Effectiveness of Interventions Designed to Prevent or Respond to Female Genital Mutilation: A Review of Evidence

"As the final decade of acceleration towards zero new cases of FGM by 2030 begins, increasing the rigour, relevance, and utility of research for programming, policy development and resource allocation is critical."

Despite intensified efforts to build the evidence base globally to inform strategies to address female genital mutilation (FGM), there has been limited rigorous high-quality evidence on what set of interventions are effective in ending the harmful practice. This research report, accompanied by an evidence brief, conveys key findings on the quality and strength of existing evidence on FGM interventions from January 1 2008 to August 31 2020. It was published by the United Nations Population Fund (UNFPA), United Nations Children's Fund (UNICEF), World Health Organization (WHO), and Population Council, Kenya, and it was conducted by the latter organisation along with the What Works Association.

In contrast to previous work, the present review: considered qualitative, quantitative, and mixed methods studies; includes literature in Arabic, English, and French; and assessed both the quality of studies and the strength of the evidence. Of 7,698 records that were retrieved, 115 studies met the inclusion criteria, 106 of which were of high and moderate quality.

Study findings were organised according to the four levels of the multi-sectoral approach underpinning the global overarching theory of change of the UNFPA-UNICEF Joint Programme on the Elimination of Female Genital Mutilation: Accelerating Change, which funded this study. Both the global theory of change and the compendium of indicators embrace a holistic and multisectoral approach to ending FGM. Interventions were therefore considered according to these four areas, based on the level at which they were implemented:

1. System level (providing an enabling environment for ending FGM): Interventions at this level included enactment and legislation-focused interventions. In summary, evidence suggests that legislation works more effectively where there is political will, the existence of locally appropriate enforcement mechanisms, a combination of other interventions that are acceptable to the community, sufficient resources for implementation, and sensitisation. Legislation can also be useful in an environment where it will be applied across a geographical jurisdiction, is clear, and leaves little room for misinterpretation. Evidence suggests that legislation must be implemented in tandem with enforcement mechanisms, as well as other interventions, to show impact in knowledge, attitudes, and norms driving the practice.
2. Community level (challenging gender and social norms around FGM): This category included interventions implemented in communities with the aim of challenging existing gender inequalities and social norms associated with FGM, as follows:
   • Health education: This activity can be more effective in an environment where context is considered and other interventions are also implemented. While health education may be effective in changing knowledge, attitudes, and beliefs, an additional intervention may be needed to influence behaviour change.
   • Community engagement: Approaches that use a holistic approach and seek to empower community members have been effective in changing attitudes towards FGM and in some cases changing behaviour. Evidence also shows that the use of tailored, contextually appropriate, and locally generated interventions where the community is fully engaged can yield positive results in changing behaviour.
   • Media/social marketing campaigns/communication initiatives: Social media/marketing efforts are effective in changing social norms and attitudes towards abandoning FGM, and, in some cases, reducing the practice. However, evidence shows that interventions that only supply information and education and/or campaigns to increase FGM awareness are not sufficient to change behaviour. Advocacy and awareness-raising efforts that take a holistic multisectoral approach constitute best practices that should be sustained in order to maintain their impact for future generations.
   • Public declarations/statements: Regular and repeated awareness-raising interventions addressed at all sections of the society and that stress the detrimental effects of FGM, in addition to encouraging communities to make a declaration of abandonment, may be a first step towards changing attitudes and practices among community members in FGM-prevalent settings.
   • Engagement with religious/cultural leaders: Religious and cultural leaders can effectively pass on messages to the community, especially in communities that are ready for change. They can be at the forefront of questioning the religious underpinnings of the practice and in publicly declaring opposition.
   • Conversion of traditional practitioners: Evidence suggests that while the role of traditional practitioners in the elimination of FGM cannot be underestimated, efforts to provide them with an alternative income have been largely ineffective. These efforts may need to be recalibrated.
3. Individual level (empowering women and girls): Interventions at this level aim to empower girls and women to make their own informed decisions regarding their sexual and reproductive rights. They include:
   • Formal education: Evidence shows that formal education is effective in reducing FGM prevalence. It plays a significant role in empowering women and girls to demand their rights and to challenge existing gender and social inequalities such as FGM.
   • Alternative rites of passage (ARP): While some components of ARP, such as educational programmes, can be effective in changing attitudes, the risk of exclusion, perceived loss of cultural identity, changing meanings ascribed to cultural practices, lack of precise knowledge about subjective sexual experience, and negative stereotyping limit the success of such programmes. It has been argued that effective ARP requires a combination of behaviour change support at the community level, law enforcement and monitoring, and open and persistent advocacy by diverse representatives of communities.
4. Service level (providing services for FGM prevention, protection, and care): These interventions aim to protect girls and women at risk of FGM, prevent FGM, and provide care to women and girls who have undergone FGM. Interventions assessed for effectiveness in this review include:
   • Training healthcare providers and capacity-building of the health system: Available evidence shows that training healthcare providers can improve their knowledge and skills to act as agents of change in the prevention of FGM and offer quality services to clients seeking care post-FGM.
   • Rescue centres: The few available studies show that these centres can provide short-term refuge for girls at risk of FGM but are limited in providing long-term solutions to ending the practice.

