Preventing Female Genital Mutilation in High Income Countries

Njue et al. Reproductive Health (2019) 16:113 https://doi.org/10.1186/s12978-019-0774-x

REVIEW Open Access Preventing female genital mutilation in high income countries: a systematic review of the evidence Carolyne Njue1* , Jamlick Karumbi2, Tammary Esho3, Nesrin Varol4 and Angela Dawson1

Abstract Background: Female genital mutilation (FGM) is prevalent in communities of migration. Given the harmful effects of the practice and its illegal status in many countries, there have been concerted primary, secondary and tertiary prevention efforts to protect girls from FGM. However, there is paucity of evidence concerning useful strategies and approaches to prevent FGM and improve the health and social outcomes of affected women and girls. Methods: We analysed peer-reviewed and grey literature to extract the evidence for FGM prevention interventions from a public health perspective in high income countries by a systematic search of bibliographic databases and websites using appropriate keywords. Identified publications were screened against selection criteria, following the PRISMA guidelines. We examined the characteristics of prevention interventions, including their programmatic approaches and strategies, target audiences and evaluation findings using an apriori template. Findings: Eleven documents included in this review described primary and secondary prevention activities. High income countries have given attention to legislative action, bureaucratic interventions to address social injustice and protect those at risk of FGM, alongside prevention activities that favour health persuasion, foster engagement with the local community through outreach and the involvement of community champions, healthcare professional training and capacity strengthening. Study types are largely process evaluations that include measures of short-term outcomes (pre- and post-changes in attitude, knowledge and confidence or audits of practices). There is a dearth of evaluative research focused on empowerment-oriented preventative activities that involve individual women and girls who are affected by FGM. Beattie’s framework provides a useful way of articulating negotiated and authoritative prevention actions required to address FGM at national and local levels. Conclusion: FGM is a complex and deeply rooted sociocultural issue that requires a multifaceted response that encompasses socio-economic, physical and environmental factors, education and learning, health services and facilities, and community mobilisation activities. Investment in the rigorous longitudinal evaluation of FGM health prevention efforts are needed to provide strong evidence of impact to guide future decision making. A national evidence-based framework would bring logic, clarity, comprehension, evidence and economically more effective response for current and future prevention interventions addressing FGM in high income countries. Keywords: Female genital mutilation, Migrants, Health prevention, Systematic review, High-income countries

* Correspondence: [email protected] 1The Australian Centre for Public and Population Health Research, Faculty of Public Health, University of Technology Sydney, PO Box 123, Broadway, Sydney, NSW 2007, Australia Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Njue et al. Reproductive Health (2019) 16:113 Page 2 of 20

Plain English summary risk of undergoing FGM in their countries of origin. Female Genital Mutilation (FGM) is a cultural practice Some migrants have continued the practice in their that is associated with poor health outcomes. The migra- countries of migration, with the aim of maintaining their tion of women and girls with FGM to countries such as culture and identity [10, 11]. However, there is evidence the United Kingdom, the United States of America and that migration to countries where FGM is not prevalent Australia, where FGM is not traditionally practiced, has has a positive influence on the abandonment of this led to the development of programs to prevent FGM practice [12–16]. Some of the reasons cited for this and care for affected women and girls. The purpose of change include improved knowledge of the health conse- this study is to identify and review existing literature to quences and weakening of social pressure to undertake find out what strategies and approaches are useful to FGM that is associated with changing perceptions re- prevent FGM and improve the health of affected women garding the benefits of the practice for marriageability, and girls. The majority of the documents we included in religious observance and social acceptance. Moreover, this review described laws developed to prevent FGM those affected by FGM may be stigmatised in their new and safeguard girls and women, as well as media cam- country of migration [17]. FGM is a prosecutable offence paigns and health education activities for health profes- in most HIC. Whilst this may dissuade communities sionals and community members. All the evaluations from undertaking FGM, it may also encourage families measured short term outcomes such as improvements in to conduct FGM in secret or take their children overseas knowledge and we did not find any evidence of long to be circumcised. term changes. There is a need to carry out well designed The exact number of women and girls living with evaluations to understand how interventions can change FGM in HIC is largely unknown due to the sensitive na- behaviour. This evidence can then be used to inform nature of the issue and the lack of routinely collected data. tional plans to prevent FGM. However, it is estimated that almost half a million women living in Europe have been subjected to the prac- Background tice [18]. In the United Kingdom (UK) and USA, based WHO defines female genital mutilation (FGM) as “all on 2015 estimates, there are about 137,000 women and procedures that involve the partial or total removal of girls who have undergone FGM and 507,000 who are at the external female genitalia, or other injury to the fe- risk of FGM [19, 20]. Health professionals in HIC are male genital organs for nonmedical reasons” [1]. WHO often not aware of FGM or have knowledge and skills to classifies FGM into four categories with type III (infibu- adequately care for affected women or protect children lation) being the most severe form [1]. This is a more at risk. FGM therefore presents a challenge to the health detailed description of practices than the one offered by system in HIC [21, 22]. UNICEF [2]. FGM, also known as female genital cutting Given the harmful effects of this practice and its illegal or female circumcision, has serious health consequences status in many countries, there have been concerted ef- that may lead to death from haemorrhage and/or infec- forts to prevent FGM in HIC through advocacy and tion, urinary and genital tract infections, gynaecological, other prevention activities including education, informa- obstetric, sexual and psycho-social complications or tion and public communication campaigns for affected death from haemorrhage [3–5]. While the prevalence of women and girls. Mandatory reporting protocols have FGM is decreasing and varies across countries [6] been developed in some countries, such as the United UNICEF has estimated that more than 200 million of girls Kingdom (UK), to protect women and girls at risk. In and women have undergone Female Genital Mutilation addition, there are police protocols and legal means to (FGM) globally and three million girls may be at risk of prosecute those suspected of carrying out the practice undergoing FGM every year [7]. FGM occurs in more [23] However, there is not enough evidence concerning than 40 countries throughout the world. It is practiced by effective strategies and approaches to prevent FGM and communities in 28 African countries, communities in the improve the health and social outcomes for affected southern parts of the Arabian Peninsula and along the women and girls. Four recent reviews have largely fo- Persian Gulf and in communities in India, Indonesia and cused on interventions from African countries [24–27]. Malaysia [8, 9]. We therefore undertook a systematic review to identify Difficult economic conditions and conflict are among the evidence for FGM prevention interventions from a the factors that have resulted in increasing migration of public health perspective in HIC. Specifically, we exam- people from FGM prevalent nations to high income ined the characteristics of interventions, including their countries (HIC) where FGM is not traditionally prac- programmatic approaches and strategies, target audi- ticed such as the United States of America (USA), ences and evaluation findings. The review aims to con- United Kingdom, Australia, New Zealand, and across tribute to improving the knowledge base to inform the Europe [9]. Many of these women and girls would be at design and evaluation of FGM health interventions to Njue et al. Reproductive Health (2019) 16:113 Page 3 of 20

