. Officials told us that the contractor will examine possible  methodologies and conduct expert interviews with community leaders on  the best approaches for obtaining information and working with the  affected communities, and is also working to explore potential difficulties  and challenges. CDC officials told us there are two major challenges to  such a study being conducted—the first being funding, and the second  being the difficulty of encouraging the population of interest to disclose  information about FGM/C, a sensitive topic that is also an illegal act in the  United States. CDC officials told us they have obtained some federal  funding for such a study and are pursuing a variety of additional potential  funding sources, including nongovernmental options.
section_title: Protections Are Available through the U.S. Immigration System to Women and Girls at Risk of or Who Have Been Subjected to FGM/C; Investigations and Prosecutions Are Few
paragraphs: Women and girls at risk of or who have been subjected to FGM/C in their  home country may seek federal protection on that basis through avenues  in the U.S. immigration system. There have been few FGM/C-related  investigations or prosecutions. Law enforcement and child protection  officials we spoke with said this may be due, in part, to instances not  being reported.
subsections: section_title: Women and Girls at Risk of or Who Have Been Subjected to FGM/C May Seek Protection through the U.S. Immigration System
paragraphs: Women and girls at risk of or who have been subjected to FGM/C in their  home country may seek federal protection on that basis through different  avenues of the immigration process. Specifically, the avenues available  are (1) asylum; (2) withholding of removal; (3) refugee resettlement; or (4)  a “U” nonimmigrant visa. According to DHS officials responsible for  managing these immigration processes, women and girls at risk of or who  have been subjected to FGM/C seeking protection on that basis have  most commonly done so through the affirmative asylum process.
subsections: section_title: Asylum
paragraphs: When applying for asylum, an individual must meet the definition of  “refugee” under section 101(a)(42)(A) of the Immigration and Nationality  Act by demonstrating that they have been persecuted or fear they will be  persecuted on account of their race, religion, nationality, membership in a  particular social group, or political opinion. Under U.S. immigration law,  the practice of FGM/C is considered a form of persecution, which can  support a valid asylum or refugee claim. According to USCIS asylum  officers, women and girls at risk of or who have already been subjected to  FGM/C typically demonstrate their eligibility for asylum status as  members of a particular social group. For example, in the decision that  established FGM/C as a valid basis for a claim of persecution, asylum  was granted to a woman because she had a well-founded fear of  persecution based on her membership in a particular social group,  defined as “oung women of the Tchamba-Kunsuntu ribe [of Northern  Togo] who have not had FGM, as practiced by that tribe, and who  oppose the practice.”
Based on our review of a generalizable sample of alien files for females  from the countries where there is a known prevalence of FGM/C, and who  were granted asylum affirmatively in fiscal years 2014 and 2015, we  estimate that approximately 40 percent (1,075 of 2,756) were granted  asylum at least partly on the basis of FGM/C. According to our file  review, as well as interviews with USCIS asylum officers, the majority of  the FGM/C-based asylum claims USCIS has adjudicated involved adults  who had previously been subjected to FGM/C. For example, 28 of the 39  alien files we reviewed where asylum was granted at least partly on the  basis of FGM/C involved adult applicants who had already been  subjected to FGM/C. Asylum officers explained that, compared to other  types of asylum claims, FGM/C-based claims are generally  straightforward to adjudicate, because applicants typically submit a  medical affidavit from a physician indicating that the applicant has been  subjected to FGM/C. This affidavit, along with other evidence, such as the  applicant’s credible testimony and information on the country conditions,  provides support for granting asylum on the basis of FGM/C. According to  asylum officers we spoke with, the main challenge in adjudicating FGM/C- based asylum claims is the nature of the act itself, which requires  sensitivity on the part of the officers who work with applicants. The  officers also noted that such sensitivity is not unique to FGM/C claims,  and is needed to adjudicate many different types of asylum claims.
Although the majority of the affirmative asylum claims involving FGM/C  that USCIS has adjudicated involved adult applicants who had previously  been subjected to FGM/C, USCIS asylum officers told us they have seen  cases involving applicants who sought asylum because they feared they  would be subjected to FGM/C if they returned to their home country. For  example, in the Board of Immigration Appeals decision that first  established FGM/C as a valid basis for an asylum claim, the applicant  testified that she had been subjected to a forced marriage at age 17 and  fled her home country when her husband and aunt planned to force her to  undergo FGM/C before the marriage was consummated. In addition,  according to USCIS officials, they have adjudicated cases where a parent  is applying for asylum to protect his or her daughter from being subjected  to FGM/C. According to officials, these cases are often more challenging  to adjudicate, because the parent has to establish that they would be the  target of persecution as a result of their daughter undergoing FGM/C.  Attorneys from U.S. Immigration and Customs Enforcement’s (ICE) Office  of the Principal Legal Advisor—the office responsible for litigating asylum  cases in immigration court—who cover three of our four selected local  communities said that most of the FGM/C-based claims they see in court  are referrals from USCIS, and many of those cases involve parents  seeking asylum to protect a daughter from FGM/C.
section_title: Withholding of Removal
paragraphs: In addition to applying for asylum, women and girls at risk of or who have  been subjected to FGM/C, and are already in immigration court  proceedings on one or more charge(s) of removability, may seek  withholding of removal to avoid being returned to the proposed country of  removal. Individuals who are applying for withholding of removal must  meet a higher legal standard than those seeking asylum. Specifically, to  be eligible for withholding, an individual must show a clear probability  that, if returned to their home country, his or her life or freedom would be  threatened, based on the same five grounds—race, religion, nationality,  membership in a particular social group, or political opinion—as those  applying for asylum. According to officials from DOJ’s Executive Office  for Immigration Review (EOIR)—the federal agency that manages the  immigration courts—they are unable to determine the number of women  and girls who were granted withholding of removal related to FGM/C,  because the agency’s database does not track certain factors such as the  gender of the applicant and the underlying grounds that support the  applicant’s claim for relief.
section_title: Refugee Resettlement
paragraphs: Individuals applying for refugee status from outside the United States  must generally meet the same legal requirements as those applying for  asylum in the United States, in that they are to demonstrate they have  been subjected to persecution or have a well-founded fear of future  persecution on account of the same five grounds—race, religion,  nationality, membership in a particular social group, or political opinion.  Although having experienced or being at risk for FGM/C is a basis for  obtaining refugee status, according to State and USCIS officials, FGM/C  is unlikely to be used in a refugee claim. According to the United Nations  High Commissioner for Refugees, refugees are often in a very vulnerable  situation—fleeing war and oppression—and cannot rely on the protection  of their own governments. Data from State’s Bureau of Population,  Refugees, and Migration show that women and girls from the Central  African Republic, Eritrea, Ethiopia, Iraq, Sierra Leone, Somalia, and  Sudan—all countries where FGM/C is practiced—are the African  nationalities that have resettled as refugees in the United States in fiscal  years 2014 and 2015. Over 27,000 women and girls from these  countries resettled in the United States during this time period. According  to State officials, they do not know how many of these women and girls  are at risk of or have been subjected to FGM/C.
