Female Genital Mutilation/Cutting: U.S. Assistance to Combat This Harmful Practice Abroad Is Limited
Released: 2016-05-19T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: More than 200 million girls and women alive today have undergone FGM/C in the 30 countries where available data show this harmful practice is concentrated. More than 3 million girls are estimated to be at risk for FGM/C annually in Africa. FGM/C comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs. It is rooted in the cultural traditions of many communities but has several adverse health consequences and the UN identifies it as a violation of human rights. In 2015, the UN General Assembly adopted a set of 17 Sustainable Development Goals for 2030 that included the elimination of FGM/C among its targets. UNFPA and UNICEF implement the Joint Program on FGM/C in 17 countries—the largest current international assistance effort to address FGM/C. State and USAID include FGM/C as part of their global strategy to respond to gender-based violence.

GAO was asked to review State's and USAID's efforts to address FGM/C abroad. This report (1) summarizes findings from recent U.S. and UN studies about factors contributing to FGM/C and approaches to addressing this practice and (2) examines State's and USAID's current efforts to address FGM/C abroad. GAO reviewed recent UN and USAID studies on assistance efforts to address FGM/C, analyzed related strategies and policies, and interviewed State and USAID officials. GAO also analyzed information on FGM/C-related projects and activities from USAID's overseas missions, and State and USAID bureaus.

GAO is making no recommendations in this report.

section_title: What GAO Found
paragraphs: U.S. and United Nations (UN) studies since 2010 have identified a variety of factors contributing to the persistence of female genital mutilation/cutting (FGM/C). In many communities where FGM/C is prevalent, FGM/C is an influential social norm that ensures social acceptance and is commonly perceived as a religious obligation. In addition, medicalization of the practice— when it is performed by health care providers rather than traditional practitioners—increases the perception of legitimacy in some countries. Although the United Nations Children's Fund (UNICEF) reports that many countries where FGM/C is prevalent have passed laws banning the practice, enforcement is a challenge. The studies also have identified key approaches to addressing FGM/C, including efforts to implement community education programs, outreach and training for medical professionals, and the inclusion of FGM/C in broader gender equality and human rights programs.

U.S. assistance efforts to address FGM/C are limited. The Department of State (State) and the U.S. Agency for International Development (USAID) each had one active standalone project in 2014, and the agencies also undertook some FGM/C-related efforts as components of projects with broader assistance goals. In addition, the U.S. government provides funding to the United Nations Population Fund (UNFPA) and UNICEF but, to date, has not contributed funds to the UN agencies' Joint Program on FGM/C. If congressional restrictions for UNFPA funding (such as the requirement for UNFPA to maintain U.S. funds in a separate account) are met, there are currently no specific legal restrictions that would prohibit U.S. funding provided to UNFPA from being available for the Joint Program on FGM/C. Competing development priorities, such as HIV/AIDS, leave little funding specifically for FGM/C, according to USAID officials.

section_title: Letter
paragraphs: At least 200 million girls and women alive today have undergone female  genital mutilation or cutting (FGM/C) in 30 countries where available data  show FGM/C is concentrated.More than 3 million girls are estimated to  be at risk for FGM/C annually in Africa. In 2015, the United Nations (UN)  General Assembly adopted a set of 17 Sustainable Development Goals  for 2030 that includes the elimination of FGM/C as a target.  Although  many countries where FGM/C is known to be concentrated have passed  laws banning this practice, enforcement is a challenge, according to U.S.  and UN studies.  The reasons why FGM/C persists include a mix of  cultural, religious, and social factors within families and communities. The  Department of State (State) and the U.S. Agency for International  Development (USAID) include FGM/C as part of their global strategy to  respond to and prevent gender-based violence. In addition, the United  Nations Population Fund (UNFPA) and the United Nations Children's  Fund (UNICEF) carry out a Joint Program in 17 countries to work toward  ending FGM/C.

You asked us to review U.S. government agencies’ efforts to address  FGM/C at home and abroad. This is the first of two reports responding to  your request. In this report, we (1) summarize findings from recent U.S.  and UN studies about the factors contributing to FGM/C and approaches  to addressing this practice internationally and (2) examine State’s and  USAID’s current efforts to address FGM/C abroad. A second report will  review U.S. efforts to address FGM/C domestically.

To identify factors contributing to FGM/C and current approaches to  address this practice, we reviewed recent U.S. and UN studies of  international efforts to accelerate the abandonment of FGM/C and  respond to victims of this practice. We selected studies published in 2010  or later. We examined a USAID-funded Population Reference Bureau  (PRB) study, reports on the first phase of the UNFPA-UNICEF Joint  Program on FGM/C, a UNICEF statistical overview of FGM/C, and a  UNICEF review of efforts to accelerate FGM/C abandonment in five  African countries.

To determine State’s and USAID’s current efforts to address FGM/C  abroad, we analyzed applicable strategy and policy documents and  interviewed State and USAID officials involved in issues related to  FGM/C.  We collected information from USAID missions in countries  where FGM/C is known to be prevalent to identify development  assistance efforts related to this practice. In addition, we examined a  State-supported FGM/C prevention program in Guinea and selected  State-funded gender-based violence projects in refugee settings to  determine if these projects had any FGM/C-related components. We  also reviewed U.S. contributions to UNFPA and UNICEF. Additionally, we  reviewed how State tracks FGM/C prevalence and countries’ prevention  efforts in its annual Country Reports on Human Rights.

We conducted this performance audit from June 2015 to April 2016 in  accordance with generally accepted government auditing standards.  Those 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.  (See app. I for more  information on our scope and methodology.)
subsections: section_title: Background
subsections: section_title: Definition and Types of FGM/C
paragraphs: FGM/C comprises all procedures that involve partial or total removal of  the external female genitalia, or other injury to the female genital organs  for non-medical reasons. The World Health Organization (WHO)  classifies FGM/C into four major types:

Type I (clitoridectomy) partially or totally removes the clitoris and/or  the skin around it;

Type II (excision) partially or totally removes the clitoris and the labia  minora, with or without excision of the labia majora;

Type III (infibulation) narrows the vaginal opening through the creation  of a covering seal  formed by cutting and repositioning the labia  minora and/or labia majora, sometimes through stitching, with or  without removal of the clitoris; and

Type IV (other) includes all other harmful procedures, including  pricking, piercing, incising, and scraping the genital area for non- medical purposes.

