The Practice of Female Genital Mutilation Across the World: Data Availability and Approaches to Measurement

Global Public Health An International Journal for Research, Policy and Practice

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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.

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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 populations, 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 mutilation’, ‘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 (MICS) have collected data on the prevalence and circumstances surrounding FGM in these countries over the last three decades. DHS and MICS are large-scale population-based surveys that produce statistically sound, internationally comparable estimates of socioeconomic and health indicators. Since their inception in 1984 (DHS) and 1995 (MICS), these two household survey programs have enabled approximately 150 low- and middle-income countries to collect nationally representative data on more than 100 key indicators in areas such as child and maternal health, nutrition, education, access to water and sanitation and HIV/AIDS. While data on FGM collected through such surveys may be subject to possible misreporting due to recall and desirability bias (Elmusharaf, Elhadi, & Almroth, 2006; Morison et al., 2001), these data sources have generated largely reliable and comparable estimates over time, thus allowing for monitoring efforts aimed at pro- moting the abandonment of FGM (UNICEF, 2013). The first DHS survey to include questions on FGM was conducted in 1989–90 in what is today known as Sudan, and the questions were addressed to girls and women of reproductive age (15–49). The questionnaire focused on the existence of FGM, the type of FGM undergone by the respondents and who performed it. Girls and women were also asked for their opinion about the practice. This pattern of questioning has been largely replicated in subsequent surveys conducted in Sudan, as well as in other countries that have implemented a DHS. Since 1989–90, questions on FGM have been used in 25 countries (Table 1). The first MICS surveys that collected data on FGM were conducted in 2000 in the Central African Republic, Chad and Sudan. These surveys used a basic questionnaire that focused on the respondents’ experiences as they relate to FGM. In subsequent surveys, MICS has generated updated data on FGM from 19 countries (Table 1) using an extended questionnaire. The standard DHS and MICS modules on FGM collect information that facilitates the calculation of two types of prevalence indicators. A first set of questions enquires about the experience of FGM among female respondents. These data are then used to estimate the proportion of girls and women who have undergone FGM. Nearly all the surveys also ask respondents at what age they underwent FGM, by whom, and what specifically was done to them. The respondents are all girls and women aged 15–49, except in Egypt (1995, 2000, 2003, 2005), Sudan (1989–90, 2000) and Yemen (1997), where the sample of respondents includes only girls and women aged 15–49 who are, or had been, married. In the case of Sierra Leone (MICS 2005) and Liberia (DHS 2007), survey questions were adjusted to eliminate direct reference to FGM, as they were deemed to be too sensitive. Ques- tions were rewritten to ask specifically if the respondent had been initiated to the Bondo society in Sierra Leone or the Sande society in Liberia, and who initiated her. Girls undergo FGM when they are initiated into these societies, mostly in their puberty; thus, these questions are used as proxies to cal- culate the prevalence of FGM. A second set of standard questions relates to the FGM status of the respondents’ daughters. These questions are used to measure the proportion of girls aged 0–14 who have undergone FGM. Nearly all the surveys also collect information on the age at which the daughter(s) underwent the practice, by whom it was performed, and what specifically was done. 4 C. CAPPA ET AL.