prevent the practice and optimize health outcomes for ‘infibulation,’‘sunna,’‘FGM intervention,’‘FGM/FGC,’ ‘FGM girls and women with FGM. or FGC program, ‘high income country,’ developed country,’ and ‘developed regions’. Peer reviewed literature was identi- Methods fied using PubMed and CINHAL (EBSCO), EMBASE and Due to the short-term nature of the largely process eval- Web of Science. We further searched institutional websites uations we identified that used a range of methodologies, and databases of organizations involved in FGM activities, we were not able to pool data to establish the overall ef- to identify reports and any possible “grey literature.” We fect of the interventions on prevalence. This determined conducted general searches using Google and Google the use of a qualitative content analysis rather than a Scholar to ensure no literaturewasmissed.Inaddition,we quantitative meta-analysis to establish effectiveness. We cross-referenced articles, which were relevant and scanned undertook a systematic review and content analysis through their bibliography to identify additional materials. using an apriori framework to analyse the characteristics The first author (CN) identified studies for relevance and underpinning approaches of interventions to pre- based on the title and abstract and the third author (TE) vent FGM in HIC and their outcomes. This review was repeated the process to ensure no relevant studies were registered with the International Prospective Register of excluded. We included studies that focus on assessments Systematic Reviews as PROSPERO CRD42018092299. or evaluations of FGM interventions published since For the purposes of this review, the term HIC is based 2000 as being eligible. We used a pre-established eligibil- on the World Bank definition, which divides member ity and inclusion and exclusion criteria to guide the countries into different income groups. A HIC is as a screening and selection process. The inclusion criteria country with a higher gross national income per capita used were the following: (i) countries described were of $12,376 USD [28]. We defined an ‘FGM intervention’ from a HIC setting as defined above; (ii) were conducted as any form of action or deliberate process to interfere in recent years (January 2000–March 2018); (iii) the with, modify or change individuals’ or groups of people’s studies focused on assessing the impact of FGM inter- knowledge, attitudes or behaviours to prevent FGM and ventions; and (iv) were in English. There was no restric- thereby reduce the prevalence and improve the health tion; all study types, designs and methodologies, those outcomes of girls and women affected by FGM. We used appearing in peer review journal or in grey literature Tannahill’s health promotion approach [29] to define from a recognised institution and/or government, or a types of interventions for inclusion and as such, clinical PhD thesis, were all included so long as there was a clear interventions were excluded. However, education pro- methodology to enable an assessment of quality. Studies grams to support affected women who may have under- were excluded if they were from low or middle-income gone de-infibulation for example, were part of this countries (LMIC), if they assessed consequences of review as was legislation to protect girls and community FGM, described national action plans, were comprised awareness to prevent FGM. We selected Tannahill’s of theoretical notes and recommendations/guidelines, or model of health promotion where prevention is a key if they were not in English. Our search located 87 study pillar [29] because it acknowledges, as other authors reports that were eligible for review as shown in the have noted, that prevention cannot be achieved without PRISMA flow chart [32] (Fig. 1). health promotion [30]. We aimed to understand the differ- Following the screening, 42 study reports were identi- ent strategies that are used to prevent FGM that reveal fied as eligible for full text review. These were retrieved power dynamics and possible ethical dilemmas. This un- and assessed by the second author (JK) and counter- derstanding informed the use of Bettie’smodel[31]to checked by first author (CN). The authors (JK and CN) further explore these strategies that recognises that preven- independently appraised the studies for quality of report- tion and health promotion are conceptually linked. ing, this included an assessment of its quality, size and To achieve a comprehensive systematic search and consistency of the body of evidence (See Tables 1 and 2). hence retrieve all contemporary empirical evidence, we The study type, design, and methodology determined assessed all types of literature, ranging from grey litera- the type of quality assessment tool used and data were ture reports to peer-reviewed literature concerned with recorded on Microsoft Excel software. the evaluation of interventions aimed at preventing and/ Of the 42 documents, 11 met the inclusion criteria or providing education for girls and women with FGM (See Table 3). Evidence from ten grey literature was in HIC. The search for evidence was limited to what was assessed for quality using Authority, Accuracy, Coverage, available online and snowballing from bibliographies of Objectivity, Date, and Significance (AACODS) Checklist retrieved articles. [45]. We used Critical Appraisal Skills Programme A set of keywords used in the search were ‘female genital (CASP) checklists to appraise one study published in mutilation/cutting,’ ‘female genital mutilation,’‘female geni- peer-reviewed journals [46]. Data was extracted from the tal cutting,’‘female circumcision,’‘clitoridectomy,’‘excision,’ findings’ sections of the included papers (ad-verbatim Njue et al. Reproductive Health (2019) 16:113 Page 4 of 20

Fig. 1 Flow Chart and marked in quotation marks) in the form of sen- interventions were successful at changing individual or tences, phrases, or text units dealing the effectiveness of group behaviour [31]. We mapped this across the four an intervention to identify patterns according to each quadrants of the model. intervention. Data extraction was undertaken by the authors (CN and JK) using a predesigned table. This was Results counterchecked by fourth (NV) and fifth (AD) authors. A total of 11 study reports are included in this review We first categorized the FGM interventions studies produced across multiple agencies involved in delivering according to different levels of prevention, namely: FGM programs in HIC. One study [33] discusses FGM primary, secondary and tertiary, as per the public health programs across 19 HIC. Five reports discuss FGM pro- approach [47] and examined the outcomes of each grams in the UK [34, 35, 39, 40, 44]. Three reports out- initiative. In addition to the levels of prevention and the line work undertaken in EU member states [37, 38, 48] associated outcomes, we then undertook a content ana- and two documents describe FGM efforts in Canada lysis informed by Beattie’s model of health promotion to [42] {Daniel, 2014 #229} and Australia [41] {Scott, 2011 understand dimensions of power and the socio-cultural #220}. The 11 studies used qualitative and quantitative context of the interventions. Drawing on this model, we methods. Six studies were judged to be of high quality examined the mode and focus of interventions specifically (five of these were based on the AACODs checklist) how negotiated action was achieved or how authoritative [37–39, 42, 48]. Five studies were judged to be of Njue ta.Rpoutv Health Reproductive al. et (2019)16:113

