WHO FGM Guidelines

WHO guidelines on the management of health complications from female genital mutilation i
WHO guidelines on the

management of health
complications from
female genital mutilation
WHO guidelines on the
management of health
complications from
female genital mutilation
WHO Library Cataloguing-in-Publication Data
WHO guidelines on the management of health complications from female genital mutilation.
I. World Health Organization.
ISBN 978 92 4 154964 6
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Contents
Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Acronyms and abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Executive summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
1. Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Types of FGM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Reasons why FGM is performed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.3 Health risks from FGM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.4 FGM and human rights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.5 Medicalization of FGM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.6 Objectives of the guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.6.1 Why these guidelines were developed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.6.2 Purpose of these guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.6.3 Target audience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2. Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.1 Guideline contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.2 Declaration of interests by external contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.3 Identification of priority research questions and outcomes scoping exercise. . . . . . . . . . . . . . . . . . . 12
2.4 Evidence retrieval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.5 Quality assessment, synthesis and grading of the evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.6 Qualitative research and human rights evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.7 Formulation of recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.8 Document preparation and peer review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3. Guidance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.1 Guiding principles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.2 Recommendations and best practice statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.2.1 Deinfibulation (recommendations 13 and best practice statements 12) . . . . . . . . . . . . . . . . . . . . . 16
3.2.2 Mental health (recommendation 4 and best practice statement 3). . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.2.3 Female sexual health (recommendation 5). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.2.4 Information and education (best practice statements 48). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.3 Interventions for which no recommendations were issued. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.3.1 What are the treatment alternatives for vulvodynia and clitoral pain in
girls and women with any type of FGM?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.3.2 What is the role of clitoral reconstruction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
4. Dissemination and implementation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4.1 Dissemination of the guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4.2 Implementation of the guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4.3 Monitoring and evaluating the impact of the guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4.4 Updating the guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
5. References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Annex 1: International and regional human rights treaties and consensus documents
providing protection and containing safeguards against female genital mutilation . . . . . . . . . . 41
Annex 2: Guideline contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Annex 4: Factors considered while rating the quality of the evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Web Annex: GRADE tables available online at:

http://www.who.int/reproductivehealth/topics/fgm/management-health-complications-fgm/en/
WHO guidelines on the management of health complications from female genital mutilation v
Acknowledgments
The Department of Reproductive Health and Dr Bassey Edet, Dr Emmananuel Effa, Dr Regina
Research, at the World Health Organization (WHO), Ejemot-Nwadiaro, Mr Ekpereonne Esu, Dr Ifeanyi
has produced this guideline document, under Ezebialu, Dr Austin Ihesie, Dr Elizabeth Inyang,
the leadership of Dr Lale Say. Dr Doris Chou and Mr Nuria Nwachuku, Dr Ogonna Nwankwo, Mr
Dr Karin Stein coordinated the development of Edward Odey, Dr Friday Odey, Dr Olabisi Oduwole,
the guideline. The WHO Steering Group (Dr Ian Dr Udoezuo K. Ogbonna, Dr Miriam Ogugbue,
Askew, Dr Lale Say, Dr Doris Chou, Dr Michelle Dr Olumuyiwa Ojo, Ms Obiamaka Okafo, Dr Uduak
Hindin, Mr Rajat Khosla, Dr Christina Pallitto, Okomo, Mr Anthony Okoro, Dr Ifeyinwa Okoye,
Dr Karin Stein) gratefully acknowledges the Dr Babasola Okusanya, Ms Chioma Oringanje,
contributions of all the Guideline Development Ms Chukwudi Oringanje, Dr Atim Udo and
Group (GDG) members: Dr Jasmine Abdulcadir, Dr Ekong E. Udoh. Many thanks also to Mr Graham
Ms Joya Banerjee, Dr Owolabi Bjalkander, Dr Susana Chan who developed the search strategies.
Fried, ProfessorAdriana Kaplan Marcusn,
Professor Joseph Karanja, Professor Caitlin This document was written on behalf of the GDG
Kennedy, DrMorissanda Kouyat, Professor Els by Dr Karin Stein and Dr Doris Chou.
Leye, ProfessorMartin M. Meremikwu, Dr Nawal We appreciate the contributions of the following
Nour, Professor Olayinka Olusola Omigbodun, individuals to the development of the guidelines:
ProfessorGamal Serour, Professor Moustapha Toure Dr Olufemi Oladapo, Ms Mara Barreix, Ms Lianne
and Dr Ingela Wiklund; and our United Nations Gonsalves and Ms Marie Hlne Doucet. We
partners from the UNFPA-UNICEF Joint Programme, thank Dr Jasmine Abdulcadir, Dr Lucrezia Catania,
on Female Genital Mutilation/Cutting: Accelerating DrPatrick Petignat, and Dr Omar Abdulcadir
Change, Dr Nafissatou J. Diop and MrCody for their assistance with conceptualization of
Donahue. illustrations on types of FGM. Many thanks to
Many thanks to the following individuals for peer MrSvetlin Kolev and Ms Janet Petitpierre for
reviewing the document: Professor Pascale A. providing technical assistance with the guideline
Allotey, Dr Comfort Momoh and Ms Marycelina H. graphics. This guideline document was edited by
Msuya. Ms Jane Patten, of Green Ink, United Kingdom.
The WHO Steering Group would also like to thank The WHO Steering Group would like to thank the
all the anonymous participants who took part in WHO Guidelines Review Committee Secretariat
the guidelines scoping survey. for the overall support during the guideline
development process, with grateful thanks to
Special thanks to Dr Helen Smith for conducting Dr Susan L. Norris.
the qualitative systematic reviews and to Professor
Martin Meremikwu of the Nigerian Branch of the The development of these guidelines was funded
South African Cochrane Centre for leading the by the UNFPAUNICEF Joint Programme on Female
systematic review team composed of the following Genital Mutilation/Cutting: Accelerating Change,
members: Dr Olukayode Abayomi, Dr Adegoke and the Department of Reproductive Health and
Adelufosi, Mr David Agamse, Mr Ememobong Research, UNDP/UNFPA/UNICEF/WHO/World Bank
Aquaisua, Mrs Dachi Arikpo, Dr Iwara Arikpo, Special Programme of Research, Development and
Dr Segun Bello, Mrs Moriam T. Chibuzor, Research Training in Human Reproduction (HRP).
vi WHO guidelines on the management of health complications from female genital mutilation
Acronyms and abbreviations
CBT cognitive behavioural therapy
CEDAW Convention on the Elimination of All Forms of Discrimination against Women
CRC Convention on the Rights of the Child
DOI declaration of interest
ERG External Review Group
FGM female genital mutilation
GDG Guideline Development Group
GRADE Grading of Recommendations Assessment, Development and Evaluation
HRP UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and

Research Training in Human Reproduction
IEC information, education and communication
NGO nongovernmental organization
OHCHR Office of the United Nations High Commissioner for Human Rights
PICO population, intervention, comparator, outcome
PTSD post-traumatic stress disorder
UN United Nations
UNAIDS Joint United Nations Programme on AIDS
UNDP United Nations Development Programme
UNECA United Nations Economic Commission for Africa
UNESCO United Nations Educational, Scientific and Cultural Organization
UNFPA United Nations Population Fund
UNHCR United Nations High Commissioner for Refugees
UNICEF United Nations Childrens Fund
UNIFEM United Nations Development Fund for Women (now UN Women)
UTI urinary tract infection
WHO World Health Organization

WHO guidelines on the management of health complications from female genital mutilation vii
Glossary
Terms associated with female genital mutilation (FGM):
Infibulation (type III FGM)

Narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia
minora and/or the labia majora, with or without excision of the clitoris.
Deinfibulation
The practice of cutting open the narrowed vaginal opening in a woman who has been infibulated, which is
often necessary for improving health and well-being as well as to allow intercourse or to facilitate childbirth.
Re-infibulation
The procedure to narrow the vaginal opening in a woman after she has been deinfibulated (i.e. after
childbirth); also known as re-suturing.
Medicalization of FGM
Situations in which the procedure (including re-infibulation) is practised by any category of health-care
provider, whether in a public or a private clinic, at home or elsewhere, at any point in time in a womans life.
Terms related to interventions:
Cognitive behavioural therapy (CBT)

A type of psychological therapy based on the idea that feelings are affected by thinking and beliefs. If
unchecked, these thoughts and beliefs can lead to unhelpful behaviours. CBT typically has a cognitive
component (i.e. helping the person develop the ability to identify and challenge unrealistic negative
thoughts) and a behavioural component.
Digital health
The use of information and communication technologies in support of health and health-related fields.
Health education
The provision of accurate, truthful information so that a person can become knowledgeable about the
subject and make an informed choice.
Information, education and communication (IEC)