Table 1. Sources and estimates on FGM in countries with data from representative surveys. Prevalence among girls and women aged 15–49 Country Source (according to the most recent survey) Benin DHS 2001, DHS 2006, DHS 2011-12, MICS 2014 9.2 Burkina Faso DHS 1998–99, DHS 2003, MICS 2006, DHS/MICS 75.8 2010 Cameroon DHS 2004 1.4 Central African DHS 1994–95, MICS 2000, MICS 2006, MICS 2010 24.2 Republic Chad MICS 2000, DHS 2004, MICS 2010, DHS 2014–15 38.4 Cote d’Ivoire DHS 1994, DHS 1998–99, AIS 2005, MICS 2006, DHS 36.7 2011–2012, MICS 2016 Djibouti* FHS 2002, MICS 2006, FHS 2012 93.1 Egypt DHS 1995, DHS 2000, DHS 2003, DHS 2005, DHS 87.2 2008, DHS 2014, DHS 2015 Eritrea DHS 1995, DHS 2002, EPHS 2010 83 Ethiopia DHS 2000, DHS 2005, WMS 2011, DHS 2016 65.2 Gambia MICS 2005–06, MICS 2010, DHS 2013 74.9 Ghana DHS 2003, MICS 2006, MICS 2011 3.8 Guinea DHS 1999, DHS 2005, DHS/MICS 2012, MICS 2016 96.8 Guinea-Bissau MICS 2006, MICS/RHS 2010, MICS 2014 44.9 Indonesia** RISKESDAS 2013 NA Iraq*** MICS 2011 8.1 Kenya DHS 1998, DHS 2003, DHS 2008–09, DHS 2014 21 Liberia DHS 2007, DHS 2013 44.4 Mali DHS 1995–96, DHS 2001, DHS 2006, MICS 2010, 82.7 MICS 2015 Mauritania DHS 2000–01, MICS 2007, MICS 2011, MICS 2015 66.6 Niger DHS 1998, DHS/MICS 2006, DHS/MICS 2012 2.0 Nigeria DHS 1999, DHS 2003, MICS 2007, DHS 2008, MICS 18.4 2011, DHS 2013, MICS 2016–2017 Senegal DHS 2005, DHS/MICS 2010–11, DHS 2014, DHS 2015, 24 DHS 2016, DHS 2017 Sierra Leone MICS 2005, DHS 2008, MICS 2010, DHS 2013, MICS 86.1 2017 Somalia MICS 2006 97.9 Sudan DHS 1989–90, MICS 2000, SHHS 2006, SHHS 2010, 86.6 MICS 2014 Tanzania DHS 1996, AIS 2003–04, DHS 2004-05, DHS 2010, 10.0 DHS 2015–16 Togo MICS 2006, MICS 2010, DHS 2013–14 4.7 Uganda DHS 2006, DHS 2011, DHS 2016 0.3 Yemen DHS 1997, FHS 2003, DHS 2013 18.5 Zambia ZSBS 1998, ZSBS 2000, ZSBS 2003, ZSBS 2005, ZSBS 0.7 2009 *The prevalence data for Djibouti presented in the table are from MICS 2006, and therefore do not come from the most recent data source. The 2012 FHS report only presents estimates for girls and women of all ages (and not for girls and women aged 15–49). **In the case of Indonesia, estimates are not presented in this table, since the RISKEDAS 2013 survey only enquired about the FGM status of girls aged 0–11, thus producing prevalence data only for this age cohort. FGM has been reported in Indonesia over decades (Feillard & Marcoes, 1998) but reliable prevalence estimates are only available since the 2013 survey. ***Earlier small-scale surveys documented the existence of the practice in the Kurdish provinces of Iraq and reported in 2007–2009 FGM prevalence ﬁgures between 40%–70% (WADI, 2010; Yasin, Al-Tawil, Shabila, & Al-Hadithi, 2013).

Most surveys include additional questions related to the respondents’ attitudes surrounding FGM, including whether this practice should continue and why. Data on girls’ and women’s attitudes towards FGM have been collected in 29 countries, while the same information has been gathered from boys and men in 19 countries. In addition to collecting data on prevalence and attitudes, a few surveys included some ad-hoc questions. For instance, in Egypt, Eritrea and Sudan speciﬁc questions were added to assess the respondents’ knowledge of campaigns aimed at discouraging FGM, while in some DHS surveys conducted in Mali, Mauritania, Niger, Senegal and Nigeria questions were asked about the health com- plications resulting from FGM. GLOBAL PUBLIC HEALTH 5