Table 1 Rating of studies reviewed, using principles of quality outlined in the CASP tool Reference Study Clear statement Appropriateness Appropriateness Appropriate Appropriate Relationship between Ethical issues Rigorous Clear Findings in context Quality type of the aims of of methodology of research recruitment data researcher and participants been taken into data statement (Contribution to body of study (code) the research design strategy collection been adequately considered consideration analysis of findings of knowledge) 1 = Yes, 0 = Can’t 1 = Yes, 0 = Can’t 1 = Yes, 0 = Can’t 1 = Yes, 0 = 1 = Yes, 0 = 1 = Yes, 0 = Can’t Tell, − 1 = No 1 = Yes, 0 = Can’t 1 = Yes, 0 = 1 = Yes, 0 = 1 = Yes, 0 = Can’t Tell, Tell, − 1=No Tell, − 1=No Tell, − 1=No Can’t Tell, − Can’t Tell, − Tell, − 1=No Can’t Tell, Can’t Tell, − 1=No 1=No 1=No − 1=No − 1=No Johansen P 1 1 0 1 1 0 0 1 1 Moderate et al., 2018 [33] ae5o 20 of 5 Page Table 2 Rating of studies reviewed, using principles of quality outlined in the AACODS checklist Njue a Reference Country Authority Accuracy Coverage Health Reproductive al. et Reputable Reputable Detailed clearly stated Peer- Data collection Edited by a Are any Individual Organisation reference stated methodology reviewed? explicit and reputable limits author? or group? list aim appropriate authority? clearly for the research? stated? E.g. Particular population or group 1 = Yes, 1 = Yes, 1 = Yes, 1 = Yes, 1 = Yes, 1 = Yes, 1 = Yes, 1 = Yes, 1 = Yes, 0 = Can’t 0 = Can’t 0 = Can’t 0 = Can’t 0 = Can’t 0 = Can’t 0 = Can’t 0 = Can’t 0 = Can’t (2019)16:113 Tell, − Tell, − Tell, − Tell, − Tell, − Tell, − Tell, − Tell, − Tell, − 1=No 1=No 1=No 1=No 1=No 1=No 1=No 1=No 1=No Brown & UK 1 1 −11 1 0 1 0 0 Porter, 2016. [34] Brown & Hemmings, 2013 [35]UK 1 1 −11 1 0 1 0 0 EIGE, 2013 [36] EU and 01 111 01 1 1 Croatia Leye & EU 01 011 01 0 1 Alexia, countries 2009 [37] Leye & EU countries 0 1 1 1 1 0 1 0 1 Deblonde, 2004 [38] McCracken, UK 0 1 1 1 1 0 1 0 1 Fitzsimons et al., 2017 [39] Mohamed, UK 0 1 1 1 1 −11 0 1 Schickler et al., 2014 [40] Scott & Australia 0 1 0 1 1 0 1 0 1 Jerse, 2011 [41] Simret, D., Canada 0 1 1 1 1 −11 0 1 2014 [42] NHS England 0 1 −11 1 0 0 1 −1 England 2016 [43] aThis domain was rated No, where there was lack of peer review and details about the editors. $ A majority of our evidence being from programmes were not peer reviewed and hence scored no. Ratings: 0–6 being 20 of 6 Page Low quality; 7–11 being moderate quality; 12–17 represents high quality Table 2 Rating of studies reviewed, using principles of quality outlined in the AACODS checklist (Continued) Njue

Reference Objectivity$ Date Significance Quality Health Reproductive al. et of study The Does the work seem to Clearly stated Key Item meaningful? (this Add Strengthen or Does it have impact? (in the sense author’s be balanced in date related to contemporary incorporates feasibility, utility context? refute a current of influencing the work or standpoint presentation? content? material been and relevance) position? behaviour of others) clear? included? 1 = Yes, 1 = Yes, 1 = Yes, 1 = Yes, 1 = Yes, 1 = Yes, 1 = Yes, 1 = Yes, 0 = Can’t 0 = Can’t 0 = Can’t 0 = Can’t 0 = Can’t 0 = Can’t 0 = Can’t 0 = Can’t Tell, − 1=No Tell, − Tell, − Tell, − Tell, − Tell, − Tell, − Tell, − 1=No 1=No 1=No 1=No 1=No 1=No 1=No (2019)16:113 Brown & 1 1 1 0 1 1 1 1 Moderate Porter, 2016. [34] Brown & 1 1 1 0 1 1 1 1 Moderate Hemmings, 2013 [35] EIGE, 2013 1 1 1 1 1 1 1 1 High [36] Leye & 1 1 1 0 1 1 1 1 High Alexia, 2009 [37] Leye & 1 1 1 1 1 1 1 0 High Deblonde, 2004 [38] McCracken, 1 1 1 0 1 1 1 1 High Fitzsimons et al., 2017 [39] Mohamed, 1 0 1 1 1 0 1 1 Moderate Schickler et al., 2014 [40] Scott & 1 0 1 0 1 1 1 1 Moderate Jerse, 2011 [41] Simret, D., 1 1 1 1 1 1 1 0 High 2014 [42] NHS 1 0 1 1 1 1 1 1 Moderate England 2016 [43] ae7o 20 of 7 Page Table 3 Characteristics of included studies and type of intervention, associated strategies and findings Njue

