Female genital mutilation: Reflections from field experience for intercultural health training

2. Alternative rite of passage: A new way to end FGM

Roughly 100 000 immigrants in the Nordic countries originate from areas in Africa where the tradition of FGC is still well known. A majority of this immigrant group consists of Somali women and men (approximately 25 000 in Sweden 16 000 in Denmark 8000 in Norway and 7000 in Finland less than 10 in Iceland; national statistics figures). FGC in the Nordic countries became an issue in the 1980s. The civil war in Somalia caused many Somalis to leave their country in the early 1990s. The arrival of large groups of Somali families forced the Nordic societies to take a stand on the health issue of FGC. Traditionally Somali girls are infibulated which involves excision of the clitoris labia minora and stitching of the vaginal opening. Health providers and social professionals in the Nordic countries are therefore obliged to know how to handle this issue. The primary motives for FGC in Somalia are that the practice is experienced as a religious duty and a prerequisite of marriage. Based on clinical experience the most common reaction to FGC in a Western country is one of disgust and rejection. However in countries where FGC is practiced it is looked upon as the "normal" state sometimes expressed in line with the following citations: "being smooth in the genital area without flaps is a beauty ideal" "if the labia minora are not cut they will continue to grow" "the clitoris and the labia minora have to be concealed in order to reduce sexual desire to reduce the risk of promiscuity promote fertility and make childbirth easier or the girl will not become a woman" "circumcision will ensure that the woman is a virgin as she gets married." These examples of motives do not necessarily coexist in the same ethnic groups. Thus FGC has deep and complex social and cultural roots that we cannot ignore when discussing how to best deal with FGC as a health issue in the Nordic countries. (excerpt)

Female genital mutilation is a human rights issue of concern to all women and men.

BackgroundWomen, who have been subjected to female genital mutilation (FGM), can suffer serious and irreversible physical, psychological and psychosexual complications. They have more adverse obstetric outcomes as compared to women without FGM. Exploratory studies suggest radical change to abandonment of FGM by communities after migration to countries where FGM is not prevalent. Women who had been subjected to FGM as a child in their countries of origin, require specialised healthcare to reduce complications and further suffering. Our study compared obstetric outcomes in women with FGM to women without FGM who gave birth in a metropolitan Australian hospital with expertise in holistic FGM management.MethodsThe obstetric outcomes of one hundred and ninety-six women with FGM who gave birth between 2006 and 2012 at a metropolitan Australian hospital were analysed. Comparison was made with 8852 women without FGM who gave birth during the same time period. Data were extracted from a database specifically designed for women with FGM and managed by midwives specialised in care of these women, and a routine obstetric database, ObstetriX. The accuracy of data collection on FGM was determined by comparing these two databases. All women with FGM type 3 were deinfibulated antenatally or during labour. The outcome measures were (1) maternal: accuracy and grade of FGM classification, caesarean section, instrumental birth, episiotomy, genital tract trauma, postpartum blood loss of more than 500 ml; and (2) neonatal: low birth weight, admission to a special care nursery, stillbirth.ResultsThe prevalence of FGM in women who gave birth at the metropolitan hospital was 2 to 3 %. Women with FGM had similar obstetric outcomes to women without FGM, except for statistically significant higher risk of first and second degree perineal tears, and caesarean section. However, none of the caesarean sections were performed for FGM indications. The ObstetriX database was only 35 % accurate in recording the correct FGM type.ConclusionWomen with FGM had similar obstetric outcomes to women without FGM in an Australian metropolitan hospital with expertise in FGM management. Specialised FGM services with clinical practice guideline and education of healthcare professionals may increase the detection rate of FGM and improve obstetric management of women with FGM.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-016-1123-5) contains supplementary material, which is available to authorized users.