In more recent years, other nationally representative household surveys outside of MICS and DHS have collected data on FGM, notably the AIDS Indicator Surveys (AIS) conducted in Cote d’Ivoire (2005) and Tanzania (2003–04), the Sudan Household Health Surveys (SHHS), the Family Health Surveys (FHS) conducted by the Pan Arab Project for Family Health (PAPFAM) in Djibouti (2002, 2012) and Yemen (2003), the Ethiopian Welfare Monitoring Survey (WMS) of 2011, the Population and Health Survey done in Eritrea in 2010 (EPHS), the Indonesia Basic Health Research (RISKESDAS) of 2013, and the Zambia Sexual Behaviors Surveys conducted in several years (ZSBS). Data from these surveys were collected using short questionnaires that diﬀered in most cases from the standard ones used in MICS and DHS, and were primarily intended to produce basic prevalence estimates of FGM in the respective countries. In the case of Ethiopia (2011 WMS) and Indonesia (2013 RISKESDAS), the surveys only enquired about the FGM status of girls aged 0–14 (Ethiopia) and girls aged 0–11 (Indonesia), thus producing prevalence data only for these age cohorts (Table 1).

What is known about the existence of the practice in countries lacking representative survey data The 2008 interagency statement on the elimination of FGM referred to the presence of FGM among certain ethnic groups in Central and South America, and in several other countries across the world (WHO, 2008). Prevalence data on FGM are not available for most of these countries, but anecdotal accounts and small-scale research studies provide an indication of the existence of the practice. A summary overview of this evidence is provided in Table 2.

South America In Colombia, a 2011 study (United Nations Population Fund, 2011) and media outlets such as The Guardian (Brodzinsky, 2015) and Reuters (Moloney, 2015) mention that the Emberá, Colombia’s second largest indigenous group (estimated at 50,000 people), practise FGM mainly through cutting of the prepuce. Among the Pano Indians in Peru, FGM was last reported in 2012 (Almaguer & Jones, 2012) and 2013 (Rushwan). Little supporting evidence, however, can be found. As reported by Rush- wan (2013), clitoridectomies were also documented in eastern Mexico and western Brazil until the late 70s; however, there are no recent data or anecdotal information to conﬁrm that FGM is still practised today.

Eastern Europe A qualitative study reported the existence of FGM in Dagestan (Russia) among the Avars (Antonova & Sirazhudinova, 2016). The data were obtained through interviews with Dagastani women who had undergone FGM, women who had consented to their daughters undergoing FGM, women who performed FGM, as well as through expert meetings with gynecologists and other medical specialists. In some districts such as Botlikhsky and Tsuntinsky, prevalence was estimated to be 100%. In others, like Tsumadinsky or Tlyaratinsky, prevalence was approximately 50%. Between 1970 and 1990 the practice was also performed in the Untsukulsky district. Regions in the south of Dagestan, such as Agulsky and Tabasaransky, were not included in the study. Most respondents and experts reported incision as the most widespread form of FGM, although among the Andis, living in the Botlikhsky district, the researchers reported excision. The practice has also been reported among the Avars living in Georgia (Antonova & Sirazhudinova, 2016; Mirmaksumova, 2016).

Middle East In Iran, Khadivzadeh and colleagues report in their research a 69.7% prevalence rate of FGM in Minab (Hormozgan Province) in 2002 (Khadivzadeh et al., 2009). These data were inferred from a survey of 400 girls and women of reproductive age. In the predominantly Kurdish city of Ravansar, in the western provinces of Iran, a study in 2011 found that among a random sample of 348 women surveyed at a health center, 55.7% had undergone FGM (Pashaei et al., 2012). The presence of FGM 6 C. CAPPA ET AL.