According to the WHO, it is estimated that 90 percent of cases are Types  I, II, or IV; 10 percent are Type III, the most extreme form of FGM/C.

The type of FGM/C commonly practiced varies by country, according to  survey data presented by UNICEF. For example, survey data show that  more than 20 percent of girls who underwent FGM/C in Djibouti, Eritrea,  Niger, Senegal, and Somalia, experienced Type III (infibulation), whereas  Type III represented 1 or 2 percent of cases in other countries, such as  Egypt.  Appendix II presents UNICEF data showing the percentage  distribution of girls subjected to FGM/C by type of procedure in countries  where data were available.

section_title: Causes and Consequences of FGM/C
paragraphs: The WHO notes that in every society where it is practiced, FGM/C is a  manifestation of gender inequality that is deeply entrenched in traditional  social, economic, and political structures. The practice is often  considered a necessary part of raising a girl properly, and a way to  prepare her for adulthood and marriage. FGM/C is often motivated by  beliefs about what is considered proper sexual behavior and is linked to  premarital virginity and marital fidelity.

FGM/C has no health benefits and can have numerous short- and long- term adverse health consequences, according to the WHO. Short-term  consequences can include severe pain, swelling, delayed or incomplete  healing, and shock, as well as infections and excessive bleeding, which  can lead to death.   Long-term consequences may include chronic pain  and infections, scar tissue, and menstrual and urinary tract problems. In  addition, FGM/C can lead to sexual problems and obstetric complications,  which increase the need for Caesarean sections and risks to the health of  newborns.  Transmission of HIV remains a longer-term risk because of  increased risk of bleeding during intercourse as a result of FGM/C.

section_title: Prevalence of FGM/C
paragraphs: Available data from nationally representative surveys show that FGM/C is  concentrated in 30 countries and at least 200 million girls and women  alive today have undergone some form of FGM/C, according to UNICEF  (see fig. 1).  Evidence suggests that FGM/C exists in some places in  South America, such as Colombia, and elsewhere in the world including  in India, Malaysia, Oman, Saudi Arabia, and the United Arab Emirates;  however, no nationally representative data on FGM/C were available for  these countries, according to UNICEF. The practice is also found in  Europe, Australia, and North America, which are destinations for migrants  from countries where the practice still occurs.  UNICEF also estimates  that more than 3 million girls annually are at risk for FGM/C in Africa.  In  some countries, including Djibouti, Guinea, and Somalia, the percentage  of girls and women, aged 15 to 49, who have undergone FGM/C is over  90 percent. In most of the countries with available data, the majority of  girls are cut before the age of 5, according to UNICEF.  However, in  Somalia, Egypt, Chad, and the Central African Republic, at least 80  percent of girls who have undergone FGM/C were cut between the ages  of 5 and 14.

UNICEF data show that the practice is becoming less common in many  high-prevalence countries. For example, in Kenya and Tanzania, women  aged 45 to 49 are approximately three times more likely to have  undergone FGM/C than girls aged 15 to 19.  In most countries where  FGM/C is practiced, the majority of girls and women think it should end,  and the percentage of females who support FGM/C is substantially lower  than the share of girls and women who have undergone the procedure,  according to UNICEF.

In addition, UNICEF reported in 2013 that 24 countries where FGM/C is  prevalent have enacted legislation related to FGM/C (see app. III).  These laws reportedly vary in their scope. UNICEF reports that some ban  the practice only in medical facilities; others ban the practice anywhere.

section_title: International Response to FGM/C
paragraphs: In 1993, the World Conference on Human Rights in Vienna recognized  violence against women as a human rights violation, and the UN  General Assembly included FGM/C in the definition of violence against  women, stating that it violates women’s right to be free from cruel,  inhuman, or degrading treatment. FGM/C also deprives girls and  women from making the decision about a procedure that has a lasting  effect on their bodies and infringes on their autonomy and control over  their lives, according to the WHO.

In December 2012, the UN General Assembly adopted a resolution  urging member states to condemn and work to eliminate all harmful  practices that affect women and girls, in particular FGM/C, and to take all  necessary measures, including enacting and enforcing legislation to  prohibit FGM/C.  Two years later, the UN General Assembly adopted  another resolution calling upon member states to develop, support, and  implement comprehensive and integrated strategies for the prevention of  FGM/C, including training of medical personnel, social workers, and  community and religious leaders to ensure that they provide competent,  supportive services and care to women and girls who are at risk of or who  have undergone FGM/C.

In September 2015, the UN General Assembly formally adopted the 2030  Agenda for Sustainable Development, along with a set of 17 Sustainable  Development Goals and 169 associated targets. One of the 17 goals is  “achieve gender equality and empower all women and girls” and one of  the targets for this goal is to “eliminate all harmful practices, such as child,  early and forced marriage and female genital mutilation.”

In 2008, UNFPA and UNICEF established the Joint Program on FGM/C,  which represents the largest international effort to accelerate  abandonment of this practice.  The UNFPA-UNICEF Joint Program brings  together both agencies’ expertise, often with grassroots community  organizations, using a human rights-based approach to engage  communities to act collectively to abandon the practice. The Joint  Program also supports health and protective services for those who have  undergone FGM/C.  Donor countries make annual contributions directly to  the Joint Program.