Female genital mutilation (FGM) is one of the important aspects of reproductive health. The economic, social and health consequences of FGM threaten the achievement of sustainable development goals. The purpose of this study was to assess the economic, social and reproductive health consequences of FGM from the perspective of individual, family, community and health system. In this study, we reviewed 1536 articles from 1979 to 2015. Fifty-one studies were directly related to our goal. Research papers, review articles, case studies and books on the research topic were used. The results of this review showed that most studies on FGM, have investigated health complications of FGM, and few studies have addressed its socioeconomic aspects. The complications from the FGM can impose a significant economic burden on individuals, society and health system. Social consequences of FGM are more irritating than health consequences, so to tackle this practice; its social aspects should be more emphasized. Significant short and long term consequences of FGM threaten women's reproductive health; Reproductive health is one of the essential prerequisites of sustainable development. Sustainable development will be achieved if women are healthy. This practice can threaten achieving sustainable development. In Iran, FGM is performed in some areas, but there are no official statistics about it and there has yet been no plan to deal with FGM. FGM is a form of social injustice which women suffer. Ending FGM requires a deep and long-term commitment. Knowing its consequences and its effects on individual, families, the health system and community will help supporters to continue fighting this practice. Any money spent on eliminating this harmful practice, compared with the costs of complications, would not be wasteful. It seems that further studies are needed to assess socioeconomic effects of FGM and the relationship between type of FGM and induced complications. Such studies will help policymakers to tackle this practice.

British Journal of Midwifery • June 2012 • Vol 20, No 6 In light of the recent press coverage on female genital mutilation (FGM) (Laville, 2012), earlier this month the Chief Medical Officer and the Director of Nursing asked all general practitioners, practice nurses, health visitors and school nurses to familiarise themselves with the actions they need to take where they have reason to believe that a girl has undergone, or is at risk of, FGM (Department of Health (DH), 2012). I wholeheartedly support this and am very passionate that FGM is eradicated. It is often looked on as a taboo subject as many health professionals do not want to interfere with what is seen as a cultural belief. It is not, it is child abuse. FGM is illegal in the UK. The law clearly states that it is an offence to excise, infibulate or mutilate the whole or any part of a girl or woman’s labia majora, minora or clitoris. It is also an offence to assist a girl to mutilate her own genitalia, and the UK FGM Act (2003) and the Scottish Act in 2005 also makes it illegal to remove a girl from the country to perform a mutilation. A person guilty of an offence under this Act is liable to a 14 year term. The prevalence of FGM in the UK has been notoriously difficult to calculate. FORWARD, the UK charity working to tackle FGM, estimated that 66 000 women with FGM are living in England and Wales (FORWARD, 2007) and that there are nearly 21 000 girls under the age of 15 at high risk of mutilation. However, this figure will only increase as the immigrant population in the UK from the western, eastern, and north-eastern regions of Africa, and from Asian and Middle Eastern countries increase. Therefore it is imperative that appropriate safeguarding is in place to stop this practice from going unnoticed. There are no health benefits to FGM. It can harm a woman both physically and psychologically. The immediate physical complications can include severe pain, shock, haemorrhage, tetanus or sepsis, urine retention, open sores in the genital region and injury to nearby genital tissue (WHO, 2012). However, the long-term psychological effects may scar a woman for life. FGM is performed sometime between infancy and the age of 15 and, as a result, may be the first memory the woman has. This memory may come back to haunt her when she is giving birth—having her legs held back may spark flash-backs of the procedure. It is important to be aware of this when delivering a baby from an FGM mother and to ensure that counselling is offered to the woman at booking. Midwives are often the first health professional to encounter women who have been subject to FGM, and are best placed to initiate safeguarding. In 2011, the DH issued multi-agency guidelines that advocated a multidisciplinary approach to safeguarding those at risk of FGM (DH, 2011). This aims to ensure that no women or child falls out of the system and appropriate actions can be taken. When a woman who has undergone FGM gives birth to a daughter, she should be provided with clear information that FGM is illegal in the UK and should not be performed on her daughter. This should be done in a sensitive manner as the woman may have been a victim of enforced FGM and may be distressed at the suggestion that she would do the same to her daughter (DH, 2011). It is upsetting that FGM still takes place but lets hope that by working together with general practitioners, practice nurses, health visitors and school nurses, we can put an end to this illegal practice. Please join us at our free study day in Belfast on Friday 12 October to find out more about FGM. BJM