section_title: “U” Nonimmigrant Visas
paragraphs: “U” visas allow victims of qualifying crimes (including FGM/C), who have  suffered substantial physical or mental abuse and meet certain other  criteria, to remain in the United States to assist federal, state, or local  authorities investigating or prosecuting the qualifying criminal activities.  Further, the qualifying crime that the victim is providing information to law  enforcement about must have occurred in the United States or violated  U.S. law, and the victim must be legally admissible to the United States.  “U” visa recipients commonly are authorized to stay in the United States  for a period of up to 4 years, which can be extended by DHS. There is  also a process in place for “U” visa recipients to petition for permanent  residency. Family members of such victims may also be eligible to obtain  derivative “U” nonimmigrant status. The number of “U” visas that may be  granted to principal petitioners each year is limited by law to 10,000.  However, there is no cap for family members accompanying the victim’s  petition, such as the spouse, children, or other eligible family members.
section_title: There Have Been Few FGM/C-Related Investigations or Prosecutions Due, in Part, to Instances Not Being Reported
paragraphs: Officials from federal and other law enforcement agencies in our review  identified few investigations and prosecutions that were related to  FGM/C. At the federal level, DOJ’s Federal Bureau of Investigation  (FBI) had two investigations from fiscal year 1997 to 2015, one of which  resulted in a prosecution on other charges. In fiscal year 2002, the FBI  investigated two cases—one in El Paso, Texas, and one in Los Angeles,  California—but no actual victims were identified in either of these cases.  The FBI field office in El Paso initiated an investigation related to FGM/C,  but the case did not result in any arrests or prosecutions. This  investigation was pursued based on an email tip from an unidentified  female. She alleged that she was subjected to FGM/C and that an  unknown male was cutting other girls in El Paso. However, because she  could not be identified, the investigation ended and the case was closed.  The FBI field office in Los Angeles conducted an undercover investigation  that resulted in the arrest of two individuals who were subsequently  prosecuted and convicted. In that case, a man ran a business that offered  body piercing and modifications, and during communications with an  undercover FBI agent, he claimed to have performed FGM/C in the past  and offered to perform FGM/C on two fictitious 8- and 12-year-old girls.  He and his girlfriend pled guilty to conspiracy, child pornography, and  obscenity charges, and were sentenced to 5 years and 2 years in federal  prison, respectively.
Also at the federal level, ICE officials stated that the agency has not had  any criminal investigations of FGM/C. However, the officials identified at  least 25 individuals in immigration court proceedings who were suspected  of assistance in the perpetration of FGM/C. Of the 25 suspected  perpetrators, officials were aware of 1 individual who was removed from  the country in July 2005. The remaining 24 were granted relief or  protection from removal, were still in immigration proceedings, or were  not issued a travel document by their home country to implement the  immigration court’s final order of removal. The individuals in these cases  were suspected of involvement with FGM/C that occurred abroad, either  through vacation cutting or prior to their arrival to the United States. ICE  identified most of the individuals through their own admissions of  involvement in FGM/C or by reviewing travel records and medical records  of the individuals’ children, and identifying contradictory timeline  information.
At the state and local levels, we found few investigations and  prosecutions related to FGM/C in states with and without specific laws  against the practice. According to DOJ officials, they were aware of two  state prosecutions related to FGM/C. In 2006, an Ethiopian man in  Georgia was convicted of aggravated battery and cruelty to children for  cutting his daughter’s genitalia, and sentenced to 10 years in prison. In  2013, a woman in Illinois was found guilty by a jury of aggravated battery  and was sentenced to 10 years in prison for cutting her 13-month-old  daughter. Three of the four local law enforcement agencies we spoke with  from our selected metropolitan areas were each aware of at least one  case related to FGM/C in their respective jurisdictions, none of which  resulted in a prosecution because the FGM/C occurred overseas or the  victim stopped cooperating with law enforcement. For example, one  local law enforcement agency investigated a case in 2012, in which a  woman came forward about being subjected to FGM/C when she was a  child. According to officials from that agency, the woman reported that  she was sexually abused by a male relative over the course of several  years, which occurred prior to and after her arrival in the United States.  During one episode of abuse when she began to fight back, he cut her  genitalia with the intent of making her undesirable to other men. In  addition, all four of the local child protection agencies we spoke with  confirmed that reports of FGM/C performed on minors would be  considered a form of child abuse or neglect if a minor’s parent or guardian  were involved, and such reports would trigger an investigation. Officials  from only one of the four child protection agencies we spoke with were  aware of a case related to FGM/C.
There is no designated federal tipline where individuals can report actual  or suspected instances of FGM/C for investigation or potential  prosecution; however, there are several existing tiplines that could be  used for this purpose. Federal law enforcement agencies, as well as  others, provide avenues to report instances of FGM/C for investigation  and potential prosecution, but few instances have been reported. FGM/C,  as well as other crimes, can be reported to federal tiplines managed by  the FBI and ICE; the agencies have received a total of five reports related  to FGM/C. FBI’s tipline received three reports related to FGM/C from  fiscal year 1997 to 2015, and FBI officials stated that no information was  available to indicate that any of those reports resulted in an  investigation. ICE’s tipline received two reports that were related to  FGM/C since fiscal year 2014, and ICE officials stated that those reports  were determined not to be actionable. According to officials from DOJ’s  Human Rights and Special Prosecutions Section, instances of FGM/C  can also be reported to their tipline, which forwards the information to law  enforcement, and has received two tips related to FGM/C. Officials from  three of the four local child protection agencies in our selected  communities and one other that we spoke with said that all instances of  child abuse and neglect that happen within their jurisdiction are reported  through their tiplines.
In addition to the federal tiplines, the National Center for Missing and  Exploited Children maintains the CyberTipline, which accepts reports  from the general public and electronic service providers related to the  sexual exploitation of children, in general. These reports are  subsequently passed on to law enforcement. Officials said that, of the 7  million reports they received since the CyberTipline was launched in  1998, they have not identified any reports that were related to an actual  instance of FGM/C.