During phase I of the Joint Program (2008-2013), 15 countries  participated (see fig. 2). According to the 2013 evaluation of the Joint  Program, funding limitations reduced the number of countries involved  during phase 1. The overall budget for phase I was about $41 million over  its 5 years.  Phase II (2014-2017) currently is under way in 17 countries— the original 15 countries, as well as Yemen and Nigeria. Phase II aims for  a 40 percent decrease in prevalence among girls 14 and younger in at  least 5 countries, with at least 1 country declaring total elimination of the  practice, by the end of 2017. The Joint Program estimated its budget for  phase II to be $54 million over 4 years.

section_title: State and USAID Strategies and Policies Related to FGM/C
paragraphs: Under the U.S. foreign policy framework, FGM/C is identified as a form of  gender based-violence. In March 2012, USAID released its Gender  Equality and Female Empowerment Policy, which provides guidance on  incorporating gender issues—including gender-based violence—into  development programming. In addition, State and USAID jointly  developed the U.S. Strategy to Prevent and Respond to Gender-Based  Violence Globally, released in August 2012. These two documents  identify FGM/C as a form of gender-based violence but do not provide  any specific guidance on assistance related to FGM/C. In addition, the  Secretary of State announced in March 2016 the release of the United  States Global Strategy to Empower Adolescent Girls, which includes the  goal of reducing girls’ vulnerability to gender-based violence. The  strategy highlights FGM/C as a form of gender-based violence.

State’s and USAID’s set of standard indicators, developed to assess  foreign assistance, includes nine standard indicators related to gender  issues. Three of the nine indicators cover gender-based violence, which  includes FGM/C; however, the indicators do not specify the type of  gender-based violence addressed.

In 2000, USAID released guidance on FGM/C, incorporating this issue  into its development agenda.  USAID updated the guidance in February  2016, during the course of our review. The guidance recognizes FGM/C  as a harmful, traditional practice that reflects deep-rooted gender  inequalities and constitutes an extreme form of discrimination against  women.  The guidance states that USAID will support the integration of  efforts to combat FGM/C into all aspects of the USAID program cycle  where feasible and appropriate.  It also states that USAID will assist  countries in implementing their laws prohibiting FGM/C and support  community-based programming to raise awareness of the harmful effects  of this practice to reduce demand.  USAID officials stated that the agency  also plans to develop a resource guide on FGM/C that provides  information for USAID missions and staff on how best to incorporate  efforts to address FGM/C into their programming.

section_title: U.S. and UN Studies Have Identified Factors Contributing to the Persistence of FGM/C and Approaches to Address It
subsections: section_title: Factors Contributing to the Persistence of FGM/C
paragraphs: FGM/C has persisted into the 21st century despite UN resolutions  condemning this practice and the passage of laws banning it in many  countries where it is prevalent, as UNICEF has reported. Recent U.S. and  UN studies of efforts to address FGM/C have identified several factors  contributing to its prevalence, including its power as a social norm, the  belief that FGM/C is a religious obligation, the medicalization of the  practice, and challenges enforcing existing laws.
subsections: section_title: Influential Social Norm
paragraphs: FGM/C is a powerful social norm—what communities believe and how  they act and expect other members of that community to act—making its  abandonment difficult, according to PRB and UNICEF. FGM/C is  embedded in the culture and beliefs of many communities and ensures  membership in these communities, according to PRB. If most families in a  community practice FGM/C, it is difficult for an individual family to  abandon the practice, according to UNICEF.  UNICEF also reported that,  among surveyed girls and women aged 15 to 49, the most commonly  reported benefit of FGM/C is that it ensures social acceptance.

Because some communities view FGM/C as a social norm, it is viewed as  a caring act. Parents may believe that FGM/C is in the best interest of  their daughter, despite the physical harm it causes, in order to avoid  social exclusion, according to UNICEF.  In addition, the practice is  exacerbated by poverty and poor education.  FGM/C may signal that a  girl is ready for marriage, which can spare a family the girl’s school  expenses.  Parents also may rely on the money received for marriages,  according to an evaluation of the UNFPA and UNICEF Joint Program on  FGM/C.  In addition, prevalence is highest among daughters of women  with no education and declines as the mother’s education level rises,  according to UNICEF.

section_title: Religious Obligation
paragraphs: The common belief that FGM/C is a religious obligation is a  misconception, but one that contributes to its continued use, according to  UNICEF. UNICEF notes that FGM/C is not mandated in any religious  texts and predates the birth of Islam and Christianity. Scholars and  activists have concentrated on demonstrating the lack of support within  scriptures. However, the religious motivation for FGM/C is often  intertwined with social norms and tradition, according to UNICEF. In  addition, some communities believe the practice is a religious  requirement that makes a girl spiritually “pure,” according to UNICEF.  Thus, many who continue practicing FGM/C often cite religion as their  motivation. In 4 of 14 countries surveyed, more than 50 percent of girls  and women aged 15 to 49 regard FGM/C as a religious obligation,  according to UNICEF. These countries were Mali, Eritrea, Mauritania, and  Guinea.

section_title: Medicalization
paragraphs: Another challenge in encouraging abandonment of FGM/C is the  medicalization of the practice, which contributes to its perceived  legitimacy, according to PRB. Medicalization refers to the performance of  FGM/C by health care providers rather than traditional practitioners.  According to PRB, 18 percent of girls and women worldwide who have  been cut had the procedure performed by medical professionals. UNICEF  reports that this percentage can be much higher in certain countries; for  example, 77 percent of girls in Egypt and 41 percent of girls in Kenya who  underwent FGM/C were cut by medical professionals. UNICEF found  that medicalization of FGM/C may have increased as a result of the  assistance community’s earlier focus on the harmful health risks of the  practice to encourage abandonment of FGM/C without also framing it as  a human rights issue. Thus, early FGM/C prevention campaigns may  have inadvertently contributed to the perception that FGM/C would be  acceptable if performed by medical professionals, thus institutionalizing  the practice within the medical community, according to UNICEF.

