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

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