Local law enforcement and child protection officials told us that immigrant  communities may underreport due to cultural norms, victims’ reluctance to  betray their community or family members, and concern about potential  effects on their immigration status and that of their family members. In  addition, although many professionals who may be in contact with girls at  risk for FGM/C are mandatory reporters (e.g., health care, school, and  child care officials), they may be uncertain about whether FGM/C should  be reported. For example, health care providers we spoke with stated that  they may not report instances of girls being at risk of or subjected to  FGM/C due to uncertainty about mandatory reporting requirements (e.g.,  if FGM/C occurred before arriving in the United States), or because they  prefer to counsel parents on the consequences of FGM/C to change  parents’ position on the issue. School officials we spoke with had little or  no experience encountering FGM/C among their students, in general, and  school officials may not be certain of what actions are appropriate when  they encounter suspicions of FGM/C, which can affect reporting. For  example, an official from a nongovernmental organization that works with  Somali women said teachers contacted them for guidance on dealing with  suspicions of vacation cutting. In addition, a former school psychologist  who now works with a national organization told us about an instance  when school officials had suspicions of vacation cutting that was not  reported. However, they did not confirm these suspicions with the student  or her family, out of concern that she would be pulled out of school and  her home environment would be disrupted. Without clear evidence that  FGM/C had occurred, the officials decided to provide the student with  general support for trauma. States’ mandatory reporting requirements  vary across jurisdictions, are dependent on the relevant facts and  circumstances, and would be subject to some level of interpretation by  the reporting official. These factors can make it challenging to determine  the appropriate course of action when encountering potential instances or  risks of FGM/C on minors.
section_title: Federal Agencies and Others Provide Education and Assistance Related to FGM/C, but Gaps Exist and Federal Agencies Lack Documented Plans for Future Efforts
paragraphs: Federal agencies and others have provided education and assistance  related to FGM/C in immigrant communities, but such efforts made before  immigrants’ arrival in the United States are limited by the gaps in how  State makes FGM/C-related information available to certain visa  recipients. While federal agencies have made efforts to increase  awareness of FGM/C for key stakeholder groups, they lack documented  plans for future education and outreach efforts.
subsections: section_title: Federal Agencies and Nongovernmental Organizations Provide Education and Assistance to Immigrant Communities, but Gaps Exist in Notifying Certain Visa Recipients About FGM/C
paragraphs: Federal agencies provide education on the health and legal  consequences of FGM/C and assistance to immigrants before and after  arrival in the United States.
Before arrival. Before arrival in the United States, State provides  education on FGM/C to both refugees and visa recipients. According to  an official from State’s Bureau of Population, Refugees, and Migration,  refugees receive a hard copy of the U.S. Government Fact Sheet on  Female Genital Mutilation or Cutting along with the letter that informs  them that their refugee status is approved. During the cultural orientation  process, one fact sheet is provided per family for all African nationalities.  The fact sheet was last updated in June 2014 through an interagency  effort led by USCIS. (See appendix II for a copy of the fact sheet.) In  addition, the official said FGM/C is often covered during the 2 to 5 day  cultural orientation process, which has sessions where they discuss  frequently asked questions, as well as U.S. law. The official explained  that refugees are not required to participate in cultural orientation, but it is  highly encouraged.
DHS, in cooperation with State, is also required by law to make  information available to individuals who are issued immigrant visas or  nonimmigrant visas about the health consequences of FGM/C and the  legal consequences of involvement in the practice in the United States.  In addition, the law instructs the agencies to limit the provision of the  information to individuals from countries where FGM/C is “commonly  practiced.” State has taken the lead in implementing this requirement,  and according to the agency’s Foreign Affairs Manual, the Bureau of  Consular Affairs should emphasize making this information available to IV  recipients compared to NIV recipients.
As such, IV recipients who applied in countries where FGM/C is  commonly practiced are directly provided a hard copy of the fact sheet at  the time of their in-person interview. NIV recipients, however, are not  provided a hard copy of the fact sheet during their interview; instead,  Consular Affairs has made the fact sheet indirectly available to them by  displaying it in the posts’ visa section waiting area. Figure 3 is a  photograph of the fact sheet displayed at the post in Tanzania.
According to State data, from fiscal year 2012 to 2015, about 200,000 IV  recipients and over 1 million NIV recipients applied through countries  where FGM/C is commonly practiced. Therefore, only about one in six  visa recipients in these countries would have been directly provided  information about FGM/C by receiving a hard copy of the fact sheet  during the interview; the remaining recipients would have been informed if  they independently found and reviewed the fact sheet in the post waiting  area. State officials could not determine why the agency initially decided  not to provide a hard copy of the fact sheet to NIV recipients. However,  officials stated that NIV recipients are expected to be in the United States  on a short-term, temporary basis. Further, State officials said that there  are a larger number of NIV applicants, who are migratory in nature, in  which case providing them with the fact sheet would be an inefficient  approach to addressing FGM/C. Nevertheless, several NIVs permit stays  in the United States for multiple years. For example, according to federal  law, recipients of “L” NIVs—individuals (and their spouse and minor  children) who are transferring from their employer’s foreign office to an  office in the United States to work in a management or executive role, or  in a position requiring specialized knowledge—may stay for up to 7 years  for managers or executives and 5 years for specialized employees.  Recipients of “B” NIVs—individuals travelling to the United States for  business or pleasure—are initially admitted for not more than 1 year and,  if authorized by DHS, may subsequently extend their stay in increments  of up to 6 months each. Certain NIV recipients, such as “K,” “T,” and “U”  visa holders, may be eligible for lawful permanent residence, provided  they satisfy the applicable statutory criteria. Furthermore, NIV recipients  may overstay their visas. ICE officials identified at least one instance  when a woman who overstayed her “B” visa subjected her daughters to  FGM/C through suspected vacation cutting. After overstaying her visitor  visa, officials said that the woman gave birth to three U.S. citizen  daughters and subsequently sent two daughters back to her home  country where they were suspected to have been cut. ICE officials argued  that the woman should be barred from relief because she did little to  protect her daughters from being subjected to FGM/C.
According to the Office of Management and Budget, risk assessment  should encompass all appropriate hazards (e.g., risks to human health).  This guidance also states that the depth or extent of the analysis of the  risks, benefits, and costs associated with a decision should be  commensurate with the nature and significance of the decision. Under  State’s current approach, a relatively large number of NIV recipients from  countries where FGM/C is commonly practiced may not be informed of  the health and legal consequences of FGM/C and may choose to  participate in the practice.