section_title: Law Enforcement Challenges
paragraphs: Although many countries have passed laws addressing FGM/C, enforcing  these laws is a challenge, according to the Joint Program evaluation.  The  evaluation found that in many countries, there is a lack of resources,  difficulty reaching remote areas, and limitations on the capacities of law  enforcement agents. In addition, the implementation of anti-FGM/C laws  may be undermined by a lack of awareness by local officials and law  enforcement, and a lack of community buy-in, according to PRB. Further,  the threat of social exclusion from being uncut may be more influential  than the threat of legal punishment, according to UNICEF.

section_title: Approaches to Addressing FGM/C
paragraphs: U.S. and UN studies have identified a variety of approaches to  accelerating FGM/C abandonment. These include efforts to increase  awareness and enforcement of laws against FGM/C; establish community  education programs; and provide outreach to a variety of community  members, including religious leaders, elders, men and boys, and medical  practitioners.  Studies also highlight the importance of incorporating  FGM/C into broader gender equality and human rights programs, and  encouraging community actions such as alternative rites of passage and  public declarations for abandonment.
subsections: section_title: Increasing Awareness and Enforcement of FGM/C Laws
paragraphs: The existence of a law can help abandonment efforts, but other  interventions at the community level must also be undertaken for the law  to be effective, according to PRB and UNICEF. PRB noted that resources  are needed after the adoption of anti-FGM/C policies to ensure  awareness and enforcement of the law. For example, in Burkina Faso,  the Joint Program helped raise awareness of FGM/C laws for personnel  in the justice sector, informing them about current policies and their  implications for their work. In addition, in Uganda, the Joint Program  supported six community policing sessions that provided communities  with information on existing laws and helped ensure their implementation.   The growing interest and understanding of the law within the communities  led to the arrest of two cutters, according to the program’s focal point in  Uganda.

section_title: Community Education on Ending FGM/C
paragraphs: Education is an important way to raise awareness about the dangers of  FGM/C and its impact as a social norm. Community education programs  play an essential role in encouraging communities to reconsider the  practice, according to UNICEF. A community education project could last  for a number of years and include a wide range of participants such as  government officials, media, health professionals, and at-risk girls.  Communities are encouraged to reflect on the role of women and girls  and how FGM/C affects their lives. Educational activities and community  dialogues create a safe, non-threatening environment where people can  evaluate their beliefs regarding FGM/C, according to the Joint Program  evaluation. Events may focus on FGM/C specifically or may combine  information on FGM/C with information on health, religion, or human  rights.

section_title: Engaging Religious Leaders, Males, and Elders in Dialogue
paragraphs: Efforts to abandon FGM/C are strengthened when a wide range of  actors—including religious leaders, and boys and men—are included in  community education, according to PRB. Because religion is often cited  as a reason for continuing the practice, engaging religious leaders in  public education can be effective in encouraging abandonment, according  to a Joint Program evaluation. Religious leaders often already have the  community’s respect and can be a powerful influence on dispelling the  belief that there is a religious obligation. Religious leaders in one  Ethiopian community participated in public discussions about  abandonment, according to a UNICEF study. By the end of the sessions,  six of seven villages pledged to abandon the practice, and religious  leaders led a special prayer binding the decision. Working with religious  leaders is a core strategy and a critical component of community  engagement in the Joint Program as well. For example, the Joint Program  reported that, through its efforts, 304 religious leaders were educated  about FGM/C in Mauritania.

Involving boys and men in outreach efforts is also essential in ending  FGM/C. In about half of the countries where FGM/C is prevalent, men  outnumber women in their opposition to FGM/C, according to a Joint  Program report. For example, 42 percent of boys and men in Guinea  think FGM/C should stop, compared to 19 percent of girls and women,  according to UNICEF. The Joint Program increased its efforts to engage  men and boys in 2014, resulting in their voices against FGM/C becoming  more prominent on social media, according to a Joint Program report. For  instance, male advocacy emerged in Somalia where men have posted  their support of uncut women on Facebook, stating, “Don’t do it for us.”  Often, women are misinformed about their husbands’ opinions on FGM/C.  Men may not talk about FGM/C because it is considered a “women’s  issue.” Open dialogue between the sexes could reduce this ignorance,  according to UNICEF.

Intergenerational dialogue is another approach to changing behaviors,  according to PRB. This approach recognizes that the older generations’  full engagement is needed, given their role as decision-makers and  gatekeepers, and because they are likely to feel threatened by changing  traditions. For example, the Grandmother Project in Senegal increased  participants’ appreciation of positive cultural traditions and changing  attitudes towards harmful traditions, according to PRB. Because senior  women are viewed as valuable cultural resources and influential  members of their communities, communities are more comfortable with  an approach that includes dialogue between elders and youth, according  to PRB.

section_title: Media Campaigns
paragraphs: Media campaigns can also educate the public on the harmful effects of  the practice and can shape the public discourse around FGM/C,  according to the Joint Program evaluation. They can help spread  information on decreasing support for FGM/C. Radio, in particular,  enables the dissemination of information to remote villages and illiterate  populations. Forums for discussion can include talk shows,  documentaries, and educational TV. Social media is particularly effective  with adolescents and can be instrumental in spreading information. In all  15 countries in the Joint Program’s first phase, programs used media to  increase awareness of the practice’s harmful effects and encourage  abandonment. Media campaigns, like other approaches, have the  greatest impact when they are part of a larger effort, according to PRB.  Figure 3 shows a road sign promoting the campaign against FGM/C in  Uganda.