A public health approach aiming at changing or reinforcing health-related behaviours in a target audience,
concerning a specific problem and within a pre-defined period of time, through communication methods
and principles.
viii WHO guidelines on the management of health complications from female genital mutilation
Executive summary
Female genital mutilation (FGM) comprises all developing and implementing national and local
procedures that involve the partial or total removal health-care protocols and policies. The information
of external genitalia or other injury to the female contained in this document will also be useful for
genital organs for non-medical reasons. The designing job aids and pre- and in-service professional
procedure has no known health benefits. Moreover, training curricula in the areas of medicine, nursing,
the removal of or damage to healthy genital tissue midwifery and public health for health-care providers
interferes with the natural functioning of the body caring for girls and women living with FGM.
and may cause several immediate and long-term
health consequences. Girls and women who have Guideline development methods
undergone FGM are therefore at risk of suffering
from its complications throughout their lives. In This document was developed using standard
addition, FGM violates a series of well-established operating procedures in accordance with the
human rights principles, including the principles of process described in the WHO handbook for guideline
equality and non-discrimination on the basis of sex, development, second edition.1 In summary, the
the right to life when the procedure results in death, process involved: (i)identification of critical research
and the right to freedom from torture or cruel, questions and outcomes; (ii)commissioning of
inhuman or degrading treatment or punishment, as experts to conduct systematic reviews; (iii)retrieval
well as the rights of the child. of up-to-date evidence; (iv) quality assessment
and synthesis of the evidence; (v)formulation
The practice prevalent in 30 countries in Africa and of recommendations; and (vi)planning for the
in a few countries in Asia and the Middle East is dissemination, implementation, impact evaluation
now present across the globe due to international and updating of the guidelines. The scientific
migration. Health-care providers in all countries may evidence that informed the recommendations and
therefore face the need to provide health care to this best practice statements was synthesized using
population. Unfortunately, health workers are often the Grading of Recommendations Assessment,
unaware of the many negative health consequences Development and Evaluation (GRADE) methods.2
of FGM and many remain inadequately trained to For each priority research question, evidence profiles
recognize and treat them properly. were prepared from existing or commissioned
Recognizing the persistence of FGM despite systematic reviews. Values and preferences of clients
concerted efforts to eradicate or abandon the and health-care providers were assessed using
practice in some affected communities, and evidence from qualitative reviews on the context
acknowledging the 200million girls and women and conditions of interventions used to manage
living with or at risk of suffering the associated health complications of FGM.3 The recommendations
negative health consequences, these guidelines and best practice statements were developed using
aim to provide up-to-date, evidence-informed a consensus-based approach by the Guideline
recommendations on the management of health Development Group (GDG), an international group of
complications from FGM. This document also experts in the field of FGM, during a meeting at the
intends to provide standards that may serve as the 1 WHO handbook for guideline development, 2nd ed.
basis for developing local and national guidelines Geneva: World Health Organization; 2014.
and health-care provider training programmes. 2 Further information available at:
http://www.gradeworkinggroup.org/
Target audience 3 The GDG issued recommendations when the available
evidence and ancillary criteria supported their
These guidelines are intended primarily for health-care development. When the available evidence is of low
professionals involved in the care of girls and women quality or weak but the contents of the recommended
statement were based upon sound judgement and
who have been subjected to any form of FGM. This
supported by human rights and equity principles, public
document also provides guidance for policy-makers, or medical practices, and judged to have little to no risk of
health-care managers and others in charge of planning, harm to health, best practice statements were issued.
WHO guidelines on the management of health complications from female genital mutilation ix
World Health Organization (WHO) headquarters in of the proposed intervention. Where there was a
Geneva on 12 September 2015. need for guidance, but no relevant research evidence
was available, recommendations and best practice
Guidance: recommendations and statements were agreed if they were supported by
best practice statements the public health or medical practice expertise of
the members of the GDG. In order to ensure each
The guideline development process led to the recommendation and best practice statement could
adoption of three statements of guiding principles, be understood and used as it was intended, the GDG
five recommendations and eight best practice offered further clarifications as needed, which are
statements, covering the use of deinfibulation, noted below the relevant recommendations and best
mental health, female sexual health, and practice statements where they are presented in full
information and education (see Guidance summary within the text of these guidelines.
tables). For each recommendation and best practice
statement the quality of the evidence was graded Input from peer reviewers and a range of