In addition to not directly notifying NIV recipients in countries where  FGM/C is commonly practiced, State does not directly notify IV or NIV  recipients who are nationals of these countries, but received their visas  outside of the relevant countries identified by State or UNICEF.  Individuals are not obligated to apply for visas in their home country, so  those who are from a country where FGM/C is commonly practiced or  known to be prevalent may also apply for visas at posts in other  countries. For example, the U.S. post in London issued at least 6,581  NIVs to nationals of countries with known prevalence of FGM/C in fiscal  year 2015, which is comparable to the number of visas issued at posts in  countries with known prevalence of FGM/C, such as the post in Burkina  Faso that issued 5,450 NIVs. However, under State’s current policy, the  NIV recipients who were issued an NIV in London would not have been  directly informed about the health and legal consequences of FGM/C in  the United States. Instead, this information is made available through the  fact sheet posted in each post’s visa section waiting area. Under State’s  current policy and practice as outlined in the Foreign Affairs Manual,  direct provision of the fact sheet is limited to IV recipients who are issued  their visas at posts in the countries where FGM/C is commonly practiced.  Table 2 lists other posts that issued at least 1,000 NIVs to nationals from  countries with known prevalence of FGM/C.
Further, certain countries with known prevalence of FGM/C have a  relatively large proportion of their nationals who were issued NIVs in  countries without known prevalence. For example, in fiscal year 2015, 81  percent (3,664 of 4,525) of Yemen nationals were issued NIVs in  countries where the practice was not prevalent, such as in Saudi Arabia.  Also in fiscal year 2015, there were 12 nationalities that had over 1,000  individuals issued NIVs through posts located in countries without known  prevalence of FGM/C. For example, 13,118 of 156,147 Nigerian nationals  worldwide (about 8 percent) applied for NIVs through other posts, such as  in Calgary and London. (See appendix IV for more information on the  nationalities with the highest numbers and percentages of visa recipients  applying through other posts.) Under State’s Foreign Affairs Manual,  these individuals were not directly provided information on FGM/C.
The law requires that, to the extent practicable, the provision of  information on the consequences of FGM/C be limited to individuals from  countries where FGM/C is “commonly practiced.” State’s current policy  and practices have implemented this limiting provision by providing the  fact sheet only to individuals who are issued IVs at posts located in these  countries. Consular Affairs officials told us there would be significant  costs and training involved with changing their current approach to make  the information available to IV and NIV recipients from countries where  FGM/C is commonly practiced—regardless of where the individual  applied—in an identical manner. For example, officials stated that in  addition to the cost of making additional photocopies of the fact sheet,  they would have to update the Foreign Affairs Manual and send guidance  to all posts regarding which IV and NIV recipients should receive the fact  sheet. However, we believe the costs and training associated with  making the information available to NIV recipients in the same manner as  for IV recipients, whether or not such IV or NIV recipients applied from  posts in countries where FGM/C is commonly practiced, would be  minimal under State’s current approach. For example, while consular  officers would have to receive updated guidance regarding which visa  recipients should receive the fact sheet, they would not have to receive  any additional guidance on the content of the fact sheet because,  according to Consular Affairs officials, consular officers are not supposed  to engage in discussion about the fact sheet. Further, a 2014 survey by  Consular Affairs found that no visa recipients had asked questions about  the fact sheet. There have been thousands of IV and NIV recipients who  are nationals of countries with known prevalence of FGM/C who were not  directly provided this information during their visa application process. As  a result, they may have entered the United States without having been  made aware of the health and legal consequences of FGM/C, and they  may have participated in the practice.
After arrival. After arrival in the United States, HHS, State, and USCIS  provide education and assistance to immigrant communities on FGM/C  through both general and targeted efforts. State’s Office of Religion and  Global Affairs has ongoing outreach efforts to religious groups in U.S.  immigrant communities and has targeted the issue of FGM/C. For  example, agency officials said they met with the Council on American- Islamic Relations to add content about FGM/C to personal booklets,  which summarize individuals’ rights and responsibilities while living in the  United States. According to agency officials, USCIS has prioritized raising  awareness about FGM/C by developing informational materials targeted  toward immigrant communities. For example, USCIS developed a general  brochure with information about FGM/C similar to what is included in the  fact sheet, and will develop a child-friendly brochure to inform children  about actions to take if they are concerned about being subjected to  FGM/C. The officials also said that they plan to develop an audiovisual  product for audiences who are unable to read with information about the  consequences of FGM/C.
HHS’s Office on Women’s Health Helpline—which is open to and  intended for the general public—provides callers with information and  connects them to resources on health care topics including FGM/C. Also,  CDC officials told us that it can facilitate providing targeted assistance to  some immigrants through the agency’s role in the refugee process. CDC  is responsible for ensuring that immigrants and refugees entering the  United States do not pose a public health threat. The immigrant visa and  refugee medical examination is one method of evaluating the health of  individuals applying for entry into the United States; these mandatory  exams are performed overseas by physicians under the guidance of  CDC’s Technical Instructions. The primary purpose of the overseas  exam is to ensure the safety and protection of U.S. public health from  communicable illnesses. In addition to the Technical Instructions for  overseas exams, CDC has developed the Refugee Health Guidelines,  which are best practices for state public health departments and health  care providers to use in conducting the initial domestic health exams of  refugees upon arrival in the United States, including screening for  FGM/C. According to HHS officials, there are four primary purposes of the  domestic medical exam: (1) follow up on health issues identified during  the overseas exam; (2) identify communicable diseases not already  identified; (3) identify personal health conditions that left unidentified  could impact an individual’s ability to successfully resettle; and (4) refer  refugees to primary care and ensure continuity of care between the  overseas exam and when the refugee resettles in the United States.  According to HHS officials, while the domestic health exam for the  refugee resettlement process is not mandated by federal regulations,  officials from HHS told us it is highly encouraged for states to perform  these exams. When the domestic medical exam is performed, it may  provide an opportunity for health care providers to provide targeted  assistance to women and girls who have undergone FGM/C, such as  referrals for specialized care or mental health services. One health care  provider we spoke with said that during the domestic exam, FGM/C is  something that providers in his practice screen for, although they may  delay this screening until they have established a relationship with the  patient.
In addition to their general and targeted efforts addressing FGM/C,  federal agencies have several grant programs that have either been  designated specifically for or may be used to provide education and  assistance to immigrant communities related to FGM/C. For example,  HHS’s Office on Women’s Health released a funding announcement in  January 2016 designated for FGM/C-related activities. The  announcement was for the Female Genital Cutting Community-Centered  Health Care and Prevention Project, a new project that will provide  funding for organizations that focus directly on addressing problems with  FGM/C-related health care needs and prevention. Other agencies also  have grant programs under which FGM/C-related activities are allowable.  For example, officials from HHS’s Office of Refugee Resettlement said  that their office funds Ethnic Community Self-Help grants, which have  provided funding to four organizations that specifically described  supporting FGM/C activities.