Education and training for medical professionals can encourage them to  help prevent FGM/C and also prepare them to provide appropriate  treatment for those who have undergone FGM/C procedures. In response  to medicalization, the Joint Program began working with the WHO to  ensure medical professionals’ support for FGM/C abandonment. The  Joint Program’s first phase prioritized integrating FGM/C prevention into  antenatal and neonatal care and immunization services in countries  where a large portion of girls are cut between birth and age 5.  Specifically, during phase I, a total of 5,571 health facilities integrated  FGM/C prevention into their antenatal and postnatal care, and more than  100,000 doctors, midwives, and nurses have participated in training on  integrating FGM/C prevention, response, and care into their services. In  all 15 Joint Program countries, medical staff were trained on the negative  consequences of FGM/C and, in many cases, how to treat medical  complications from the practice. Such training has strengthened the  medical community’s capacities for preventing and responding to FGM/C.  In 2014, about 200,000 girls and women received prevention, protection,  or care services relating to FGM/C through the Joint Program, according  to the Joint Program report.  The report also noted that, as a result of an  initiative led by the Joint Program, Djibouti is the first African country  where girls are physically examined for evidence of FGM/C during routine  check-ups.

section_title: Including FGM/C in Broader Gender Equality and Human Rights Efforts
paragraphs: FGM/C should be addressed as part of broader efforts to promote gender  equality and female empowerment, according to PRB. In the Joint  Program, FGM/C is approached as one of many forms of gender-based  violence.  In addition, the Joint Program highlights the intersection  between FGM/C, women’s reproductive health, and girls’ education. By  addressing the practice as part of broader issues, interventions are able  to address how existing practices negatively affect opportunities for  women and girls. When FGM/C is incorporated into programming that  challenges assumptions about gender relationships, it directly advances  broader goals of reducing gender inequality and gender-based violence,  according to UNICEF.

Increasingly, discussions about FGM/C have been shaped within a  human rights approach, which can lead to public declarations against  FGM/C in thousands of communities, according to UNICEF. Human rights  vocabulary needs to be adapted for use by its program participants and it  should include relevant symbols, narratives, or religious language so that  it resonates with the local community. The Joint Program incorporates  issues of gender equality and human rights in the design and  implementation of its efforts. It has simultaneously conceptualized FGM/C  as an abuse of human rights and a form of gender-based violence while  also seeking to be culturally sensitive to the value the practice holds in  many communities.

section_title: Alternative Rites of Passage
paragraphs: A Joint Program report highlighted alternative rites of passage as an  effective means of abandoning FGM/C.  In certain communities, rites of  passage have for centuries marked the transition from child to adult,  according to the Joint Program evaluation. For girls, that rite of passage is  often combined with FGM/C. Some communities may be reluctant to  abandon FGM/C because they are reluctant to give up this rite of  passage ceremony. In Kenya, thousands of girls have participated, since  2008 in alternative rites of passage to encourage abandonment while  preserving this tradition, according to a Joint Program report. The effort  typically involves sending the girls away for a week to an orientation  program that includes teaching about the harmful effects of FGM/C. The  Joint Program report noted that in Kenya in 2014, the Joint Program  supported an alternative rites of passage program for more than 1600  girls.  This program involved final celebrations that included certificates of  recognition for the commitment to stay uncut.  Figure 4 shows an  alternative rite of passage ceremony in Kenya.

Expressing public commitment to stop the practice of FGM/C is a  promising approach to abandonment, according to several studies.  Village-level declarations are one way to measure a program’s impact on  FGM/C, according to PRB. Public declarations encouraged by the Joint  Program are typically preceded by community discussions and  engagement with community leaders and members. Public declarations  do not guarantee a change in behavior, but they do have an influence on  social norms, according to the Joint Program evaluation. A public  commitment applies social pressure that makes it difficult to return to old  behaviors. In Egypt and Senegal, public commitments to end FGM/C  occurred only after human rights discourse was introduced into basic  education curricula, according to UNICEF. A 2008 UNICEF evaluation of  a public declaration program in Senegal found that prevalence dropped  by more than half in villages that had taken public pledges to abandon the  practice. Since 2008, when the Joint Program was established, nearly  10,000 communities in 15 countries, representing about 8 million people,  have renounced the practice.

section_title: State’s and USAID’s Efforts to Address FGM/C Abroad Are Limited
paragraphs: State and USAID currently have limited international assistance efforts to  address FGM/C. In 2014, State and USAID each had one active  standalone project to address FGM/C. In addition, we identified projects  with broader goals that included components to address FGM/C but we  were unable to determine the full extent of FGM/C-related efforts because  State and USAID do not specifically track these efforts. USAID has  competing development priorities, which leaves little funding available for  FGM/C-related efforts, according to USAID officials.  The largest current  international assistance effort to address FGM/C is the UNFPA/UNICEF  Joint Program on FGM/C.  State provides funding to UNFPA and UNICEF  but, to date, has not contributed to this Joint Program. However, if the  general restrictions for UNFPA funding are met, there are currently no  specific legal restrictions that would prohibit U.S. funding provided to  UNFPA from being available for the Joint Program on FGM/C.
subsections: section_title: State Provides Limited Assistance to Combat FGM/C
subsections: section_title: State Has One Standalone FGM/C Program
paragraphs: State’s one standalone FGM/C program is in Guinea, where 97 percent of  girls and women aged 15 to 49 have undergone FGM/C. This program  is funded by about $1.5 million in grants from the Full Participation Fund,  an initiative created by State and funded through various appropriations  accounts to support gender integration efforts.  It began in the fall of  2014 and will run through April 2016, according to State officials.

Through partnerships with the government of Guinea, UNICEF, and 26  local civic and human rights organizations, the U.S. Embassy in Conakry  established nationwide educational and media campaigns that engage  policymakers, health professionals, traditional excisors, religious  leaders, and the general public to abandon FGM/C. Activities include  establishing a National Strategic Plan to abandon FGM/C in line with  existing legal frameworks, capacity building and specialized training of  institutions and individuals combating FGM/C, and support of multimedia  information and communication awareness campaigns.

