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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

Summary: 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. 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.