DOJ also has grant programs through its Office on Violence Against  Women and Office of Justice Programs (through its Office for Victims of  Crime, and the Office of Juvenile Justice and Delinquency Prevention),  but that are not solely designated for FGM/C-related activities. According  to Office on Violence Against Women officials, the agency does not have  the statutory authority to target funding to assist victims of FGM/C through  the Violence Against Women Act, which funds services specifically for  victims of domestic violence, dating violence, sexual assault, and stalking,  and their families. However, according to DOJ officials from the Office on  Violence Against Women and the Office of Justice Programs, women who  have been subjected to or threatened with FGM/C could access services  from the grantees if they would otherwise qualify for services. For  example, DOJ’s Office on Violence Against Women reported that a  grantee from their Legal Assistance for Victims Program provided  assistance to a woman who was a victim of domestic violence whose  husband had threatened to subject her three daughters to FGM/C.
Several nongovernmental organizations and health care providers also  provide education and assistance on FGM/C to immigrants and their  communities. We identified two nongovernmental organizations that  provide legal services for immigrants, including women and girls at risk of  or who have been subjected to FGM/C. These organizations also provide  referrals for other services as needed and have provided girls who are at  risk of FGM/C with general guidance and preventative assistance. For  example, to help prevent vacation cutting, one such organization supports  the concept of developing safety plans for at-risk girls who travel abroad.
According to child protection officials in one of our selected communities,  another nongovernmental organization has developed protection plans for  at-risk girls, such as by making copies of passports and developing  strategies for helping them to escape to a consular post if in danger. We  also identified two specialized clinics in the United States that provide  treatment to women and girls who were subjected to FGM/C, and several  health care providers who conduct research and outreach to immigrant  communities on FGM/C. Additionally, there are several health care  providers who offer certain FGM/C-related health care services, such as  defibulation (the reconstructive surgery of scar tissue used to reverse  certain types of FGM/C).
section_title: Federal Agencies and Others Have Targeted Education and Outreach Activities to Key Stakeholder Groups, but Federal Agencies Lack Documented Plans for Future Efforts
paragraphs: Federal agencies and other entities have made efforts to increase  awareness of FGM/C for key stakeholder groups. The federal government  has demonstrated a commitment to increasing awareness about FGM/C  among key stakeholders in the United States, including nongovernmental  organizations, law enforcement officials, immigration officials, educators,  and health care providers. The United States participated in the Girl  Summit 2014 hosted by the United Kingdom and UNICEF—a convening  of government officials, civil society groups, and those from the private  sector—to discuss domestic and international strategies for combating  FGM/C and other types of gender-based violence. Following the summit,  the U.S. government committed to taking several actions to address  FGM/C in the United States, several of which involved education and  outreach to key stakeholders. Specifically, the government committed to  the education and outreach goals of providing information on FGM/C to educators and immigrant and  refugee service provider organizations in communities throughout the  United States with large populations of girls at risk;  strengthening awareness and training for health care providers  serving girls and women at risk for or living with the consequences of  FGM/C, and disseminate information to clinicians in community health  centers; and establishing an information and resources depository with links to  health and legal providers, to inform women and girls of their rights,  and provide options for those seeking help.
Table 3 provides a summary of selected efforts agency officials told us  they have made to provide education and outreach to key stakeholder  groups on FGM/C, many of which are in line with the Girl Summit  commitments.
Nongovernmental organizations have also undertaken education and  outreach efforts on their own to provide assistance to key stakeholder  groups. For example, a nongovernmental organization in Washington,  D.C., has hosted semiannual discussions about FGM/C with participants  from federal agencies, European governments, various advocacy  organizations, and health care providers. Additionally, two  nongovernmental organizations provided training to local law enforcement  agencies. One medical association has developed guidelines for treating  patients who have experienced FGM/C. However, the existence of these  guidelines may not be widely known among providers. Another medical  association developed a brochure that pregnant women who had  undergone FGM/C could give to their health care providers to help the  providers understand the practice and discuss FGM/C in a culturally  sensitive and respectful manner. Further, several health care providers  we spoke with have developed their own training materials on FGM/C,  and have conducted speaking tours at medical schools and hospitals to  raise awareness of FGM/C amongst providers, including how to treat  women who have been subjected to the practice.
When we asked key stakeholder groups about the federal government’s  role related to education and outreach on FGM/C, these groups noted  that they would like to see the federal government provide additional  information on FGM/C, which would include increasing awareness on the  issue. For example, officials from local child protection agencies  suggested that the federal government’s role should include providing  education to immigrant communities, stakeholder coordination, and  guidance to states on FGM/C laws and policy development. In general,  despite having higher populations of immigrants from countries with  known prevalence of FGM/C, local officials in our selected communities  described having little or no experience encountering instances of  FGM/C. Given this relative lack of experience with encountering FGM/C,  some officials said that the federal government could play an important  role in providing access to informational resources, including education  on FGM/C and guidance on how to respond if they do encounter  instances of FGM/C. In addition, local law enforcement and child  protection officials told us that it would be helpful to receive training on  FGM/C and guidance for mandatory reporters from the federal  government.
As discussed previously, federal agencies have made efforts to increase  stakeholders’ awareness of FGM/C, and agency officials identified  additional activities they have planned for the near future. For example,  DOJ officials stated that, in June 2016, they will be part of a panel at a  national conference for refugee health providers, which will include two  health care providers and an FGM/C activist. DOJ officials also stated  that, in June 2016, officials will participate in a webinar with the  Department of Education for the American School Health Association,  and will then host a roundtable for stakeholders in Maryland in  coordination with the U.S. Attorney’s Office, Education, FBI, HHS, ICE,  and USCIS in the summer of 2016. Additionally, DOJ officials said they  are working with officials from HHS’s Office on Child Abuse and Neglect  to discuss holding an FGM/C panel at the HHS-sponsored National  Conference on Child Abuse and Neglect in August 2016. Officials from  DHS told us that they are in the process of developing a child-friendly  brochure to inform children about actions to take if they are concerned  about being subjected to FGM/C. Additionally, officials from State’s Office  of Religion and Global Affairs stated that they plan to continue their  outreach to religious groups in order to better link the agency’s domestic  and international advocacy efforts on FGM/C.