Reference/ context Aim Methodology / Sample Prevention activities examined Findings: intervention outcomes Health Reproductive al. et Primary prevention Johansen et al., To examine Countries Mixed methods: •Training of health care •4 of the 19 countries 2018. [33] national policies on desktop review, professionals (HCP), (France, Ireland, the Australia, Austria, Belgium, FGM and health survey with 21 involving HCP in the Netherlands and Norway) Finland, France, Germany, sector involvement in respondents in preventive work had policies on FGM that Greece, Ireland, Italy, the management of FGM 19 countries •Legal regulations on were implemented, funded, Netherlands, Norway, HCP duties to avert and coordinated and with systems Portugal, Saudi Arabia, report as well as to of monitoring and evaluation Slovakia, Spain, Sweden, perform FGM in place; Switzerland, UK, USA •Availability of •15 countries had (2019)16:113 healthcare services national policy on FGM, (de-infibulation, clitoral (exception Austria, Greece); reconstruction, sexual • 12 countries had assigned and psychological counselling coordination bodies (exception Australia, Austria, Greece, Sweden, and USA); 13 have partially or fully implemented the plans (exception: Austria, Greece, Spain, Sweden,); HCPs are legally prohibited from performing FGM on minors in •Psychological and sexual counselling were available predominantly in 13 countries Leye & Deblonde, To examine FGM Mixed methods: -content • Legal provisions • 5 countries have child 2004 [38], Austria, legislation specifically: analysis of legal documents, pertaining to FGM protection guidelines or Belgium, Denmark, Criminal laws, Child/Minor semi-structured interview protocols that guide those Finland, France, Protection laws, Specific with key informants who are confronted with a Germany, Greece, FGM legislation, General in 5-member states girl at risk of FGM, Ireland, Italy, Criminal Law, (Belgium, France, Spain, except in Belgium Luxemburg, Professional secrecy law. Sweden, UK) (number • Cases are reported, and Portugal, Spain, of participants in each investigations have been Sweden, country not stated) initiated, although the number Netherlands, UK of cases brought to criminal court is limited (in France and Spain) • Issues in relation to type IV and piercing and cosmetic surgery where the latter has not been taken into consideration by legislators hence ambiguity. • Lack of knowledge of the law among health professionals, authorities and police. • Attitudes of these people may obstruct implementation

i.e. fear of being labelled as racist 20 of 8 Page • Workshops for professionals raised awareness of FGM Leye & Alexia, 2009 [44], To examine the Mixed methods: content • FGM related laws • Legislation alone is not enough Belgium, France, implementation analysis of documents, • Awareness raising and (Barriers - Case identification Table 3 Characteristics of included studies and type of intervention, associated strategies and findings (Continued) Njue

Reference/ context Aim Methodology / Sample Prevention activities examined Findings: intervention outcomes Health Reproductive al. et Spain, Sweden, of criminal and survey questionnaire education to improve and Collection of sufficient United Kingdom child protection laws with key informants, knowledge and compliance evidence to mount a prosecution) on FGM in 5 EU in-depth interviews with the law including • No evidence was found member states and with participants capacity building workshops to state that specific criminal associated activities from 5 countries, for professionals from law provisions are necessary (number not stated). various sectors (targeted to guarantee the punishment training and information of FGM, or that they are more campaigns about FGM successful in their issues, legislation, child implementation than

protection procedures) general criminal law provisions. (2019)16:113 • Only France and Italy have had prosecutions Mohamed, To report on participatory Qualitative. 36 • 5 local women trained • At the end of the workshops Schickler et al., workshops on FGM to grandmothers, 52 young as community champions 25% of participants stated 2014 [40], UK increase knowledge mothers; 38 men were to conduct 10 that FGM was required by and awareness of FGM interviewed using participatory religion compared with a structured questionnaire workshops on FGM 40% before the workshops began. • The champions held • At the end of the workshops 79% one-to-one sessions of participants agreed that FGM with women, home should be stopped compared visits were also made with 62% at the start. to speak with families • Stories of women informed about FGM the development of • Visits were made materials and scenarios for discussion to mosques to • Principles developed for action educate men and to schools Scott & Jerse, To evaluate the state Mixed methods: • Continuing professional • Build strong links with 2011 [41], New wide FGM multidisciplinary document, consultations development for health the community South Wales, model of service delivery. with 72 stakeholder and other professionals; • increased awareness, Australia informants and • Education and community knowledge and on-line survey of development with affected empowerment of 63 respondents. communities involving affected community community workers; members and increased • Resource and information understanding in a development and diversity of professional dissemination health and other • Advocacy to prevention community service providers. FGM including media campaigns on ethnic radio run over 8 weeks • Collaborative work with NSW Police Child Protection Unit Simret, 2014 To evaluate a Qualitative: focus groups, • Manual of materials • Increased knowledge of [42], Winnipeg, community-based questionnaires and designed for services mainly “high” to “very Canada education program, observations with to use with migrant high” of women on 10 weeks of educational, 187 immigrants and and refugee women FGM issues; 88% health and sociocultural refugee participants •Networking with key “strongly agreed” support sessions on FGM in 3 African national community organisations that workshops were ae9o 20 of 9 Page communities; 24 service • Workshops for health suited to their needs; providers & other and social service professionals healthcare professionals professionals. Examination on cultural competence showed increase in of staff logs, and knowledge; most documentation review. “strongly agreed” Table 3 Characteristics of included studies and type of intervention, associated strategies and findings (Continued) Njue

Reference/ context Aim Methodology / Sample Prevention activities examined Findings: intervention outcomes Health Reproductive al. et that content & process of training were appropriate • Having community co-facilitators helps ease the communications and acceptability of the intervention