Table 2. Recently published sources and estimates of FGM in countries lacking representative survey data. Country Source Scale South-America Colombia UNFPA (2011), Brodzinsky (2015), Moloney Embera population (2015) Peru Almaguer and Jones (2012), Rushwan (2013) Pano population (anecdotal) Mexico Rushwan (2013) Easter regions (anecdotal) Brazil Rushwan (2013) Western regions (anecdotal)

Eastern Europe Georgia Antonova & Siradzhudinova (2016), Avar population, Eastern Georgia Mirmaksumova (2016) Russia Antonova and Sirazhudinova (2016) Dagastan; 50%–100% of the local population depending on the district Middle East Iran Khadivzadeh, Ahadi, and Seyedialavi (2009) Hormozgan Province; 69.7% of respondents Pashaei, Rahimi, Ardalan, Felah, and Majlessi city of Ravansar; 55.7% of respondents (2012) Ahmady (2015) West and South Iran; 16%–60% of respondents Oman Al Hinai (2014) city of Muscat; 78% of respondents Kuwait Chibber, El-Saleh, and El Harmi (2011) 38% of respondents United Arab Al Marzouqi (2011) 34% of respondents Emirates Jordan Sabbagh-Gargour (2003) city of Rahmah Israel WHO (2008) Bedouin population (anecdotal)

Southeast Asia Malaysia Isa, Shuib, and Othman (1999) Kelentan region Khan, Patil, and Valimalar (2009) Northern Malaysia Dahlui, Yut Lin, and Wan Yuen (2012) 93% of respondents Sta Maria (2012) Kelentan, Selangor, Kedah, Johor regions Ainslie (2015) Malay community Singapore Marranci (2015) Malay community Thailand Merli (2010) Malay community Philippines Calsalin (2008) region of Besilan India Anantnarayan, Diler, and Menon (2018) Bohra population; 98% of female respondents and 75% of daughters Pakistan IRIN (2011); Baweja (2017) 50%–80% of Bohras Sri Lanka Senanayake (1996); UN ESCAP (2012) Bohra population Bangladesh UN ESCAP (2012) Unspeciﬁed

Africa Malawi United States Department of State (2017) Unspecified Congo DRC WHO (2008) Unspecified Note for “anecdotal”: FGM has been reported as occurring in the past but there is no evidence of the presence of the practice in recent years. Note for “unspecified”: the available sources do not provide any information on where the practice can be found nor any estimate of the size of the affected population. in Iran has also been confirmed by a 2014 study, based on a convenience sample of 3000 women and 1000 men, which showed that FGM is prevalent in the rural areas of western and southern provinces of Iran: West-Azerbaijan (21% of population affected), Kurdistan (16%), Kermanshah (18%) and Hormozgan (60%) (Ahmady, 2015). In Muscat, the capital of Oman, Al Hinai conducted a 2014 non-probability study on FGM (2014). One hundred women, 16 years or older, were interviewed in a shopping mall, hypermarket, university and hospital, of which 78% reported to have undergone FGM. In Kuwait, Chibber et al. (2011), using a non-probability sample of clinical examinations of 4800 pregnant women from 2001 to 2004, estimated the prevalence of FGM to be 38%. FGM has also been reported amongst the Bed- ouin population in Israel (WHO, 2008); however, recent studies show that the practice has disap- peared over the last decade (Halila, Belmaker, Rabia, Froimovici, & Applebaum, 2009; Belmaker, 2012). The presence of FGM has been reported in the United Arab Emirates (Kvello & Sayed, GLOBAL PUBLIC HEALTH 7

2002 as cited in WHO, 2008; Al Marzouqi, 2011). In particular, Al Marzouqi (2011) quotes a Desert Dawn survey of 200 Emiratis from both sexes on the subject of female circumcision, and mentions that 34% of female respondents were circumcised. FGM has been reported in a town of 500 inhabi- tants named Rahmah in Jordan (Sabbagh-Gargour, 2003), but prevalence ﬁgures are unavailable and no additional sources could be found.