U.S. embassy staff are responsible for monitoring the project, which has  13 performance indicators. Examples of the performance indicators  include the number of girls and women identified as abandoning FGM/C  practices; the reduction in the number of group excision ceremonies held  in targeted districts and villages; and the number of people trained by the  U.S.-funded intervention providing gender-based violence services  relating to FGM/C (e.g., law officers, judges, teachers, excision  practitioners, health workers, religious leaders, policymakers, and  potential victims). State reported in July 2015 that the campaign had led  to approximately 265 villages in Guinea voluntarily and publicly  denouncing this harmful practice since the start of 2015.  State plans to  conduct a separate impact evaluation in 2017, according to State officials.

section_title: State Supports Projects Addressing Gender-Based Violence in Refugee Settings That May Include FGM/C
paragraphs: State provides funding to international organizations and non- governmental organizations to provide assistance to vulnerable  populations in refugee settings overseas to meet their basic needs,  including programs providing water and sanitation, shelter, and  healthcare, as well as programs to prevent and respond to gender-based  violence.  In fiscal year 2014, State’s Bureau of Population Refugees  and Migration (PRM) awarded about $35.7 million for 93 cooperative  agreement awards to projects focused on or including gender-based  violence activities. State officials told us that some of these projects may  include assistance related to FGM/C; however, State does not capture  this level of programmatic detail for these projects.

We contacted project implementers for nine of the largest gender-based  violence projects in countries where FGM/C is prevalent and found that  two of them provided assistance related to FGM/C. One of these  projects, which received $800,000 from State in fiscal year 2014,  provided gender-based violence assistance to Central African Republic  Refugees and Chadian returnees in Southern Chad, including education  and awareness-raising about FGM/C with project beneficiaries and local  law enforcement authorities. The project also provided specialist referral  services to individuals who have undergone FGM/C.  The other project,  which received $1,000,000 from State in fiscal year 2014, was focused on  prevention and response to gender-based violence for refugees in  Uganda.  This project included focus group discussions and interviews  with selected members of the Somali refugee community in Uganda to  raise awareness about the negative effects of FGM/C.

section_title: U.S. Contributions to UNFPA and UNICEF Have Not Supported Their Joint Program on FGM/C
paragraphs: State provides annual funding to UNFPA and UNICEF but, to date, none  of this funding supports the Joint Program on FGM/C, the largest  international effort to address FGM/C. In fiscal year 2014, the U.S.  government provided funding to UNFPA and UNICEF that included  general contributions to be used at the UN agencies’ discretion in support  of their overall missions, as well as contributions pledged to specific  projects such as humanitarian relief efforts, according to State officials.

Congress routinely places restrictions on U.S. funding in annual  appropriations for UNFPA. However, if the general restrictions for  UNFPA funding are met, there are currently no specific legal restrictions  that would prohibit U.S. funding provided to UNFPA from being available  for the Joint Program on FGM/C. State and UNFPA officials agree that  the restrictions on UNFPA funding would not stop the U.S. government  from funding the Joint Program if it chose to devote funds to it. State  officials told us that the Joint Program, which is a long-term effort, may  not have been considered for targeted contributions to UNFPA because  those funds are generally provided in response to short-term  humanitarian appeals.  However, on March 15, 2016, the Secretary of  State announced that State intends to contribute to the UNFPA – UNICEF  Joint Program on FGM/C.

section_title: Embassies Engage in Diplomatic Efforts to Raise Awareness about FGM/C
paragraphs: State depends on its embassies to use diplomacy to encourage  abandonment of FGM/C, according to State officials.  State officials from  the Bureau of African Affairs provided several examples in which U.S.  embassies engaged diplomatically with local communities to raise  awareness or provide training about FGM/C.  For example, in Chad,  Central African Republic, Ethiopia, and Niger, U.S. embassies hosted a  screening of a film about FGM/C for student or women’s groups to  encourage abandonment of this practice.  Some of these screenings were  held to commemorate the International Day of Zero Tolerance for FGM/C,  which occurs every year on February 6th. In Eritrea, the embassy held a  Zero Tolerance Day event, displaying posters and distributing brochures  on FGM/C.

section_title: State Human Rights Reporting Addresses FGM/C
paragraphs: Since 2012, State’s annual Country Reports on Human Rights Practices  have included information on FGM/C, according to State. State is  required to report on the status of internationally recognized human rights  for all countries receiving assistance and all United Nations member  states. Since 2012, State has expanded the reports’ coverage to include  multiple forms of gender-based violence, including FGM/C and child,  early, and forced marriage.  Among other things, the 2014 human rights  reports we reviewed identified countries’ prevalence rates of FGM/C,  common types of FGM/C, legal restrictions of FGM/C, and educational  efforts undertaken to raise awareness about the dangers of this  practice. Tracking host government actions and policies related to  FGM/C as part of human rights reporting helps State build the knowledge  necessary to diplomatically encourage actions to end this practice,  according to State officials. In addition, State officials noted that the  Department of the Treasury relies on this information to advise the United  States Executive Director of each international financial institution, such  as the World Bank, regarding whether they should support loans to  countries where FGM/C is practiced.

section_title: USAID’s Assistance Efforts to Combat FGM/C Are Limited
subsections: section_title: Competing Priorities Limit USAID Funding for FGM/C
paragraphs: USAID has competing development priorities, which leave little funding  available for FGM/C-related efforts, according to USAID officials.  For  example, all Global Health Programs account funds are programmed to  achieve outcomes in three priority areas in the health sector—ending  preventable child and maternal deaths, creating an AIDS-free generation,  and protecting communities from other infectious diseases.  In addressing  these goals, funds are used first for programs expected to have the  greatest impact in achieving them, according to USAID officials.