However, the agencies have not documented their previous and planned  education and outreach efforts. Therefore, it is unclear whether and how  these agencies will continue or expand their efforts to key stakeholders in  the longer term. Officials from all five agencies we spoke with told us that  they do not have a written plan for how they will conduct education and  outreach efforts on FGM/C moving forward, in part, because the agencies  had not considered developing such a plan. Project management  standards state that when an entity is planning a project—that is, a  temporary endeavor to create a unique product, service, or result—it is  important to define relevant activities and determine the scope, sequence,  and schedule of those activities, among other things. In addition, GAO’s  Standards for Internal Control in the Federal Government state that  federal agencies should establish plans to help ensure goals and  objectives—such as increasing awareness about FGM/C—can be met.  Furthermore, internal controls state that documentation of agency  decisions and activities is important because it provides a means to retain  organizational knowledge, mitigate the risk of having that knowledge  limited to a few personnel, and communicate that knowledge to external  parties, as appropriate.
Officials from DOJ told us that they were unsure how a written plan would  improve coordination or efforts to conduct education and outreach beyond  current efforts. For example, agency officials said that they coordinate  with other agencies in planning education and outreach activities and  share information about planned activities, as needed, through email or  meetings, which we have identified as a promising practice for agencies  that have similar goals and objectives.
However, having a written plan can assist agencies in communicating  their intended education and outreach activities on FGM/C, and benefit  agencies’ coordination efforts and information sharing with one another.  Moreover, given that stakeholders we interviewed have expressed  interest in receiving additional information and guidance on FGM/C from  the federal government, it would also be beneficial for agencies to  articulate and share their education and outreach plans with these  stakeholders as appropriate. It is important to equip key stakeholders,  particularly those at the state and local level, with information on the  health and legal consequences of FGM/C, so that they will be able to take  appropriate action and provide needed assistance when appropriate if  they encounter someone who is at risk of or has been subjected to  FGM/C. Additionally, documentation, such as a written plan, could assist  agencies by establishing and communicating the who, what, where,  when, and why regarding efforts to increase awareness about FGM/C.  Without a documented plan for each agency’s education and outreach  efforts, agencies may be unable to ensure that activities on FGM/C meet  the needs of external parties, such as key stakeholder groups, or  effectively use federal resources to combat FGM/C. Furthermore, given  the different agencies that play a role in providing education and outreach  on FGM/C in the United States and the likelihood that these agencies  may conduct outreach to similar stakeholders, having a written plan that  is shared with other agencies could help enhance agencies’ ongoing  coordination and collaboration efforts.
section_title: Conclusions
paragraphs: Estimates suggest that at least 200 million women and girls worldwide  have been subjected to FGM/C, and about half a million in the United  States are at risk of or have undergone the practice. FGM/C has both  immediate and long-term health and social consequences. While federal  agencies have made efforts to provide assistance to women and girls in  the United States at risk of or who have been subjected to FGM/C, and  increase awareness of the issue, certain efforts to educate immigrant  communities and plan agency activities on FGM/C are lacking. Since the  Department of State does not provide a fact sheet on FGM/C directly to  NIV recipients or to any visa recipients from countries where FGM/C is  commonly practiced but who apply elsewhere, these recipients may be  unaware of the health and legal consequences of FGM/C and choose to  participate in this practice. Given the significant long-term effects that  FGM/C can have on women and girls, the potential benefit of providing  the fact sheet to additional visa recipients—helping to prevent the further  practice of FGM/C—outweighs the likely additional effort and costs of  doing so. Furthermore, while multiple agencies throughout the federal  government have made efforts to increase awareness of FGM/C through  ad hoc education and outreach efforts, it is unclear how these agencies  will identify and implement needed efforts moving forward. Absent a  documented plan for each agency’s education and outreach efforts, the  federal government may be unable to ensure that its activities to increase  awareness of FGM/C are meeting the needs of and communicated  effectively to external parties, such as key stakeholder groups, or that it is  making the best use of federal resources. Identifying these opportunities  through project planning and sharing the plans among federal agencies  and stakeholder groups with different roles and expertise could potentially  enhance collaboration to combat FGM/C in the United States, and be  responsive to stakeholders’ request for additional guidance.
section_title: Recommendations for Executive Action
paragraphs: To increase awareness of the health and legal consequences of FGM/C  among visa recipients, we recommend that the Secretary of State update  the Foreign Affairs Manual to require posts located in countries where FGM/C is commonly practiced to  directly provide information about FGM/C to nonimmigrant visa  recipients in the same manner as is done for immigrant visa  recipients; and posts located outside of the countries where FGM/C is commonly  practiced to directly provide information on FGM/C to immigrant and  nonimmigrant visa recipients who are nationals of countries where  FGM/C is commonly practiced.
To make the best use of federal resources directed toward combating  FGM/C in the United States, we recommend that the Attorney General  and the Secretaries of Education, Health and Human Services, Homeland  Security, and State each develop a written plan that describes the agency’s approach for  conducting education and outreach to key stakeholders in the United  States regarding FGM/C; and  communicate the plan with other relevant federal agencies and  stakeholder groups, as appropriate.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to DHS, DOJ, Education, HHS, and  State. The agencies provided technical comments, which we incorporated  as appropriate. DHS, Education, HHS, and State also provided written  comments, which are reprinted in appendixes V, VI, VII, and VIII.
State agreed with our recommendation that it expand the direct provision  of information about FGM/C to immigrant and nonimmigrant visa  recipients who are nationals of countries where FGM/C is commonly  practiced. In its written comments, State described its plan to change the  manner in which the fact sheet is distributed. As part of that change,  State’s Bureau of Consular Affairs is revising its current procedure in  order to provide the fact sheet to applicants electronically during the  application process. Once electronic, the Bureau of Consular Affairs will  directly provide the fact sheet to applicants for both immigrant and  nonimmigrant visas who are nationals from countries where FGM/C is  commonly practiced no matter where they apply. State will then update  the Foreign Affairs Manual to reflect this new process.
State disagreed with our recommendation that it develop and share a  written plan, and, in its agency comments, emphasized that its activities  are to provide information about FGM/C abroad and not domestically.  However, as we noted in the report, State’s Office of Religion and Global  Affairs has undertaken several activities to reach out to immigrant  populations as part of its efforts to link the agency’s domestic and  international advocacy on FGM/C. While State’s domestic activities may  be limited to this population, we believe that having a plan to describe its  role and outreach efforts is still important to communicate to other  agencies and key stakeholders.
