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.