Secondary (2019)16:113 prevention NHS 2016 To conduct a performance A formal assurance • Clear policy for adult • 37% of CCGs were [41], Clinical assessment of all CCG’s review was carried and children judged as needing commissioning safeguarding governance, out quarterly in line safeguarding that to make improvements groups (CCGs) arrangements and processes. with the published includes FGM to put in place clear in the London framework and • Service engagement children and adult Region, UK technical guidance. around FGM policies that make Eleven audits, the sufficient references Safeguarding Adults to prevent FGM Board Self-Assessment • Most CCG’s were Audit, Safeguarding assessed as Workforce Gap analysis outstanding were and baseline review, engaging with FGM serious untoward incidents policy, 21% (n =7) and section 2 audits were given this score. and the safeguarding adults review and SCR (Single Central Record) tracker for adults and children Multi-prevention Brown & Hemmings, To evaluate community Qualitative: 15 stakeholder Primary • Indication of change in 2013 [35], England based preventive work interviews, interviews with • Community engagement community views. & Wales, UK Liverpool, Leicester, to safeguard children from FGM community members and awareness raising •Community Cardiff, Middlesbrough, using PEER ethnographic incorporating FGM messages engagement improved Manchester, evaluation, rapid policy in wider sexual health rejection of FGM and Birmingham, mapping and review messages, provision of has built networks Bristol, Bolton, of self-reported M&E safe spaces for discussion of groups working & 6 projects in London on FGM, using community together champions, and use • Younger women of drama and visual arts. have been empowered Secondary to speak out and • Mainstreaming FGM make decisions under violence against • Some religious leaders have women and girls /safeguarding dismissed the perceived strategies involving religious basis for multiple agencies, clinical certain forms of FGM & community champions Secondary and community •Mainstreaming:

awareness raising resources are committed 20 of 10 Page To FGM, sustainability of efforts is high Brown & Porter, To evaluate the support Qualitative: PEER Primary • Groups where 2016 [34], provided to community-based interviews with • Community education to there was a visible England and organisations to carry 51 participants promote a rights-based shift towards speaking Table 3 Characteristics of included studies and type of intervention, associated strategies and findings (Continued) Njue

Reference/ context Aim Methodology / Sample Prevention activities examined Findings: intervention outcomes Health Reproductive al. et Wales UK out FGM prevention work approach to tackling FGM out against FGM • Awareness raising of FGM included parents, amongst affected communities, grandparents and young women policy-makers, statutory who either had undergone or agencies, and the public were at risk of FGM. • Networking of groups and • Respondents felt that policy-makers to contribute changes in attitudes, to wider campaign to end FGM awareness, levels of • Building skills and capacity information and opposition

of affected communities were closely linked to the (2019)16:113 Secondary work of the national-level • Safeguarding practices e.g. anti-FGM campaign child protection, legal action and in particular the •Developing materials- culturally community-level work appropriate means of talking of the ten projects about FGM as a part of • Discussions about child protection FGM in many • Promoting access to services areas, which many for girls and women at risk reported has changed through strengthening the status of FGM, with links between groups it no longer and statutory agencies being viewed as a ‘taboo’ subject. • Law was seen as a powerful and effective part of ending FGM EIGE, 2013, All Analysis of FGM policy Qualitative: desk review Primary • Currently, there are nine EU EU countries and legal frameworks of laws. In depth • FGM related law Member States which have and Croatia [36] of FGM in EU-27 countries interviews with • Awareness raising activities to specific criminal law provisions on FGM. and Croatia and to at least 6 people improve knowledge and • No EU Member State has a understand past and in 9 countries and five compliance with the law specific provision on international present good practices in-depth interviews at including awareness raising protection and FGM in its national in relation to prevention, European aimed at the general public legislation. protection, prosecution, /international level. •Development of training material • Sweden, the Netherlands provision of services Secondary and Italy have prioritised and partnerships. •Training professionals funding for prevention on child protection activities, but the majority of Member States have not. Prevention activities lack baseline data and are poorly evaluated Secondary • Training on child protection in relation to FGM appears random and does not seem to be conducted on a continuous, structured and nationwide basis.

• In many Member States, 20 of 11 Page health professionals cannot break their code of silence when the crime of FGM has already been performed, Table 3 Characteristics of included studies and type of intervention, associated strategies and findings (Continued) Njue

Reference/ context Aim Methodology / Sample Prevention activities examined Findings: intervention outcomes Health Reproductive al. et because FGM is not generally considered as a type of repetitive, recurrent child abuse McCracken, To evaluate a pilot FGM early Qualitative: In-depth Primary • At least 235 women Fitzsimons intervention model one-to-one semi-structured • Community advocates raise with FGM were seen et al., 2017 [39] involving clinics at local interviews with 24 awareness at local events in clinics in London; 3 local authority hospital midwifery services. professionals & 6 and identify women’s needs study showed clinics areas within women & 1 FGD with • Support & information offered referral London, UK 6 women. Structured provided to men; local pathways & education; (2019)16:113 observation of 5 and religious leaders services, confirmed stakeholder and • Engagement with physical & mental community events. students at schools health problems in • Local media used to women with FGM raise awareness • Holistic service was Secondary reportedly provided: • Training and development mental health services; of assessment tools and advice on effective protocols for health and safeguarding approaches; education professionals support to access and social workers for wider services and safeguarding and referral. benefits; links to • Community advocates community-based accompany women classes and activities; to the clinic emotional and Tertiary practical support. • Education provided to • Health and social women with FGM by care professionals, midwives, social therapists and community workers and advocates reported strong therapists at clinics working relationships and effective service protocols. ae1 f20 of 12 Page Njue et al. Reproductive Health (2019) 16:113 Page 13 of 20