Congressional reports accompanying appropriations laws for USAID  funding included specific funding for FGM/C in 2000 and 2005, but no  such report language currently exists. In 2000, a conference report  included language directing USAID to make $1.5 million available to  develop educational programs aimed at eliminating FGM/C.  In 2005,  the Senate Committee on Appropriations recommended that USAID  spend $5 million to expand community-based efforts to combat FGM/C in  high-prevalence countries. Recent congressional committee reports  have directed that USAID provide funding to address obstetric fistula,  which often occurs among populations of girls also at risk of FGM/C.

section_title: USAID Had One Standalone FGM/C Program in 2014
paragraphs: We identified one free-standing FGM/C program that was active during  calendar year 2014.  USAID supported the start-up of Nairobi University's  Africa Coordinating Center for the Abandonment of FGM/C (ACCAF) to  advocate, educate, and create a supportive environment for cultural  change; support networking and knowledge exchange between  researchers, health professionals, and community workers on the  abandonment of FGM/C; identify knowledge gaps and support and  stimulate research in the field of FGM/C; and improve health care for  women and children who have undergone FGM/C.

The program runs from October 1, 2013, through September 30, 2016,  and has a total funding level of $429,000 from the Global Health  Programs appropriations account, according to USAID officials. It was  funded as a subaward to the University of Nairobi from an existing  implementing partner in Kenya.  The Center carried out four community  trainings in fiscal year 2014 involving 114 community leaders, community  professionals, health care providers, FGM/C practitioners, FGM/C  survivors, and youths, according to its 2014 annual report. These 2-day  training sessions addressed the different dimensions of FGM/C and  helped prepare community members to advocate FGM/C abandonment  to the broader community.  The Center also supported advocacy of  FGM/C abandonment in the media, as well as networking between  researchers and health professionals, and has initiated studies of various  aspects of the issue.

As required in the subaward agreement, the ACCAF developed a  performance monitoring plan that included 20 indicators.  Examples of  these indicators include “number of advocacy teams created” and  “number of community-based providers…trained or supported.”  In  addition, the award agreement requires the ACCAF to produce, among  other things, an impact assessment within 90 days after the project end  date, which includes a summary of lessons learned, success stories, and  conclusions about areas in need of future assistance.

section_title: Some USAID Missions Identified Broader Programming That Includes FGM/C
paragraphs: We found several examples of USAID projects—active in calendar year  2014—addressing broader Global Health or Democracy and Governance  objectives that had intervention elements related to FGM/C. USAID  officials told us, however, that they could not separate the level of funding  for FGM/C efforts from other project activities.  In addition, USAID could  not verify the extent to which these examples represented all FGM/C- related efforts undertaken by missions in high-prevalence countries.  USAID’s systems for tracking funding and programming gender-based  violence efforts do not capture subactivities as specific as FGM/C efforts,  according to USAID officials.  For example, standard indicators developed  by USAID and State to track the performance of assistance efforts include  three indicators on gender-based violence prevention and response but  do not specify the type of gender-based violence, such as FGM/C.   Table 1 shows countries where USAID missions identified having projects  active in calendar year 2014 with FGM/C-related efforts.

USAID created a publicly available e-learning course on FGM/C designed  for those implementing interventions to address this practice, including  the staff of U.S. government agencies and nongovernmental  organizations. The 2-hour and 30-minute course provides an overview of  FGM/C, including definitions, medical risks from undergoing the  procedure, prevalence, promising interventions, and lessons learned from  studies of intervention efforts to prevent and respond to FGM/C.  The  course was first published in October 2008 and was last updated in  October 2015.

section_title: Agency Comments
paragraphs: We provided a draft of this report to State and USAID for their review.  State and USAID did not provide formal comments but each provided  technical comments that we incorporated as appropriate.

As agreed with your office, unless you publicly announce the contents of  the report earlier, we plan no further distribution until 30 days after the  report date.  At that time, we will send copies of this report to interested  congressional committees, the Secretary of State, and the USAID  Administrator. We will also provide copies to others on request. In  addition, the report will be 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  me at (202) 512-3149 or gootnickd@gao.gov.  Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix IV.

section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: This is the first of two reports examining U.S. agencies’ efforts to address  Female Genital Mutilation/Cutting (FGM/C) at home and abroad.  This  report (1) summarizes findings from recent U.S. and United Nations (UN)  studies about the factors contributing to FGM/C and approaches to  addressing this practice internationally and (2) examines the Department  of State’s (State) and the United States Agency for International  Development’s (USAID) current efforts to address FGM/C abroad. A  second report will review U.S. efforts to address FGM/C domestically.

To identify factors contributing to FGM/C and current approaches to  addressing this practice, we reviewed recent U.S. and UN studies of  international efforts to accelerate the abandonment of FGM/C and  respond to victims of the practice. We selected studies that examined  assistance efforts to accelerate abandonment of FGM/C in countries  where this practice is concentrated.  The studies were published in 2010  or later.  We examined a USAID-funded Population Reference Bureau study, released in an evaluation of the United Nations Population Fund (UNFPA)-United  Nations Children’s Fund (UNICEF) Joint Program on FGM/C,  released in 2013; a summary report of the first phase of the UNFPA-UNICEF Joint  Program released in 2014; a UNICEF statistical overview of FGM/C, released in 2013; and a UNICEF review of efforts to accelerate FGM/C abandonment in five  African countries, released in 2010.

To determine State’s and USAID’s current efforts to address FGM/C  abroad, we analyzed applicable strategy and policy documents and  interviewed State and USAID officials involved in issues related to  FGM/C.  These strategies and policies include:

USAID’s Gender Equality and Female Empowerment Policy, March

State’s and USAID’s United States Strategy to Prevent and Respond  to Gender-Based Violence Globally, August 2012;

USAID’s Child, Early, and Forced Marriage Resource Guide,

USAID’s USAID Guidance on Female Genital Mutilation/Cutting,  updated February 2016; and multiple agencies’ United States Global Strategy to Empower  Adolescent Girls, March 2016.