In short, this evidence review has demonstrated that there are some interventions that could lead to the abandonment of FGM. However, per the researchers, given the limited evidence across countries and regions overall, it is difficult to make strong claims about interventions that may be said to "work", particularly in varying cultural contexts. Nonetheless, a review of the evidence suggests several promising interventions with sufficient indications for additional action:

• Successful interventions with supporting evidence: While there is insufficient evidence to identify successful programming at the system level, a body of evidence exists on intermediate outcomes to behavioural change at the community and individual levels:
  • At the community level, a body of evidence demonstrates that health education and community dialogues with parents and religious leaders can change attitudes about FGM; this is an important step in the continuum of change towards abandonment of FGM. Media and social marketing can be effective in changing social norms and attitudes towards abandoning FGM, and, in some cases, reducing FGM.
  • At the individual level, educating mothers may reduce the numbers of girls undergoing FGM: The higher the level of formal education of a mother, the less likely her daughter was to undergo the procedure. Studies also show that educating girls leads to improved knowledge and changing attitudes.
• Promising interventions that need further evidence: These interventions require additional, more rigorous studies but are promising. For example, at the system level, legislation accompanied by political will, in combination with additional interventions such as sensitisation and locally appropriate enforcement mechanisms, hold promise for reducing FGM. At the community level, creating FGM-free communities via public declarations, particularly when accompanied by post-declaration follow-up, may change attitudes and potentially reduce FGM. Other studies show that public statements of opposition to FGM by religious leaders may help change attitudes towards abandoning FGM.
• Interventions that do not work: Interventions lacking evidence include, at the system level, legislation alone, which may take a long time to end FGM, as countries usually pass laws as a precursor to enforcement. Also, criminalisation may drive FGM underground, thus further entrenching the practice. At the community level, efforts to convert and/or provide traditional practitioners with alternative sources of income have not been effective in eliminating FGM. At the individual level, ARP with a focus on the public ceremonial passage of girls is not effective in reducing or eliminating FGM.

Possible areas for further research are highlighted in Appendix 2 of the report. For instance, more research is needed on service-level interventions, especially on how the health system can effectively prevent and respond to FGM.

As noted here, most of the studies reviewed consistently advocated for the implementation of holistic and multisectoral interventions to end FGM. The multisectoral approach envisages a scenario where: Laws and policies are in place and enacted, and budgets and coordinated systems are in place; community members, including men and boys and religious leaders, deliberate new norms and are equipped with the skills to motivate others to abandon FGM; girls and women are empowered to defend their rights and access education, social, health, and legal services; and FGM is mainstreamed in social development and services for women and girls. Synergies across the various levels (system, community, individual, and service) may foster FGM elimination and the advancement of gender equality.

In conclusion, this review stresses that FGM is an entrenched generational practice with deep social and cultural underpinnings. Eradicating it in a community requires concerted efforts over an extended period. The review recommends a holistic approach that brings together interventions that are sensitive to the complexity of FGM.

Click here in order to download a brief (in English, Arabic, and French) of the full report.