Southeast Asia In Malaysia, several studies have documented the existence of FGM. Hosken’s research in 1979, and Dorkenoo’s 1994, as reported by Isa et al. (1999) first mentioned the presence of the practice among the Malays, which represent today around 50% of the total population of the country. In 2008–2009, a descriptive survey in five villages in northern Malaysia, comprising 597 women who had undergone FGM, reported that a majority of the respondents wanted the practice to continue (Khan et al., 2009). Dahlui et al. (2012) conducted a study among 1196 women at public health care centers, which revealed that 93% of the respondents had undergone FGM. The findings from this survey indicate that FGM was mainly performed on girls before their first birthday. The study further reported that the procedure involves the nipping of the skin on the clitoral hood or a needle prick of the clitoris. In Isa’s study from 1999 on the practice of FGM among Muslims in Kelantan, the authors describe the practice as nicking the prepuce with a sharp object (Isa et al., 1999). This has been confirmed by Ainslie (2015), who reported that the procedure involves nicking, cutting, pricking or braising the very tip of the skin covering the clitoris. The Malaysian provinces for which information is available are Kelantan (Isa et al., 1999; Sta Maria, 2012), Penang (Khan et al., 2009), Selangor (Sta Maria, 2012), Kedah (Sta Maria, 2012), and Johor (Sta Maria, 2012). FGM is also documented amongst the Malay community in Singapore, which comprises a population of approximately 270,000 women. A qualitative study referenced in Marranci (2015) and conducted in 2011 gathered data from 15 Malay women, 2 doctors who performed circumcisions, 10 Muslim men and 3 religious teachers. The interviewees described FGM as removing a small amount of skin from the clitoral hood; however, no prevalence estimate was provide. In a qualitative study in southern Thailand among Malay Muslims (estimated at 1.5 million), Merli (2010) observed that females undergo ‘(a) mild cutting or pricking of the clitoris’. While Merli observed only one case herself, anecdotal evidence suggests that the practice is generally pre- sent; however, no prevalence data was obtained. FGM has been reported among the Yakan in Besilan, a region in the Philippines neighbouring Indonesia, with descendants believed to be from eastern Indonesia. A qualitative study (Calsalin, 2008) reports that girls aged 5–8 had undergone FGM, a practice that was described as scraping the labia majora. No prevalence figures, however, are provided.

South Asia In India and Pakistan, the ethnic community of the Bohras, which has an estimated population of 500,000 women, is reported to practise FGM. This community is situated along the border between India and Pakistan. Figures for the Pakistani Bohras suggest that 50%–80% of girls undergo FGM, which usually involves cutting the clitoris between the age of 6 and 9 (Baweja, 2017; IRIN, 2011). In India, FGM has been reported as early as 1991 (Ghadially, 1991), and the practice is described as the removal of the tip of the clitoris. A more recent qualitative case study on the Bohras from India (Anantnarayan et al., 2018) includes responses from a purposive sample of 94 participants, of which 83 were women and 11 were men. Prevalence of FGM was estimated to be 98% of female respondents and 75% of respondents’ daughters (aged seven years and above). Sri Lanka’s Muslim community, whose population of women was approximately 1 million as of the 2012 census, is reported to practise FGM (Senanayake, 1996). A report published in 2012 used anecdotal evidence from a focus group discussion and key informants (UN ESCAP, 2012) to describe a tiny genital incision that is practised on infant girls 4–5 weeks after birth. Both studies (Senanayake, 8 C. CAPPA ET AL.

1996; UN ESCAP, 2012) refer to the above mentioned Bohras, who are a also minority in Sri Lanka. The UN ESCAP report (UN ESCAP, 2012) further mentions that some forms of FGM may be practised among some Muslim communities in Bangladesh as well.

Africa Information on the prevalence of FGM remains anecdotal in African countries other than those where the practice is believed to have originated. Reports mention FGM in, for example, the Democratic Republic of the Congo (WHO, 2008) and in Malawi (United States Department of State, 2017), but more specific information on prevalence and procedures is lacking. Moreover, given the nature and patterns of migration streams in Africa, it cannot be excluded that in other African countries, significant migrant communities exist with women and girls who have undergone FGM. Here as well, reliable figures are unavailable.