As a result of the diaspora of communities that practise female genital mutilation, many more women are now living with genital mutilation in the United Kingdom, and many more girls are at risk. The campaign to end the practice in the UK has been spearheaded by committed and experienced activists (www. forwarduk.org.uk, www.equalitynow.org with wide institutional endorsement), as reflected in recent intercollegiate recommendations for dealing with the problem. The document results from collaboration between the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the Royal College of Nursing, Equality Now, and the Unite union. It merges key points from several existing guidelines into a single paper that reiterates the core message: female genital mutilation is a form of child abuse. It points to the importance of data collection and sharing between relevant agencies for effective action. It stipulates appropriate professional care for girls and young women affected by the practice. For the recommendations to be implemented (we hope urgently), a strategic implementation plan with a tight time frame is needed. Disappointingly, this gap remains unfilled. It has been suggested that female genital mutilation should be part of the mandatory training in child protection for NHS staff, implementation has been inconsistent. Being born into a community that practises genital mutilation is themost important risk factor for girls, so pregnancy presents an opportunity for prevention. However, this remains unexplored. Most pregnant women receive antenatal care in the UK, but maternity staff need knowledge and skills to identify genital mutilation. Thus far there has been little impetus for methodical research on attitudes, knowledge, skills, and confidence among maternity staff in relation to this practice. Even if there is a stronger drive to improve training, there is no evidence base on which effective training methods can be formulated. Currently, whether a pregnant woman is asked about genital mutilation—and what to do if it is identified—depend entirely on the awareness and confidence of the booking midwife. It is therefore not surprising that this practice is under-detected in pregnant women and that follow-up action is haphazard. This failure can be remedied by including routine questions about the practice in a minimum maternity dataset for every pregnant woman, regardless of ethnicity or country of origin. However, currently no designated codes, diagnostic or procedural, can record or identify female genital mutilation from NHS activity data. An international classification of diseases code for a history of female genital mutilation and an Office of Population Censuses and Surveys code for deinfibulation should be introduced without delay. Care providers need to know what to do when female genital mutilation is identified and the intercollegiate document is inconsistent with regard to this. It states that “all girls and women presenting with female genital mutilation within the NHS should be referred to the police and support services.” Yet it also recommends considering referral of pregnant women who have undergone the practice to the police “with the woman’s consent.” Individual practitioners continue to be responsible for deciding whether to refer, with no criteria to help them weigh up each situation. Half of women would have undergone genital mutilation under 5 years of age and might not remember the details. It is neither helpful nor fair to expect maternity staff to guess which families are likely to practise female genital mutilation. Routine referral of all identified women to designated social services personnel could provide an opportunity for preventive education. The service pathway should also include psychological care for women who report serious or enduring distress in relation to the practice. This would require investment. There is no guidance for the police and social services on follow-up action. For example, for how long should an unaffected girl who remains at risk be followed up, how often, and by whom?Or, if information is to be collected on all women with genital mutilation where no crime has been committed, who should have stewardship of the information? These major decisions should not be left to the discretion of individual practitioners or services. Criminal prosecution is considered central to prevention, and the UK has been compared unfavourably to France, where identification of female genital mutilation in children has resulted in more than 100 prosecutions since 1979. Without a single prosecution in the UK, the people who procure or perform female genital mutilation remain unpunished and girls remain

Female genital mutilation and obstetric outcomes: flawed systematic review and meta-analysis does not accurately reflect the available evidence.