To identify State’s efforts, we interviewed State officials in the Office of  Global Women’s Issues, and key bureaus including the Bureaus of  Population, Refugees, and Migration; Democracy, Human Rights, and  Labor; African Affairs; and Near Eastern Affairs. We reviewed documents  related to a State-funded FGM/C prevention program in Guinea. We also  reviewed a list of 54 projects addressing gender-based violence in  refugee settings overseas that received State funding in fiscal year 2014.   We identified the 10 largest of these projects (with State funding of  $500,000 or more) in countries where FGM/C is prevalent.  For 9 of these  projects, we contacted project implementers via e-mail to determine if the  projects had any FGM/C-related components. We were unable to contact  the project implementers for 1 of the 10 projects.  We also met with  officials from UNFPA and UNICEF to discuss U.S. funding for these  agencies and their Joint Program on FGM/C.  In addition, we reviewed  State’s Country Reports for Human Rights to determine how they  addressed FGM/C issues.

To identify USAID’s efforts, we interviewed USAID’s Senior Coordinator  for Gender Equality and Women's Empowerment and officials in key  USAID bureaus including Global Health; Democracy, Conflict, and  Humanitarian Assistance; Africa; and the Middle East.  We also collected  information on projects with FGM/C components from USAID’s overseas  missions in countries where FGM/C is prevalent.  To obtain this  information, we worked with USAID staff in the Office of the Senior  Gender Coordinator to ask relevant USAID missions via e-mail to identify  any FGM/C-related programming that was active in calendar year 2014.   While 12 missions reported having programs with FGM/C components in  2014, we only presented information on the 5 projects that we were able  to independently confirm as having FGM/C-related components through  searches on websites of USAID’s missions or implementing partners. At  the time of our request, Indonesia had not been identified as a country  where FGM/C was prevalent, and therefore, the USAID mission there  was not included among those contacted.

We conducted this performance audit from June 2015 to April 2016 in  accordance with generally accepted government auditing standards.  Those 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: Percentage Distribution of Girls Who Have Undergone Female Genital Mutilation/Cutting by Type of Procedure
paragraphs: The type of female genital mutilation/cutting (FGM/C) commonly practiced  varies by country, according to data presented by the United Nations  Children’s Fund, based on surveys of mothers about FGM/C performed  on their daughters (see table 2).  For example, more than 20 percent of  girls who underwent FGM/C in Somalia, Eritrea, Niger, Djibouti, and  Senegal experienced infibulation (Type III)—the most radical form of  FGM/C.  In other countries, infibulation was uncommon.  For example, in  Egypt, mothers reported that infibulation represented 2 percent of cases.

section_title: Appendix III: List of Countries Where Female Genital Mutilation/Cutting Is Concentrated with Decrees or Legislation Related to the Practice, According to the United Nations Children’s Fund
paragraphs: The United Nations Children’s Fund (UNICEF) reported in 2013 that 24  countries where Female Genital Mutilation/Cutting (FGM/C) is prevalent  have enacted legislation related to FGM/C. These laws reportedly vary in  their scope. UNICEF reports that some ban the practice only in medical  facilities; others ban the practice anywhere.

section_title: Appendix IV: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contact

section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Leslie Holen (Assistant Director),  Ashley Alley, Lynn Cothern, Howard Cott, Jill Lacey, and Nancy Santucci  made significant contributions to this report.


Question-summary annotations: questions: question: What have the US and UN determined regarding female genital mutilation/cutting (FGM/C)?
answer: U.S. and United Nations (UN) studies since 2010 have identified a variety of factors contributing to the persistence of female genital mutilation/cutting (FGM/C).

question: Why does FGM/C remain common?
answer: In many communities where FGM/C is prevalent, FGM/C is an influential social norm that ensures social acceptance and is commonly perceived as a religious obligation. In addition, medicalization of the practice— when it is performed by health care providers rather than traditional practitioners—increases the perception of legitimacy in some countries.

question: What legal steps have been taken to prevent FGM/C?
answer: Although the United Nations Children's Fund (UNICEF) reports that many countries where FGM/C is prevalent have passed laws banning the practice, enforcement is a challenge.
child_questions: question: Beyond legal actions, what steps have been taken to address FGM/C?
answer: The studies also have identified key approaches to addressing FGM/C, including efforts to implement community education programs, outreach and training for medical professionals, and the inclusion of FGM/C in broader gender equality and human rights programs.

questions: question: To what extent has the US attempted to address FGM/C through federal agencies?
answer: U.S. assistance efforts to address FGM/C are limited. The Department of State (State) and the U.S. Agency for International Development (USAID) each had one active standalone project in 2014, and the agencies also undertook some FGM/C-related efforts as components of projects with broader assistance goals.

question: To what extent has the US attempted to address FGM/C through funding?
answer: In addition, the U.S. government provides funding to the United Nations Population Fund (UNFPA) and UNICEF but, to date, has not contributed funds to the UN agencies' Joint Program on FGM/C.
child_questions: question: How do these attempts intersect with congressional funding restrictions?
answer: If congressional restrictions for UNFPA funding (such as the requirement for UNFPA to maintain U.S. funds in a separate account) are met, there are currently no specific legal restrictions that would prohibit U.S. funding provided to UNFPA from being available for the Joint Program on FGM/C.

question: Why has the US committed only limited funding to FGM/C prevention efforts?
answer: Competing development priorities, such as HIV/AIDS, leave little funding specifically for FGM/C, according to USAID officials.

questions: question: What is FGM/C?
answer: FGM/C comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs.
child_questions: question: To what extent is FGM/C a widespread practice?
answer: More than 200 million girls and women alive today have undergone FGM/C in the 30 countries where available data show this harmful practice is concentrated. More than 3 million girls are estimated to be at risk for FGM/C annually in Africa.

question: Why has FGM/C attracted international attention?
answer: It is rooted in the cultural traditions of many communities but has several adverse health consequences and the UN identifies it as a violation of human rights.

question: What actions have human-rights organizations taken to address FGM/C?
answer: In 2015, the UN General Assembly adopted a set of 17 Sustainable Development Goals for 2030 that included the elimination of FGM/C among its targets. UNFPA and UNICEF implement the Joint Program on FGM/C in 17 countries—the largest current international assistance effort to address FGM/C. State and USAID include FGM/C as part of their global strategy to respond to gender-based violence.