Available estimates on the prevalence of FGM in countries of migration Estimating of the number of girls and women who have undergone FGM in their country of migration is challenging. For countries in much of Europe (excluding Eastern Europe) and North America, as well as in Australia, New Zealand and Japan, surveys have not been consistently conducted in order to collect representative data on the prevalence of FGM. In recent years, however, considerable progress has been made in the development of indirect methodologies to estimate both the prevalence of FGM and the number of girls at risk of FGM. Since 2004, national estimates have been produced for a number of European countries. These data were derived using an extrapolation method to produce an indirect estimate of FGM prevalence. An overview of these studies is provided in Table 3. This method uses statistical data from various sources to identify female migrants from countries of origin with a high prevalence of FGM. The FGM prevalence rate in the countries of origin (as provided by DHS and MICS) is multiplied by the total number of girls and women in the country of destination who have migrated from an FGM country of origin, or were born to a mother who migrated from an FGM country of origin (EIGE, 2013). A variety of issues have been identified vis-a-vis some of these studies: lack of disaggregated data on the migrant population (e.g. sex, ethnic group) necessary to more accurately estimate the number of women affected by the practice in countries of migration; the non-inclusion of second-generation girls, asylum seekers, refugees and undocumented migrants; and the inconsistency of data collection. These limitations have resulted in the inability to assess changes over time in prevalence rates and to develop metrics that can estimate the influence of the country of migration on the prevalence of FGM among migrant women (EIGE, 2013; Leye, Mergaert, Arnaut, & Green, 2014; Yoder, Wang, & Johansen, 2013). Other scholars have argued that DHS and MICS prevalence data should be cor- rected when used for extrapolating the prevalence of FGM in countries of migration. These corrections should be based on migration characteristics such as age, wealth, education and level of urbanisation of the migrants in the countries of origin (Ortensi, Farina, & Menonna, 2015), and should take into account that the risk of being cut is influenced by migration. Furthermore, the extrapolation should consider the fact that migration is effectively a selective process, as it is the younger, wealthier, more educated and urbanised subsection of the population that is generally able to migrate. Some of the studies in Table 3 have applied corrections to the results of the indirect estimates. These corrections are based on age categories (Dubourg & Richard, 2014; Exterkate, 2013; Köszeghy, 2012), and are further refined by using the median age for undergoing FGM in the countries of origin (Dubourg & Richard, 2014). Two other categories that are used to apply corrections to the data are religion (Köszeghy, 2012) and regional differences regarding FGM in countries of origin (Exterkate, 2013). GLOBAL PUBLIC HEALTH 9