moderate quality (three of these were based on the workers from the affected communities are actively en- AACODs checklist) [35, 40, 41] and one was based on gaged [41]. Similarly, Brown and colleagues in their the CASP checklist for qualitative studies [33] {Abreu, UK studies showed that when the community is en- 2015 #222}. One study was judged to be of low quality gaged in the design of outreach interventions for based on the AACODs checklist [44]. The activities de- girls, women and men, awareness of FGM can be en- scribed in the 11 reports were classified according to hanced, enabling participants to talk freely about what their primary, secondary or tertiary prevention focus had previously been considered a taboo topic [34, 35]. (Summary Table 2). Community outreach from dedicated FGM clinical services in the UK were also found to be useful in Interventions focused on the primary prevention of FGM raising awareness [44, 39]. All documents included in the review described primary The European Institute for Gender Equality (EIGE) re- prevention activities that sought to increase individual port [48] notes that Sweden, the Netherlands and Italy professional and community awareness and understand- have prioritised funding for prevention activities, but the ing of FGM as an infringement on human rights, as well majority of European Union Member States have not as the adverse health outcomes associated with the prac- and that prevention activities lack baseline data and are tice and the law as it pertained to FGM. Studies also poorly evaluated. provided insight into the current legal status of FGM in Four of the studies [37, 38, 44, 48] provide some a number of European countries and issues relating to insight into European laws to prevent FGM and associ- the implementation of the law. ated activities to educate communities about the laws Mohammed and colleagues (2014) describe participa- and support health and other professionals to implement tory peer-to-peer educational workshops in the UK that them. The EIGE report states that in 2013 nine of the 27 involved the training of local Somali women as commu- EU Member States had specific criminal law provisions nity champions in Tower Hamlets, London [40]. These on FGM. However, no EU Member State had a specific workshops covered a wide range of FGM related topics, provision on international protection and FGM in its na- including health and well-being, FGM legislation, and tional legislation [48]. According to Leye and Deblonde stories from women who had experienced FGM. A be- (2004), national legislation is a useful first step towards fore and after workshop assessment to assess knowledge preventing FGM as it encourages institutions to take and attitudes was conducted that showed increased subsequent measures to prevent FGM but alone is not changes in knowledge acquisition, attitude, beliefs and sufficient to stop FGM [38]. There is no evidence that intention relating to FGM. Additionally, one-on-one out- the implementation of a specific law is more successful reach sessions that involved 21 visits by either a project than general criminal laws to prevent FGM. Specific laws co-ordinator or the community champions to house- include child protection laws that maybe be applied in holds to speak to families and to provide on-going sup- cases of FGM and special provisions with regards to pro- port to the households allowed women to speak in fessional secrecy and disclosure, which may be applied confidence about FGM issues. to cases of performed or planned FGM. General criminal Two studies [41, 42] conducted in Canada and laws including articles of the penal code may be applied Australia report on the outcomes of broad public educa- to FGM-related cases. tion campaigns that focused on improving community Despite the development of laws, three studies in- members and health professionals awareness of human cluded in the review note that it was very challenging to rights issues and knowledge of FGM prevention. Daniel enforce these laws. France and Italy were cited as the and colleagues (2011) describe a 10 weeks program of only countries to have had prosecutions and even then, educational, health and sociocultural support sessions to they involved long protracted processes [37]. One of the discuss, compare and share stories targeting newly ar- two main barriers for the implementation of legislation rived African migrant and refugee women in Winnipeg, is the identification of cases, which is principally Canada. Moreover, a manual of materials for services in obstructed by the lack of knowledge of FGM among relation to sexual and reproductive health and FGM in- professionals. The second important barrier is the com- formation and prevention was developed. They reported plexity of finding sufficient evidence to bring a case to that many of the women felt that by virtue of living in a court. The authors recommend that to be effective, dif- new culture, the decision not to circumcise daughters ferent sectors and the relevant professionals need to be was easier [42]. Scott and Jerse (2011) reported that edu- properly trained and involved in this process to ensure cational interventions in Australia may have some effect the harmonized implementation of criminal and child in changing attitudes and knowledge on FGM of migrant protection laws. The EIGE and Johansen et al. studies communities to abandon the practice, especially when indicate that most EU countries have laws to prosecute community champions and bilingual community adults involved in procuring FGM for girls outside of a Njue et al. Reproductive Health (2019) 16:113 Page 14 of 20

country’s borders, although its implementation is not school managers, legal professionals’ healthcare profes- uniform across nations. However, significant gaps have sionals), to improve protective mechanisms and engage- been identified in the application of the extraterritoriality ment with communities and relevant social actors. principle to protect HIC residents from being subjected Training workshops and updates for professionals to to FGM overseas [33, 48]. strengthen mandatory reporting obligations to protect The report by Leye and colleagues [37] includes an girls from FGM were described as an important adjunct evaluation of a series information and training work- to legislative actions. However, training for health, edu- shops for professionals from various sectors in five EU cation and social workers and police across nations in member countries to improve knowledge of the law as it the European Union was reported as haphazard and not relates to FGM. The evaluation suggests that building conducted on a continuous, structured and nationwide the capacities of various professionals involved in pre- basis. This is said to be hampered by the fact that in vention, child protection, law enforcement and health many Member States, health professionals cannot break such as social services, immigration officers, policemen, their code of silence when the crime of FGM has already prosecutors, health providers and other professionals been performed, because FGM is not generally consid- may lead to an increase in the number of prosecutions. ered as a type of repetitive, recurrent child abuse [48]. In the EIGE study, outreach programs targeting parents, McCracken and colleagues (2017) describe the devel- professionals and decision makers among FGM-practis- opment of pilot of FGM-specific assessment and inter- ing communities were described. These activities in- vention tools and protocols alongside training for volved education workshops and public forums that relevant professionals. This was supported by commu- provided information about the penalties for perpetra- nity outreach activities to raise awareness of FGM-re- tors, the role of professionals in reporting of FGM and lated issues, promote understanding of services and the role of extra-territoriality principle in the European legislation. Health professionals provided talks at schools Union, where courts can adjudicate on cases outside the for pupils, parents, teachers and governors [39]. Other territory of their country. Additionally, training of practi- community-based efforts to facilitate these safeguarding tioners was delivered as part of the rollout of new guide- measures include training FGM champions and creating lines on child protection laws. The study found that safe spaces for girls and women at risk of FGM to talk practitioners, and parents are becoming increasingly about FGM. Bi-lingual community co-facilitators were aware of the risk of prosecution for FGM [48]. The three engaged to communicate information about safeguard- studies discussing laws in this review suggest that legisla- ing in culturally appropriate ways and motivate commu- tion may work more effectively when viewed as a facili- nity members to support the protection legislation and tator of protection against harmful practices and when protocols [35]. used to conduct negotiations with the communities, health care workers and prosecutors. Interventions to support the tertiary prevention of FGM associated conditions Interventions to support secondary prevention Only one report [39] included an evaluation of educa- interventions tion provided to pregnant women and their partners Five documents report on efforts to support safeguard- who are eligible for de-infibulation to prevent obstetric ing by improving citizen reporting of girls they suspect complications. McCracken and colleagues (2017) de- may be at risk of FGM to authorities. For example, scribe the FGM Early Intervention Model delivered Brown and Porter [34] in their report describe collabora- across three local authority areas in London. The au- tive efforts in the UK that brought together, people from thors found that dedicated FGM clinics within hospital the voluntary and community sector, statutory agencies midwifery services played a pivotal role in identifying such as Safeguarding Boards, Metropolitan Police and women with FGM so that women could be provided health professionals, to strengthen community-based with appropriate counselling and information about the preventive work. These efforts comprise information law and available supportive services. During the pilot sharing and the development of reporting or knowledge phase of the program, 235 women were seen in the or suspicion of FGM risk to the authorities [34]. The FGM clinics. Practitioners were trained how to conduct NHS study reports on an audit undertaken of Clinical risk assessment, identify individual women’s understand- Commissioning Groups (CCG), one of which is the ings of the practice and their education and information Croydon CCG services [43]. In the studies reviewed, the needs related to FGM and to report instances where main focus of the interventions was on safeguarding that children were believed to be at risk of FGM. Only imme- included FGM, building partnerships and the capacity of diate outcomes were reported, i.e. changes in health care professionals involved (social welfare authorities, child professional knowledge and attitude, including their rec- protection officers, police officers, immigration services, ognition of the need for sensitivity in direct work to Njue et al. Reproductive Health (2019) 16:113 Page 15 of 20

