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.