Table 3. Recently published sources, methods and national estimates of FGM in countries of migration. Country Source Methods Sample Findings Australia Williams, Gbla, and Indirect estimation: Women and girls born in 13,138 below 15 Ferrari (2018) extrapolation method FGM countries and years at high risk; Data sources: migration residents in Australia, 126,371 15–49 and birth data of 2016 2016 years; and 69,590 Australian Bureau of above 50 years girls Statistics; prevalence data and women with as reported by UNICEF FGM 2016 Belgium Dubourg and Indirect estimation: Women from FGM 17,273 with FGM and Richard (2018) extrapolation method countries living in 8,644 at risk Data sources: Most recent Belgium in 2016, DHS and MICS; for female asylum seekers Belgium: Statistical Office in 2016, Statbel, Federal Agency undocumented Reception Asylum women received by Seekers, Doctors of the Doctors of World in World (undocumented 2016, births related to women), birth mothers from FGM registration data (K&G/ countries from 1998 to ONE), data from Office of 2016, girls 0–19 years the Commissioner granted refugee status General for Refugees and and subsidiary Stateless Persons protection (2017) France Andro, Lesclingand, Quantitative and Cambois, and qualitative data collection Cirbeau (2009) in multiple hospitals Indirect estimation: extrapolation method Direct estimation: Women older than 53,000 adult women with interviews on FGM 18 born in an FGM FGM status with women at country, or gynecological daughters of consultations parents born in Data sources: Etude FGM countries, de l’Histoire Familiale 2004 1999, DHS Germany TERRE DES FEMMES Indirect estimation: Girls and women living in 13,320 girls at risk of (2017) extrapolation method Germany from FGM FGM, Data sources: prevalence countries, 2016 58,093 women data as reported by with FGM UNICEF 2016, Federal Statistical Office, Stop FGM Middle East, TERRE DES FEMMES Hungary Köszeghy (2012) Indirect estimation: Women from FGM 170–350 women extrapolation method countries with a with FGM Data sources: Office of residence permit, with Immigration and refugee status in the Nationality 2011, FGM past 10 years, with prevalence data as temporary protection reported by WHO, or currently residing in prevalence data for Iraq one of the reception as reported by WADI centers, 2011 Italy Ortensi, Farina, and Direct estimation using Leye (2018) respondent-driven sampling combined with time-location sampling Indirect estimation: extrapolation method Data sources: Eurostat Women born in 60,000–80,000 foreign- 2016, DHS and MICS, FGM countries, born women with FGM Population and 2016, foreign- 15 years or older and Health Surveys, born women with 11,000–13,000 female

(Continued) 10 C. CAPPA ET AL.

Table 3. Continued. Country Source Methods Sample Findings Household and FGM and asylum asylum seekers with FGM Health Surveys, seekers 2014– 15 years or older Southern Sudan 2016 Household Survey, UNICEF (for Indonesia) Norway Ziyada, Norberg- Indirect estimation: First-generation women 3,000–7,900 at risk; Schulz, and extrapolation method who underwent FGM 15,500 potentially Johansen (2016) Data sources: Register prior to arrival and at risk; Data from Statistics those who underwent 17,300 girls and Norway, DHS and MICS FGM after arrival in women with FGM Norway and second- generation women who underwent FGM, 2013 Portugal Teixeira and Lisboa Indirect estimation: Women and girls living in 6,576 girls and (2016) extrapolation method Portugal born in FGM women with FGM; Data sources: DHS and countries, or born to 1,830 girls at risk MICS, Sudan Household mothers born in these Health Survey, 2011 countries, 2011 Census The Netherlands Exterkate (2013) Indirect estimation: Women living in the 29,120 girls and extrapolation method Netherlands women with FGM and qualitative originating from FGM information added countries, 2013 through focus group discussions Data sources used: DHS and MICS, Dutch Central Statistical Oﬃce, Central Agency for the Reception of Asylum Seekers, Youth Health Care and Reporting Centers of Child Abuse and Neglect United Kingdom: Macfarlane and Indirect estimation: Women born in FGM 1,37,000 girls and England and Wales Dorkenoo (2014) Extrapolation method countries, 2011 women with FGM; Data sources: DHS and nearly 10,000 girls MICS, Census 2011 aged 0–14 at risk USA Goldberg et al. Indirect estimation: Women born in FGM 5,13,000 women with (2016) extrapolation method countries, 2012 FGM and girls at Data sources: 2012 risk American Community Survey (ACS-2012), 1% sample of households in US, DHS and MICS

The extrapolation method is the most systematic, simplistic and cost-effective way to estimate the prevalence of FGM amongst immigrant populations in Europe (EIGE, 2015). In order, however, to have comparable data using the extrapolation method, and to produce an estimate of the total number of girls and women in countries of migration who have undergone FGM, one must have population data based on harmonised statistical classifications and definitions. For Europe, such data are provided by the 2011 European census. This census provides open access and complete and comparable statistics. Moreover, the census includes variables that are of interest when estimating the prevalence of FGM in countries of migration, such as sex, age, place of birth and residence. The application of the extrapolation method has been tested using the 2011 European census for the 28 European Union countries and Norway and Switzerland, and the results produced estimates for first-generation girls and women who have undergone FGM (Van Baelen et al., 2016). The extrapolated data suggest that in 2011, over 500,000 first-generation girls and women in the EU, Norway and GLOBAL PUBLIC HEALTH 11