<p dir="ltr">Background</p><p dir="ltr">Female Genital Mutilation (FGM) involves the partial or total removal of the external female genitalia for non-medical reasons and is associated with serious health risks. The growing number of women from countries where FGM is practiced presents new challenges for healthcare systems in receiving countries. To improve care and promote health equity, it is essential to increase understanding of both the obstetric complications associated with FGM and the healthcare experiences of affected women.</p><p dir="ltr">Aim<br><br>This thesis aimed to investigate how FGM affects obstetric outcomes with a particular focus on obstetric anal sphincter injury (OASI) and emergency cesarean section (CS), and to explore the lived experiences of women with FGM and their experience of healthcare encounters in Sweden.</p><p dir="ltr"><br>Material, methods and results<br><br></p><p dir="ltr">The first study was a nationwide cohort study including 187 738 primiparous women with singleton term vaginal births in Sweden (2014-2018). It showed that women with a registered FGM diagnosis (n=1 444) had a nearly threefold increased risk of OASI (OR 2.69, 95%CI: 2.14-3.37) compared to women without FGM diagnosis (n= 186 294). FGM was also associated with a higher rate of instrumental deliveries and episiotomy.</p><p dir="ltr">The second study was a qualitative interview study with eight women living in Sweden who had undergone FGM prior to migration. This study highlights the complexity of FGM, revealing a wide range of experiences and perceived health consequences among women affected. Additionally, women reported inadequate knowledge about FGM, disrespectful attitudes, and insensitive care when seeking healthcare, though some also reported positive encounters.</p><p dir="ltr">The third study was a nationwide cohort study (2014-2020) that included 229 026 births and examined the risk of emergency CS for women born in FGM- practicing countries (n= 14 602) compared to women born in Sweden (n= 214 424). Women from FGM-practicing countries had a higher risk of emergency CS (aOR 1.23, 95% CI: 1.17-1.30) compared to Swedish-born women. However, when adding FGM diagnosis as a covariate in the regression model, FGM diagnosis did not change the risk.</p><p dir="ltr">Conclusions</p><p dir="ltr">In our study, women with FGM had an increased risk of OASI when having a vaginal delivery in Sweden. The increased risk of emergency CS among women from FGM- practicing countries appears to be attributed to factors other than the FGM diagnosis itself. Increasing healthcare providers' knowledge about obstetric complications associated with FGM is essential to ensure optimal care and prevent adverse obstetric outcomes. Since women affected by FGM perceive their health consequences in various ways, it is further important for healthcare professionals to acknowledge the diversity within this group. Adopting a sensitive, individualized approach and improving healthcare providers' understanding of FGM is key to enhancing women's experiences and perceptions of care.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Eshraghi B,</b> Hermansson J, Berggren V, Marions L</p><p dir="ltr">Risk of obstetric anal sphincter tear among primiparous women with a history of female genital mutilation, giving birth in Sweden. PLoS One. 2022 Dec 17(12): e0279295. <a href="https://doi.org/10.1371/journal.pone.0279295" rel="noreferrer" target="_blank">https://doi.org/10.1371/journal.pone.0279295</a></p><p dir="ltr">II. <b>Eshraghi B,</b> Marions L, Berger C, Berggren V.</p><p dir="ltr">"A part of my life". A qualitative study about perceptions of female genital mutilation and experiences of healthcare among affected women residing in Sweden. BMC Women's Health. 2024 May 22;24(1):304. <a href="https://doi.org/10.1186/s12905-024-03149-1" rel="noreferrer" target="_blank">https://doi.org/10.1186/s12905-024-03149-1</a></p><p dir="ltr">III. <b>Eshraghi B,</b> Hermansson J, Marions L.</p><p dir="ltr">Risk of emergency cesarean section when giving birth in Sweden. A nationwide cohort study comparing women born in countries practicing female genital mutilation, with Swedish-born women. [Submitted]</p>

Changing culture to end FGM

Worldwide estimates of the prevalence of female genital mutilation (FGM) indicate that well over 100 million women in more than 26 countries have undergone this procedure. Illegal in most western countries, FGM is primarily practiced in sub-Saharan Africa. Many women with FGM have migrated to Western countries where they constitute a significant proportion of the population. These women have special medical and psychological problems during pregnancy, and do not readily volunteer that they have undergone the procedure. Most physicians and other health professionals in Western countries have little knowledge of FGM and its management. There has been concern over reports of increased maternal and fetal mortality during childbirth among women with FGM. Little data is available on maternal expectations and wishes concerning antenatal, intrapartum, and postpartum care. This retrospective case control study evaluated the desires and wishes of women with FGM regarding their external genitalia following delivery, and as a secondary aim investigated fetal and maternal outcomes among women with FGM compared to nonmutilated women. The study was conducted between 1999 and 2008 in a teaching hospital setting in Switzerland. The case subjects were 122 pregnant women volunteers with FGM. Controls were 110 women without FGM who were matched for maternal age and delivered at the same time. Most patients were from Africa. Defibulation, a corrective surgical procedure for infibulation, was performed in some patients before or during labor. The primary study outcome measures were patients' wishes concerning their FGM management before and during labor, their satisfaction with the postpartum outcome, and intrapartum and postpartum maternal outcome data including duration of labor and blood loss as well as fetal outcomes. When given choices for managing their FGM during pregnancy, 6.5% (8/122) wanted to have antenatal defibulation, 43% (52/122) requested defibulation during labor, 34.4% (42/122) requested defibulation during labor only if deemed necessary by the medical staff, and 16.5% (20/122) patients were unable to articulate their expectations. No statistical differences between FGM patients and controls were found for maternal blood loss or duration of labor and fetal outcomes. Women after FGM did not have a longer duration of labor than the controls. Compared to controls, women with FGM had significantly more emergency Cesarean sections and third-degree vaginal tears, and significantly fewer first-degree and second-degree tears. Overall, 76% of patients were very satisfied (53%) or satisfied (23%) with the management of their FGM. These findings suggest that appropriate management of women with FGM in pregnancy and its prevention requires an interdisciplinary team approach with special training in FGM issues.