DHS, DOJ, Education, and HHS generally concurred with our  recommendation that each agency develop and share a written plan on  their FGM/C education and outreach efforts. In agreeing with the premise  of our recommendation, Education noted in its written comments the  importance of coordination across the federal government to improve  collaboration and be responsive to stakeholder needs. For this reason,  Education suggested that our recommendation designate a lead agency  to coordinate a written plan so that agencies can agree on the roles and  responsibilities for outreach and education. HHS similarly stated that a  single, unified strategy would be more effective, and that leadership for  coordinating and disseminating such a strategy would best be filled by the  National Security Council staff’s sub-Interagency Policy Committee. While  we recommended that each agency develop its own plan, if the agencies,  under the leadership of National Security Council staff or a designated  lead agency that they select, prefer to develop a single plan, we believe  that such an approach would be consistent with the intent of our  recommendation.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution of it until 30 days from its  date. At that time, we will send copies to appropriate congressional  committees, the Attorney General and the Secretaries of Education,  Health and Human Services, Homeland Security, and State. The report is  also available at no charge on the GAO website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  us at (202) 512-7114 or crossem@gao.gov, or (202) 512-8777 or  goodwing@gao.gov. Contact points for our Offices of Congressional  Relations and Public Affairs are on the last page of this report. GAO staff  who made major contributions to this report are listed in appendix IX.
section_title: Appendix I: Scope and Methodology
paragraphs: In this report, we examine  1.  what is known about the number of women and girls in the United  States at risk of or who have been subjected to female genital  mutilation/cutting (FGM/C);  2.  the protections available and actions taken, if any, by federal and  selected state and local agencies to protect women and girls in the  United States at risk of or who have been subjected to FGM/C; and  3.  the extent to which federal agencies and others have taken action to  educate and assist immigrant communities and key stakeholders  about FGM/C.
To examine what is known about the number of women and girls in the  United States at risk of or who have been subjected to FGM/C, we  collected and reviewed agency documentation and journal articles, as  well as interviewed agency officials. Specifically, we collected and  reviewed documentation from the Department of Health and Human  Services’ (HHS) Centers for Disease Control and Prevention (CDC),  including the agency’s estimates on the prevalence of FGM/C among  women and girls living in the United States for 1990 and 2012. We also  collected and reviewed documentation related to efforts to measure  FGM/C prevalence in the United Kingdom, as well as journal articles and  reports from the United States and other countries, and publications from  nongovernmental organizations and medical associations. In addition,  we interviewed officials at CDC and government officials from the United  Kingdom about their efforts to measure prevalence.
To examine the protections available and the actions taken to protect  women and girls at risk of or who have been subjected to FGM/C, we  reviewed documentation from and held interviews with federal agency  officials who are responsible for managing the relevant immigration  processes, which foreign women at risk of or who have been subjected to  FGM/C could use to avoid potential harm in their home countries.  Specifically related to the asylum process, we spoke with officials from  the Department of Homeland Security’s (DHS) U.S. Citizenship and  Immigration Services (USCIS) about trends in FGM/C-based affirmative  asylum claims they adjudicate. We also spoke with officials from the  Department of Justice’s (DOJ) Executive Office for Immigration Review  (EOIR) and DHS’s U.S. Immigration and Customs Enforcement (ICE)  about trends in FGM/C-based asylum and withholding of removal cases  adjudicated in immigration courts. Related to the refugee process, we  spoke with officials from the Department of State’s (State) Bureau of  Population, Refugees, and Migration, HHS’s Office of Refugee  Resettlement, and USCIS about their efforts to resettle refugees in the  United States who come from countries with known prevalence of  FGM/C. We also interviewed officials from two relevant nongovernmental  organizations—Sanctuary for Families and the Tahirih Justice Center— both of which provide legal support to immigrant women. In addition, we  obtained case information from and interviewed agency officials who are  responsible for investigating and prosecuting FGM/C-related crimes,  including officials from DOJ’s Human Rights and Special Prosecutions  Section and Federal Bureau of Investigation (FBI). We also spoke with  officials from ICE regarding investigations.
In order to estimate the number of women and girls who are at risk of or  who have been subjected to FGM/C and were granted affirmative asylum  in the United States, we obtained data and reviewed case files on granted  affirmative asylum claims involving females from countries with known  prevalence of FGM/C, as identified by the United Nations Children’s Fund  (UNICEF) in 2013. Specifically, we obtained data on individual asylum  applicants from USCIS’s Refugee, Asylum, and Parole System database  for all cases adjudicated by USCIS in fiscal years 2014 and 2015. We  chose this time period to understand recent efforts to seek asylum among  females from countries with known prevalence of FGM/C. To determine  the reliability of the data, we reviewed relevant documentation from  USCIS on the database, conferred with knowledgeable officials, and  reviewed the data for any obvious errors or abnormalities. We determined  that the data were sufficiently reliable for the purposes of our reporting  objectives. We analyzed the data to develop a list of cases involving  female applicants from the countries with known prevalence of FGM/C  who were granted asylum affirmatively by USCIS during this time period.  We then selected a random, generalizable sample of 100 cases from a  population of 2,756 cases and reviewed the alien file associated with  each case to determine whether USCIS had granted asylum, at least in  part, on the basis of FGM/C. We limited our review of files to affirmative  asylum cases granted by USCIS rather than affirmative cases granted by  EOIR after referral from USCIS, defensive asylum claims originating in  removal proceedings, or claims for withholding of removal, because  EOIR—the agency responsible for adjudicating these types of cases in  immigration court—does not track certain factors such as the gender of  the applicant and the underlying grounds that support the applicant’s  claim for relief or protection from removal. Further, DHS and DOJ officials  told us that the highest volume of FGM/C-based asylum claims would be  affirmative asylum claims. To enhance and confirm our understanding of  the data, we also conducted interviews with USCIS asylum officers in five  of the eight asylum offices nationwide, as well as ICE attorneys  responsible for litigating asylum cases in the four immigration courts that  serve areas with large populations of immigrants from countries with  known prevalence of FGM/C. Our methodology for selecting the locations  for these interviews is described in more detail below.
To learn about the actions taken on the local level to protect women and  girls who are at risk of or have been subjected to FGM/C, we interviewed  officials from selected local law enforcement and child protective services  agencies on the extent to which the agencies had conducted any FGM/C- related investigations. These agencies were located in four communities  with large populations of immigrants from countries with known  prevalence of FGM/C. To select these communities, we consulted data  from multiple sources. These included
UNICEF’s 2013 statistical report on FGM/C,
U.S. Census Bureau’s 2008 American Community Survey data on  foreign-born populations from Africa,
Population Reference Bureau’s 2015 report that identified the top 10  metropolitan statistical areas in the United States for women and girls  potentially at risk of FGM/C, and  field locations for key federal agencies we planned to interview, such  as the local asylum offices that serve these metropolitan statistical  areas.