Switzerland had undergone FGM before migrating. The estimates were based on foreign-born girls and women because they represent a more homogenous group. Furthermore, these estimates used the number of first-generation migrant girls and women irrespective of possible naturalisation pro- cesses that could bias the comparability of figures between countries. Including second-generation girls and women in the dataset would have introduced an additional bias, as their risk of undergoing FGM is lower as compared to first-generation girls and women (Van Baelen et al., 2016). No harmonised data, such as the 2011 European census data, are available for other countries (USA, Canada, Australia, New Zealand or Japan). For this reason, fully comparable estimates cannot be generated across various countries of migration, which undermines the possibility of generating a global estimate of the first-generation of girls and women affected by FGM in countries of migration. Many of the limitations of indirect estimates can be addressed when using direct methods (such as interviews) to estimate prevalence. Direct estimates, however, face a number of challenges, such as capturing a representative sample of the female population with FGM, or those who are at risk of FGM. Additional challenges include the fact that in many countries FGM is illegal which can result in underreporting, and the significant time and cost to conduct a survey under these circumstances. Only two European countries, France and Italy, have attempted to generate data using a direct method. For instance, the FGM-PREV-survey (Leye et al., 2017) used a combination of respondent-driven and time-location sampling in 9 communities in Italy (Ortensi et al., 2018). Ultimately, the choice to opt for an indirect or direct estimation should depend on resources as well as the expected FGM prevalence in the country of migration (De Schrijver, Van Baelen, & Leye, 2018).

Discussion

The last three decades have witnessed a proliferation of measurement activities aimed at shedding light on the magnitude of FGM. This increase in data availability has gone hand in hand with the recog- nition of the practice’s existence outside of the African continent and its global relevance due to migration. The availability of nationally representative data has significantly increased in recent years through the inclusion of FGM questions in international survey programs such as DHS and MICS, as well as in other national surveys. As a result of these data collection efforts, statistics on the prevalence of FGM among girls and women, the reasons behind its persistence and the circumstances surrounding its occurrence are now available from over 100 surveys. These surveys, however, have been implemented in countries where the practice is believed to have originated and persists. While there is evidence that FGM is practised among certain communities across the world, robust data for many of these contexts remain scarce. Anecdotal evidence in many countries suggests that the practice is too localised to justify the inclusion of FGM-related questions in a national survey. Notable exceptions are Iran and Malaysia, where the figures obtained through local studies suggest a widespread existence of the practice and point to the need for conducting nationwide prevalence surveys to obtain a better understand of the proportion of girls and women affected. In Europe, the USA and Australia most estimations are based on the indirect extrapolation method. Recently, considerable progress has been made in developing more accurate methods for estimating FGM prevalence in countries of migration. Producing a total number of girls and women affected by the practice for countries of migration, and making cross-country comparisons remains challenging, due to the incomparability of the available data. The international community recently adopted a new set of goals and targets – the Sustainable Development Goals (SDGs). The SDGs build on international commitments, obligations under international law, and the progress of the Millennium Development Goals (MDGs) in order to, in part, address gaps in the current monitoring landscape. SDG target 5.3.2 calls for the elimination of all harmful traditional practices, thus placing FGM at the core of the global agenda. Reliable data are needed for all contexts where the practice continues to exist, as the absence of accurate statistics undermines efforts to promote the eradication of FGM and provide care and services to all women and girls who have undergone the practice worldwide. 12 C. CAPPA ET AL.

Disclosure statement

No potential conﬂict of interest was reported by the authors.

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