<p dir="ltr">Background</p><p dir="ltr">Female Genital Mutilation (FGM) involves the partial or total removal of the external female genitalia for non-medical reasons and is associated with serious health risks. The growing number of women from countries where FGM is practiced presents new challenges for healthcare systems in receiving countries. To improve care and promote health equity, it is essential to increase understanding of both the obstetric complications associated with FGM and the healthcare experiences of affected women.</p><p dir="ltr">Aim<br><br>This thesis aimed to investigate how FGM affects obstetric outcomes with a particular focus on obstetric anal sphincter injury (OASI) and emergency cesarean section (CS), and to explore the lived experiences of women with FGM and their experience of healthcare encounters in Sweden.</p><p dir="ltr"><br>Material, methods and results<br><br></p><p dir="ltr">The first study was a nationwide cohort study including 187 738 primiparous women with singleton term vaginal births in Sweden (2014-2018). It showed that women with a registered FGM diagnosis (n=1 444) had a nearly threefold increased risk of OASI (OR 2.69, 95%CI: 2.14-3.37) compared to women without FGM diagnosis (n= 186 294). FGM was also associated with a higher rate of instrumental deliveries and episiotomy.</p><p dir="ltr">The second study was a qualitative interview study with eight women living in Sweden who had undergone FGM prior to migration. This study highlights the complexity of FGM, revealing a wide range of experiences and perceived health consequences among women affected. Additionally, women reported inadequate knowledge about FGM, disrespectful attitudes, and insensitive care when seeking healthcare, though some also reported positive encounters.</p><p dir="ltr">The third study was a nationwide cohort study (2014-2020) that included 229 026 births and examined the risk of emergency CS for women born in FGM- practicing countries (n= 14 602) compared to women born in Sweden (n= 214 424). Women from FGM-practicing countries had a higher risk of emergency CS (aOR 1.23, 95% CI: 1.17-1.30) compared to Swedish-born women. However, when adding FGM diagnosis as a covariate in the regression model, FGM diagnosis did not change the risk.</p><p dir="ltr">Conclusions</p><p dir="ltr">In our study, women with FGM had an increased risk of OASI when having a vaginal delivery in Sweden. The increased risk of emergency CS among women from FGM- practicing countries appears to be attributed to factors other than the FGM diagnosis itself. Increasing healthcare providers' knowledge about obstetric complications associated with FGM is essential to ensure optimal care and prevent adverse obstetric outcomes. Since women affected by FGM perceive their health consequences in various ways, it is further important for healthcare professionals to acknowledge the diversity within this group. Adopting a sensitive, individualized approach and improving healthcare providers' understanding of FGM is key to enhancing women's experiences and perceptions of care.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Eshraghi B,</b> Hermansson J, Berggren V, Marions L</p><p dir="ltr">Risk of obstetric anal sphincter tear among primiparous women with a history of female genital mutilation, giving birth in Sweden. PLoS One. 2022 Dec 17(12): e0279295. <a href="https://doi.org/10.1371/journal.pone.0279295" rel="noreferrer" target="_blank">https://doi.org/10.1371/journal.pone.0279295</a></p><p dir="ltr">II. <b>Eshraghi B,</b> Marions L, Berger C, Berggren V.</p><p dir="ltr">"A part of my life". A qualitative study about perceptions of female genital mutilation and experiences of healthcare among affected women residing in Sweden. BMC Women's Health. 2024 May 22;24(1):304. <a href="https://doi.org/10.1186/s12905-024-03149-1" rel="noreferrer" target="_blank">https://doi.org/10.1186/s12905-024-03149-1</a></p><p dir="ltr">III. <b>Eshraghi B,</b> Hermansson J, Marions L.</p><p dir="ltr">Risk of emergency cesarean section when giving birth in Sweden. A nationwide cohort study comparing women born in countries practicing female genital mutilation, with Swedish-born women. [Submitted]</p>

