Girls are one-third less likely to be subjected to female genital mutilation (FGM) today than 30 years ago. However, rapid population growth in some of the world’s poorest countries, where FGM persists, threatens to roll back progress. In 2020 alone, an estimated 4.1 million girls were at risk of being subjected to FGM. Without concerted and accelerated actions to end the practice, an estimated 68 million additional girls will have been subjected to FGM by 2030. Despite intensified global research efforts to inform strategies to address FGM, there has been little synergy between evidence generation and the implementation of programmes and policy designed to end the practice. 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. This study aimed to synthesize and assess the quality and strength of existing evidence on FGM interventions reported between 2008 and 2020, mapped onto the current theory of change for FGM programming. Study findings will contribute to strengthening the synergy between evidence generation and FGM programmes and inform a global research agenda for FGM.
This study drew on a Rapid Evidence Assessment of the available literature on FGM interventions published from 2008–2020. We conducted a systematic search of the literature in scientific databases. We also searched literature from websites of institutions or organizations involved in FGM work (n=45). Additional literature was identified by searching references of retrieved studies and suggestions from experts in the FGM field.
The quality of studies was assessed using the ‘How to Note: Assessing the Strength of Evidence’ guidelines published by the United Kingdom’s Department for International Development. The strength of evidence was evaluated using a modified Gray scale that has been previously applied to other reproductive health interventions.
Of the 7,698 records retrieved, 115 studies met the inclusion criteria. Of the 115 studies included in the final analysis, 106 were of high and moderate quality. Study findings were organised according to the four levels of the multisectoral approach underpinning the UNFPA–UNICEF Joint Programme on the Elimination of Female Genital Mutilation: Accelerating Change’s global, overarching theory of change. At the system level, legislation accompanied by political will, in combination with additional interventions such as sensitization and locally appropriate enforcement mechanisms, are promising practices in reducing FGM. However, law and legal enforcement take a long time to produce results. At the community level, health education and community dialogues with parents and religious leaders can change attitudes towards FGM, an important step in the continuum of change towards the abandonment of the practice. Media and social marketing efforts are effective in changing social norms and attitudes towards abandoning and, in some cases, reducing FGM. Notably, efforts to convert and/or provide traditional practitioners with alternative sources of income are not effective in eliminating FGM. At the individual level, formal education (educating mothers) can reduce the number of girls being subjected to FGM, while educating girls leads to improved knowledge on the consequences of FGM and changing attitudes towards the need for the practice. At the service level, available evidence, though limited, shows that health-care provider training can improve the capacity for prevention and treatment of FGM. Notably, most of the studies addressed intermediate outcomes for behavioural change such as knowledge and attitudinal change.
At the system level, legislation-related interventions must be multifaceted to be effective. Community-level interventions are effective for changing attitudes towards FGM, but more must be done to innovate with these interventions so that they move beyond affecting attitudes alone to creating behaviour change. At the individual level, formal education is effective in reducing FGM prevalence among girls. However, the returns of formal education in ending FGM may take many years to be realized, so interventions targeting intermediate outcomes, such as improvement in knowledge and change in attitudes and beliefs towards FGM, are equally needed at the individual level. More research is needed at the service level, especially into how the health system can effectively prevent and respond to FGM.