avoid re-traumatising or alienating women who have level legal action, policy and reporting protocols for safe- undergone FGM, and other members of potentially-af- guarding girls to prevent FGM and prosecute those for fected communities [39]. No information about changes procuring or intending to procure FGM. These include in the knowledge and attitudes of women as a result of both primary and secondary prevention activities. Inter- information provided by health care professionals is ventions described in six papers (in the top left quad- available. rant) employ the authority of public-health expertise to re-direct the behaviour of community members and pro- Mapping interventions according to mode and focus fessionals in top-down prescriptive ways, such as the use Mapping the interventions described in the papers in- of media to raise awareness, health education workshops cluded in this review according to mode and foci of and continuing professional development that are largely Beattie’s model [31], (see Fig. 2) provides insight into ap- primary prevention strategies. proaches taken to address FGM in HIC. The majority of There are fewer interventions described in the the interventions (described in nine papers) occupy the reviewed papers that can be mapped to the negotiated top half of this framework and are authoritative in mode. lower half of the framework. Only one paper [39]de- In the top right quadrant, most focus on population scribes individual personal counselling activities also noted

Fig. 2 Mode and focus of the interventions evaluated in papers included in the review Njue et al. Reproductive Health (2019) 16:113 Page 16 of 20

previously as tertiary prevention directed at women who Multifaceted comprehensive health promotion for FGM have FGM. Three papers outline interventions that focus While legislative action and health persuasion are on collective community development activities that are important, the focus on these action paradigms do focused on primary prevention [35, 40, 41]. not appear to be justified by a strategic approach Several papers describe interventions with multiple that is informed by baseline research. A focus on modes and foci and are therefore represented in more these paradigms may result in limited change and an than one quadrant. Three documents in the review unnecessary focus on risk factors that do not ac- [34, 37, 48] identified activities that are authoritative knowledge the social determinants of health. Thomas in mode with activities that focus on individual or and Stewart [49] have argued that a focus on these groups and populations. Two documents [35, 41]de- top-down approaches may lead to “victim blaming” scribe authoritative, individually focused education and can work to disempower those most affected, in workshops, as well as collective community develop- this case migrant and refugee women and girls from ment strategies with affected communities involving countries where FGM is practiced. FGM is a com- community workers. McCracken et al. [39]includes plex issue that requires a multifaceted response that activities across all but one paradigm. Scott and Jerse encompasses socio-economic, physical and environ- [41] describe both individual and collective education mental factors, education and learning, services and interventions to address FGM in two quadrants while facilities, and community activities. Beattie’smodel McCracken et al., describe personal counselling, pro- supports this concept and illustrates that approaches fessional training and safeguarding protocols that oc- across all quadrants and axes are required for holis- cupy three quadrants. tic, well-rounded health promotion policy and practice. A health promotion approach is therefore required that considers prevention activities as part of a holistic Discussion program of action to prevent FGM but also engage com- This review sought to gain insights into the charac- munities in positive health enhancement. teristics of health interventions and associated outcomes. We examined programmatic approaches and Evidence to prevent FGM strategies, target audiences and evaluation findings of This review was not able to establish the effectiveness of interventions in HIC to improve the knowledge base one intervention over another, or the cumulative effects to inform the design and evaluation of FGM health of one or several interventions on the prevalence of interventions. The majority of the reports included in FGM. The evidence on the interventions outlined in the this review described primary prevention activities in reports included in this review is therefore limited. The the UK and across Europe that are largely prescriptive assessments are largely process evaluations that include or top-down forms of social intervention as compared measures of short-term outcomes or audits of practices. with participative or ‘bottom-up’ forms. Emphasis is Much of the available evidence has focused on measur- given to legislative action and strengthening the cap- ing immediate outputs such as pre and post intervention acity of health care professionals, education and changes in attitude, knowledge and confidence. It points awareness raising for community members. This para- to the possibility of these interventions being useful in digm suggests the predominance of reformist and helping migrant communities abandon this harmful conservative ideologies and prescriptive structures. practice. Reports examining FGM legislation are largely Beattie [31] depicts reformist legislative activities as descriptive overviews of the current legal and policy “deprivation models” where bureaucratic interventions situation in HIC that has recently been captured in the can address social injustice and work to protect those World Bank’s Compendium on international and na- at risk of FGM. On the other hand, activities that tional legal frameworks on FGM and in a recent text favour health persuasion are focused on a “deficit [50, 51]. These evaluations have been hampered by a model”, where selected individuals whose FGM know- lack of monitoring and reporting systems [33] and the ledge and practices are regarded as lacking, are cor- implementation of legislation, affected by a lack of clear rected. These approaches contrast with the few guidelines, legal ambiguity, and reluctance to report par- bottom-up and participative approaches identified in ents and community members. A review by Balfour and this review. Three papers [35, 40, 41] outline commu- others also shows that the evidence on educational/pro- nity development activities that support an “emanci- motional interventions is weak and mainly focuses on pation model” that mobilises community groups to surrogate markers of opinion change etc. [52]. This re- design and deliver their own health promotion. One view included only peer reviewed evidence and as such report identified tailored activities aimed at empower- included only two studies. This review has shown little ing individual women [39]. insight into the long-term impact of single or multiple Njue et al. Reproductive Health (2019) 16:113 Page 17 of 20