Worldwide estimates of the prevalence of female genital mutilation (FGM) indicate that well over 100 million women in more than 26 countries have undergone this procedure. Illegal in most western countries, FGM is primarily practiced in sub-Saharan Africa. Many women with FGM have migrated to Western countries where they constitute a significant proportion of the population. These women have special medical and psychological problems during pregnancy, and do not readily volunteer that they have undergone the procedure. Most physicians and other health professionals in Western countries have little knowledge of FGM and its management. There has been concern over reports of increased maternal and fetal mortality during childbirth among women with FGM. Little data is available on maternal expectations and wishes concerning antenatal, intrapartum, and postpartum care. This retrospective case control study evaluated the desires and wishes of women with FGM regarding their external genitalia following delivery, and as a secondary aim investigated fetal and maternal outcomes among women with FGM compared to nonmutilated women. The study was conducted between 1999 and 2008 in a teaching hospital setting in Switzerland. The case subjects were 122 pregnant women volunteers with FGM. Controls were 110 women without FGM who were matched for maternal age and delivered at the same time. Most patients were from Africa. Defibulation, a corrective surgical procedure for infibulation, was performed in some patients before or during labor. The primary study outcome measures were patients' wishes concerning their FGM management before and during labor, their satisfaction with the postpartum outcome, and intrapartum and postpartum maternal outcome data including duration of labor and blood loss as well as fetal outcomes. When given choices for managing their FGM during pregnancy, 6.5% (8/122) wanted to have antenatal defibulation, 43% (52/122) requested defibulation during labor, 34.4% (42/122) requested defibulation during labor only if deemed necessary by the medical staff, and 16.5% (20/122) patients were unable to articulate their expectations. No statistical differences between FGM patients and controls were found for maternal blood loss or duration of labor and fetal outcomes. Women after FGM did not have a longer duration of labor than the controls. Compared to controls, women with FGM had significantly more emergency Cesarean sections and third-degree vaginal tears, and significantly fewer first-degree and second-degree tears. Overall, 76% of patients were very satisfied (53%) or satisfied (23%) with the management of their FGM. These findings suggest that appropriate management of women with FGM in pregnancy and its prevention requires an interdisciplinary team approach with special training in FGM issues.

This pilot study researched the attitudes towards and the knowledge of female genital mutilation (FGM) in adult women with FGM and their partners. The participant population consisted of English-speaking women and men over 18 years old attending specialist FGM clinics in two London hospitals. The participants completed a questionnaire on the attitudes and the knowledge of FGM, which were adapted with permission from the United Nations Children’s Fund and the United States Agency for International Development household surveys. 54 participants (51 women, 3 men) took part in the surveys. 89% of participants thought that FGM should be stopped (95%CI: 0.81–0.97) and 72% said they knew FGM is illegal in the United Kingdom (UK). 15% reported that FGM caused no danger, or were unaware of any danger to women’s health. This study demonstrates the opposition to FGM by participants, but some lack of knowledge regarding the legal and health implications. The exploration of attitudes in diaspora community groups is often cited as key to safeguarding girls from FGM. This is one of the first UK studies of individuals from FGM-practising communities, and we recommend use of the study questionnaires for a multicentre, cross-community study.Impact statementWhat is already known about this subject? Women and children are affected by female genital mutilation (FGM) globally and in the United Kingdom (UK). The majority of knowledge on practices and the attitudes towards FGM comes from UNICEF and USAID research in Africa and there is scant data on FGM practices in diaspora communities in the UK.What do the results of this study add? This study provides an appropriate questionnaire and protocol for use in community-based national research to improve healthcare for women by collecting up-to-date data on the attitudes towards FGM among the members of FGM-practising communities in the UK.What are the implications of these findings for clinical practice and further research? The implications of the results of this study are that health professionals need to understand that patients do not always know the law on FGM, even after a consultation. Health and social care professionals are placed in a unique position to work with community members to educate men and women to end FGM.

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