Global Public Health An International Journal for Research, Policy and Practice ISSN: 1744-1692 (Print) 1744-1706 (Online) Journal homepage: https://www.tandfonline.com/loi/rgph20 The practice of female genital mutilation across the world: Data availability and approaches to measurement Claudia Cappa, Luk Van Baelen & Els Leye To cite this article: Claudia Cappa, Luk Van Baelen & Els Leye (2019): The practice of female genital mutilation across the world: Data availability and approaches to measurement, Global Public Health, DOI: 10.1080/17441692.2019.1571091 To link to this article: https://doi.org/10.1080/17441692.2019.1571091 Published online: 06 Feb 2019. Submit your article to this journal Article views: 3 View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=rgph20 GLOBAL PUBLIC HEALTH https://doi.org/10.1080/17441692.2019.1571091 The practice of female genital mutilation across the world: Data availability and approaches to measurement Claudia Cappaa, Luk Van Baelenb and Els Leyeb aData and Analytics Section, Division of Data, Research and Policy (DRP), UNICEF, New York, NY, USA; bInternational Centre for Reproductive Health, Ghent University, Gent, Belgium ABSTRACT ARTICLE HISTORY While Female Genital Mutilation (FGM) has been in existence for centuries, Received 17 July 2018 the rigorous and systematic documentation of the extent of the practice is Accepted 14 December 2018 a recent undertaking. This paper discusses data availability related to the KEYWORDS practice of FGM and reviews the methods used to generate prevalence Female genital mutilation; estimates. The aim is to illustrate strengths and limitations of the data; estimates; Africa; available data. The review is organised around two main categories of prevalence countries: FGM countries of origin, where representative prevalence data exist, and countries of migration for women and girls who have undergone FGM, for which representative prevalence data are lacking. This second category also includes countries across the world where FGM is only found among small autochthonous populations. Introduction Female Genital Mutilation (FGM) is defined as ‘all procedures involving partial or total removal of the female external genitalia or other injury to the female genital organs for non-medical reasons’ (World Health Organization, 2008). The origins of this practice have been linked to ancient empires such as the Nubia, Kush and Meroe in the territory of modern-day Sudan and Egypt, and as well in the Mande Empire in West Africa (Mackie, 2000). Both historically, and currently, this practice has been used as a means to control women’s sexuality and as part of cultural and religious initiation rites. While FGM has been in existence for centuries, the rigorous and systematic documentation of the extent of the practice is a recent undertaking. The earliest attempt at quantifying the number of women who have undergone FGM dates back to the publication of the The Hosken Report: Genital and Sexual Mutilation of Females in the late 1970s (Hosken, 1979). The author reported the existence of FGM in 26 countries and estimated the total number of girls and women subjected to the practice to be around 80 million. While this report acknowledged the presence of the practice in a few more African countries, it also suggested that only a small proportion of the female population in these countries had undergone FGM. The Hosken Report brought the problem of FGM to the world’s attention; however, the estimates it contained were based on questionable methods and sources. National figures erred with regard to prevalence levels when compared to subsequent, and more rigorous, data collection efforts (United Nations Children’s Fund, 2013). Starting from the late 1980s, data on the practice of FGM have been collected at regular intervals through nationally representative population-based surveys in countries in Africa. In more recent years, the systematic collection of survey data has expanded beyond Africa, CONTACT Claudia Cappa [email protected] Data and Analytics Section, Division of Data, Research and Policy (DRP), UNICEF, 3 UN Plaza, New York, NY 10017, USA © 2019 Informa UK Limited, trading as Taylor & Francis Group 2 C. CAPPA ET AL. and generated estimates of the extent of the practice in countries such as Iraq and Indonesia. These data collection efforts have helped draw a more comprehensive picture of the practice, and the total number of women and girls living today who have undergone FGM is estimated at more than 200 million (UNICEF, 2016). These estimates, however, only provide an account of the practice in the 30 countries for which nationally representative survey data are currently available. The collection of data in countries where FGM is believed to have originated has gone hand in hand with the realisation that FGM can be found among small autochthonous groups, as well as among migrants from countries where FGM is widely pratised. In fact, FGM has become an issue of concern in much of Europe, as well as in North America, Australia, New Zealand and Japan, which have all been the destination of female migrant populations from countries where FGM is common. Data availability on the extent of the practice among autochthonous groups and migrant communities remains scarce, and thus a global estimate of the number of girls and women who have undergone FGM does not exist. Important work to close this data gap, however, has been undertaken in recent years (EIGE, 2013, 2015, 2018; Van Baelen, Ortensi, & Leye, 2016). This paper discusses data availability related to the practice of FGM and reviews the methods used to generate prevalence estimates. The aim is to illustrate strengths and limitations of the available data. The review is organised around two main categories of countries: countries where representative prevalence data exist, and countries for which representative prevalence data are lacking. This second category includes countries across the world where FGM is found among small autochthonous popu- lations, as well as countries of migration for girls and women from countries where FGM is common. Materials and methods The data sources included in the article were identified using different search criteria. Representative household surveys were found through an electronic search conducted on the websites of the Demo- graphic and Health Surveys (DHS, dhsprogram.com), the Multiple Indicator Cluster Surveys (MICS, mics.unicef.org), and the catalogue of the International Household Survey Network (IHSN, http:// www.ihsn.org/survey-catalogs), using search terms which combined variations of ‘FGM’ (e.g. ‘female genital mutilation’, ‘female circumcision’ or ‘FGC’). The definition of FGM followed in the paper encompasses all the four types included in WHO classification (WHO, 2008). For countries lacking representative survey data, local reports and small-scale studies provide an indication of the existence of the practice. Most of these reports and studies have not been published in international peer-reviewed journals, and thus belong to what is called ‘grey literature’. In order to include all available documented evidence and reduce susceptibility to bias, the data from these countries were collected through a combination of three sources. First, the authors reviewed scien- tific online citation databases such as Thomson Reuters’ Web of Science Core Collections citation database (https://webofknowledge.com/) and search engines such as Google Scholar (https:// scholar.google.com) using search terms that combined variations of ‘FGM’ (e.g. ‘female genital muti- lation’, ‘female circumcision’ or ‘FGC’) and potential countries. Second, based on the same search terms, further information was sought through general non-academic search engines such as Google (www.google.com). Third, existing FGM-specific databases and online reports were explored, such as Stop FGM Middle East (http://www.stopfgmmideast.org/) and the Orchid Project (https:// orchidproject.org). For most studies a quality assessment was impossible because of lack of detailed information on methods and materials. The sources rather mention the existence of the practice in the country and in some cases give an indication of the size of the affected population, often based on non-representative one-off surveys. For countries of migration, inclusion criteria were any peer-reviewed articles on prevalence of FGM in countries of migration published between 2000 and 2018. A country of migration is defined here as the country of destination for females who have migrated from a country where FGM is common, e.g. any European country, USA, Canada, Australia, Japan and New Zealand. Only national estimates were taken into consideration. Exclusion criteria were: articles published GLOBAL PUBLIC HEALTH 3 in popular media such as newspapers or magazines, articles that could not be accessed, regional studies and documents that were published before 2000 or did not concern countries of migration. Sources were identified through a systematic web-based search, in Google Scholar, Web of Science and PubMed. Results Available data on FGM from representative surveys FGM has been historically practised by populations living in countries located in sub-Saharan Africa, between the Sahel region, the Atlantic coast and the Horn of Africa extending into Yemen. USAID- sponsored Demographic and Health Surveys (DHS) and the UNICEF-supported Multiple Indicator Cluster Surveys