We then compared the metropolitan statistical areas identified by the  American Community Survey, the Population Reference Bureau, and  asylum office locations to find areas of overlap. Through this analysis, we  identified three metropolitan statistical areas that were present in all three  sources—Washington, D.C.; Los Angeles, California; and New York City,  New York/Newark, New Jersey. Given that UNICEF data reports the  highest prevalence of FGM/C in Somalia, we wanted to ensure that at  least one metropolitan statistical area with a large population of Somali- born immigrants was included. Therefore, we added Minneapolis,  Minnesota, as an additional community for our review. To target our  interviews with local law enforcement and child protection agencies, we  used 2014 county-level American Community Survey data to identify the  single county within each of the four metropolitan statistical areas that  had the largest African-born population from countries with known  prevalence of FGM/C. The counties we identified were Montgomery  County, Maryland (Washington, D.C.); Los Angeles County, California  (Los Angeles); Bronx County, New York (New York City/Newark); and  Hennepin County, Minnesota (Minneapolis).
To examine the extent to which the federal agencies and others have  taken action to educate and assist immigrant communities and key  stakeholders about FGM/C, we reviewed documentation and interviewed  agency officials from the Department of Education’s Office of Safe and  Healthy Students; DHS; DOJ; HHS’s CDC, Office of Refugee  Resettlement, and Office on Women’s Health; and State regarding their  outreach and collaborative efforts. We also interviewed health care  providers who are knowledgeable about FGM/C and officials from three  medical associations, as well as three nongovernmental organizations on  their outreach efforts. For the medical associations, we interviewed  officials from the American Congress of Obstetricians and Gynecologists,  the American Academy of Pediatrics, and the American College of Nurse- Midwives. For the nongovernmental organizations, we interviewed  officials from Isuroon, Safe Hands for Girls, Sanctuary for Families, and  the Tahirih Justice Center. To understand FGM/C efforts at the state and  local level, we contacted state refugee health coordinators, and state and  local health department officials from our selected communities and  corresponding states. We also spoke with officials from three school  districts in the Washington, D.C., metropolitan area—Montgomery County  Public Schools (Maryland), Alexandria City Public Schools (Virginia), and  Fairfax County Public Schools (Virginia). Further, we spoke with the  National Association of School Psychologists. We also assessed federal  agency actions against the relevant standards for internal control in the  federal government.
To understand State’s outreach efforts pertaining to informing visa  recipients on the consequences of FGM/C, we obtained data from State’s  Bureau of Consular Affairs on the number of immigrant visas (IV) and  nonimmigrant visas (NIV) issued during fiscal years 2012 through 2015 to  individuals from and posts located in countries with a known prevalence  of FGM/C. Per State’s Foreign Affairs Manual, consular officers are to (1)  provide a copy of the U.S. Government Fact Sheet on FGM/C to  individuals who were issued an IV at specific posts designated to provide  IV services to the 30 countries where State determined FGM/C is  commonly practiced (direct notification); and (2) display a copy of the fact  sheet in the waiting area of all posts worldwide (indirect notification). To  determine how many IV and NIV recipients from the countries where  FGM/C is commonly practiced, including nationals from those countries,  were directly versus indirectly provided information on FGM/C, we  obtained and analyzed IV and NIV data. For the 30 countries identified by  State as being where FGM/C is commonly practiced, we analyzed State  data from fiscal year 2012 to 2015 on (1) the total number of IVs issued  by the 20 posts that provide IV services, and (2) the total number of  issued NIVs by the 27 countries with posts that provide NIV services.  For the 30 countries determined by UNICEF as being where FGM/C is  considered prevalent, we analyzed State data from fiscal year 2015 on (1)  the total number of NIVs issued to nationals of each of the 30 countries,  and (2) the number of NIVs issued at a post located outside of the 30  countries to nationals of the 30 countries. We chose the time period of  fiscal years 2012 through 2015 to be able to identify any trends before  and after vacation cutting was added to the statute criminalizing FGM/C in  2013. We obtained data from two systems used by State’s Bureau of  Consular Affairs: the Immigrant Visa Allocation Management System and  the Consular Consolidated Database. We assessed the reliability of the  data by reviewing documentation provided by the Bureau of Consular  Affairs, speaking with knowledgeable agency officials, and reviewing our  prior work on the systems. We determined that the data obtained from  these systems were sufficiently reliable for the purposes of our reporting  objectives. We also examined the agency’s decisions to target  information to certain visa recipients against the Office of Management  and Budget’s Memorandum on Updated Principles for Risk Analysis.
We conducted this performance audit from June 2015 to June 2016 in  accordance with generally accepted government auditing standards.  These standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
section_title: Appendix II: U.S. Government Fact Sheet on Female Genital Mutilation or Cutting
section_title: Appendix III: Nonimmigrant Visas Issued in Countries with Known Prevalence of Female Genital Mutilation/Cutting
paragraphs: Appendix III: Nonimmigrant Visas Issued in  Countries with Known Prevalence of Female  Genital Mutilation/Cutting Post location: Country (City)  Nigeria (Lagos)
Nigeria (Abuja)
Indonesia (Jakarta)
Egypt (Cairo)
Kenya (Nairobi)
Indonesia (Surabaya)
Ethiopia (Addis Ababa)
Ghana (Accra)
Uganda (Kampala)
Tanzania (Dar es Salaam)
Cameroon (Yaoundé)
Burkina Faso (Ouagadougou)
Cote D’Ivoire (Abidjan)
Liberia (Monrovia)
Senegal (Dakar)
Iraq (Erbil)
Sudan (Khartoum)
Iraq (Baghdad)
Mali (Bamako)
Benin (Cotonou)
Togo (Lomé)
Eritrea (Asmara)
Mauritania (Nouakchott)
Sierra Leone (Freetown)
Niger (Niamey)
Guinea (Conakry)
Chad (N’Djamena)
Gambia (Banjul)
Yemen (Sanaa)
Djibouti (Djibouti)
section_title: Appendix IV: Nationals of Countries with Known Prevalence of Female Genital Mutilation/Cutting Issued Nonimmigrant Visas in Countries without Known Prevalence
section_title: Appendix V: Agency Comments from the Department of Education
section_title: Appendix VI: Agency Comments from the Department of Health and Human Services
section_title: Appendix VII: Agency Comments from the Department of Homeland Security
section_title: Appendix VIII: Agency Comments from the Department of State
section_title: Appendix IX: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Acknowledgments
paragraphs: In addition to the contacts named above, Robert Copeland, Assistant  Director; Kristy Love, Assistant Director; Ashley Dixon; Amber Gray; Julie  T. Stewart; Julia Vieweg; and E. Jane Whipple made key contributions to  this report. Jill K. Center; Justin Fisher; Cynthia Grant; Eric Hauswirth;  Drew Long; Amanda Miller; Jan Montgomery; Jon Najmi; and Emily  Wilson also contributed to the development of this report.