health prevention activities. Given the significant There are a number of documents to guideline multi- amount of effort and resources spent on programs spe- agency response in HIC. In the UK, the Government has cifically designed to promote the abandonment of FGM, produced Multi-agency Statutory Guidelines for front- there is need to strengthen research designs to include line professionals [56] working to safeguard children at more robust methodologies, community driven, cross- risk from FGM in England and Wales. In Spain, an Ac- disciplinary and international collaborative studies which tion protocol for the prevention of FGM [57] lays out take into consideration not just the immediate outcomes ways in which health care, education, social services, but the impact of the interventions. child care services and security professionals can collab- orate to identify and report children at risk in Catalunya. Health professional themselves have also produced Involving women and girls in the design and evaluation guidelines for inter-professional collaboration for safe- of health prevention guarding such as the Intercollegiate recommendations Our review located one report [39] that examined out- for identifying, recording and reporting in the UK [58]. comes of an initiative that involved the training of health In Australia, service coordination emphasises guidelines professionals to provide education and information dur- have been produced to facilitated collaborative partner- ing consultations with pregnant women who have expe- ships between services and organisations in the commu- rienced FGM. While this sheds some light on the nity [59]. importance of improving the skills of professionals to provide quality care as emphasised in WHO guidelines Best practice health prevention guidelines for FGM [1], evidence is needed concerning the experience of The interventions in this review were largely guided by women and girls and their values and preferences during the law as it relates to FGM and clinical practice guide- clinical consultations. A recent review has examined the lines. However, no mention is made of guidelines in this maternity care experiences and health needs of women area. In Australia, the National Education Toolkit for with FGM in HIC [53]. Another study on health infor- FGM/C Awareness (NETFA) Best Practice Guide pro- mation and education interventions for FGM included vides nationally accepted benchmarks for culturally ap- women’s perspectives [54]. While the papers included in propriate FGM prevention programs for community these reviews do not investigate the outcomes of specific organisations [60]. These ten standards include the need interventions, rather current care, they do indicate that for resources to be inclusive and interactive, relevant, ac- there is much to be done to better meet women’s needs curate, respectful of human rights and cultural dignity for health promotion. Both reviews highlight poor pro- and empowering. The European commission through vider communication, negative attitudes and a lack of the REPLACE Approach provides a toolkit or ‘how to’ knowledge about FGM. If women centred, culturally ap- guide for community members affected by FGM, and propriate health promotion including prevention is to be community leaders and organisations working with them delivered during consultations that empowers women to to bring about an end to FGM in the EU. [18]. The RE- take control over their own health, then women’s needs PLACE approach has three pillars that emphasise behav- must be considered in such interactions. Women should ioural change that recognises the socio-cultural context be involved in the design and evaluation of education and social norm transformation, the importance of en- and information resources [55]. gaging and working with communities and the need for evaluation to inform all stages of programming. Multi-agency response to FGM The majority of the interventions in our review involve a Limitations wide range of professionals from multiple agencies, in- One of the limitations of our study is paucity of peer cluding health professionals, police, social workers and reviewed evidence for the research topic. The majority school teachers across the public and non-state sector. of the evidence retrieved for this study is therefore from This cross-sector approach to FGM prevention was grey literature, specifically from programmatic evalua- highlighted in the evaluations of safeguarding practices tions undertaken by consultants. As such, quality assess- from the UK where collaboration was fostered through ment may be variable, affecting the analysis. However, networking, linking national child protection policy with two authors appraised the studies independently to en- organization policy, and training initiatives. However, sure the quality of reporting, methodological, rigour and central to many of these efforts were activities to foster conceptual depth and breadth of all included studies. engagement with the local community through outreach Secondly, given the heterogeneous nature of the re- and the involvement of community champions and ad- trieved evidence (methods, purposes, between programs, vocates to raise awareness of safeguarding laws and target audiences, duration and content), it was difficult reporting processes. to make firm conclusions, particularly as many of the Njue et al. Reproductive Health (2019) 16:113 Page 18 of 20

outcomes and measures for determining effectiveness Acknowledgements varied widely. However, the inclusion of individual case Not applicable studies of programs, provides rich, descriptive evidence Authors’ contributions of interventions, a useful contribution to address the AD conceptualised the study. JK, CN and TE contributed to the screening, questions on how governments, public health entities data extraction and analysis, AD and NV counterchecked the studies. CN, AD and providers have attempted to address the FGM in and JK drafted the paper. All authors commented on and approved the final manuscript. HIC.

Funding Conclusion The authors report no special funding. Studies show that current evaluations conducted in HIC Availability of data and materials are mainly of primary preventions and top-down ap- Data generated and analysed during the study are included in this proaches that seek to employ the authority of public manuscript and its supplementary information files. health expertise to re-direct the behaviour of community members and professionals. Few interventions focused Ethics approval and consent to participate Ethical approval or informed consent is not applicable, as this is a systematic on collective activities within communities or were review. aimed at empowering individual women. To streamline all the efforts in practice, there is a clear need for an in- Consent for publication tegrated health promotion approach to best organise the Not applicable multifaceted, multilayered and often overlapping public Competing interests health interventions to address the medical, social and The authors declare that they have no competing interests. cultural issues involved in curtailing FGM. Moreover, evidence of the effectiveness of interventions on redu- Author details 1The Australian Centre for Public and Population Health Research, Faculty of cing the prevalence of FGM is lacking highlighting the Public Health, University of Technology Sydney, PO Box 123, Broadway, need for investment in impact evaluation and rigorous Sydney, NSW 2007, Australia. 2Ministry of Health, PO Box 30016-00100, study designs. Nairobi, Kenya. 3Community and Public Health, Technical University of Kenya, ’ PO Box 52428-00202, Nairobi, Kenya. 4Sydney Medical School, The University Beattie s framework may provide a useful way of guid- of Sydney, 135 Macquarie St, Sydney, NSW 2000, Australia. ing and articulating negotiated and authoritative health promotion actions required to address FGM at national Received: 27 February 2019 Accepted: 9 July 2019 and local levels. Such a framework would promote partnerships, synergies and communication between all References stakeholders including education, health, police, social 1. WHO. Guidelines on the management of health complications from female care agencies and the community to improve awareness genital mutilation. Geneva: World Health Organization; 2016. http://apps. who.int/iris/bitstream/handle/10665/206437/9789241549646_eng.pdf; and support for women and girls. 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