as very low, low, moderate or high, based stakeholders, including colleagues working directly
on the GRADE methods. When no evidence was with girls and women living with FGM, was also
identified for a recommendation or best practice sought and helped to further clarify the wording
statement, or only indirect evidence was available, of the recommendations and best practice
this was indicated in the summary of the evidence. statements. Important knowledge gaps that need
to be addressed through primary research were
Recommendations were considered as strong identified and included in the document.
(two recommendations) or conditional (three
recommendations), based on the available evidence, The recommendations and best practice
as well as considerations of the balance between statements on the management of health
benefits and harms, womens and health-care complications from FGM are summarized in the
providers preferences, human and other resource table below. They will be reviewed and updated
implications, priority of the problem, equity and following identification of new evidence.
human rights issues, and acceptability and feasibility
Guidance summary
Guiding principles
I Girls and women living with female genital mutilation (FGM) have experienced a harmful practice
and should be provided quality health care.
II All stakeholders at the community, national, regional and international level should initiate or
continue actions directed towards primary prevention of FGM.
III Medicalization of FGM (i.e. performance of FGM by health-care providers) is never acceptable
because this violates medical ethics since (i) FGM is a harmful practice; (ii) medicalization perpetuates
FGM; and (iii) the risks of the procedure outweigh any perceived benefit.
x WHO guidelines on the management of health complications from female genital mutilation
Summary of the recommendations (R) and best practice statements (BP)
DEINFIBULATION
R-1 Deinfibulation is recommended for preventing and treating obstetric complications in women
living with type III FGM (strong recommendation; very low-quality evidence).
R-2 Either antepartum or intrapartum deinfibulation is recommended to facilitate childbirth in
women living with type III FGM (conditional recommendation; very low-quality evidence).
R-3 Deinfibulation is recommended for preventing and treating urologic complications specifically
recurrent urinary tract infections and urinary retention in girls and women living with type III FGM
(strong recommendation; no direct evidence).
BP-1 Girls and women who are candidates for deinfibulation should receive adequate preoperative
briefing (Best practice statement).
BP-2 Girls and women undergoing deinfibulation should be offered local anaesthesia (Best practice statement).
MENTAL HEALTH
R-4 Cognitive behavioural therapy (CBT) should be considered for girls and women living with FGM
who are experiencing symptoms consistent with anxiety disorders, depression or post-traumatic stress
disorder (PTSD) (conditional recommendation; no direct evidence).
BP-3 Psychological support should be available for girls and women who will receive or have
received any surgical intervention to correct health complications of FGM (Best practice statement).
FEMALE SEXUAL HEALTH
R-5 Sexual counselling is recommended for preventing or treating female sexual dysfunction among
women living with FGM (conditional recommendation; no direct evidence).
INFORMATION AND EDUCATION
BP-4 Information, education and communication (IEC)4 interventions regarding FGM and womens
health should be provided to girls and women living with any type of FGM (Best practice statement).
BP-5 Health education5 information on deinfibulation should be provided to girls and women living
with type III FGM (Best practice statement).
BP-6 Health-care providers have the responsibility to convey accurate and clear information, using
language and methods that can be readily understood by clients (Best practice statement).
BP-7 Information regarding different types of FGM and the associated respective immediate and
long-term health risks should be provided to health-care providers who care for girls and women
living with FGM (Best practice statement).
BP-8 Information about FGM delivered to health workers should clearly convey the message that
medicalization is unacceptable (Best practice statement).
4 WHO defines information, education and communication (IEC) interventions as a public health approach aiming at
changing or reinforcing health-related behaviours in a target audience, concerning a specific problem and within a
pre-defined period of time, through communication methods and principles. Source: Information, education and
communication lessons from the past; perspectives for the future. Geneva: World Health Organization; 2001.
5 Health education is the provision of accurate, truthful information so that a person can become knowledgeable about
the subject and make an informed choice. Source: Training modules for the syndromic management of sexually
transmitted infections: educating and counselling the patient. Geneva: World Health Organization; 2007.
WHO guidelines on the management of health complications from female genital mutilation 1
1. Background
Female genital mutilation (FGM) comprises 1.2 Reasons why FGM is

all procedures that involve the partial or total performed
removal of external genitalia or other injury
to the female genital organs for non-medical FGM is practised for a variety of sociocultural
reasons (1). Although it is internationally reasons, varying from one region and ethnic group
recognized as a violation of human rights and to another. The primary reason is that it is part of
legislation to prohibit the procedure has been the history and cultural tradition of the community.
put in place in many countries, to date the In many cultures, it constitutes a rite of passage to
practice is still being reported in 30 countries adulthood and is also performed in order to confer
in Africa and in a few countries in Asia and the a sense of ethnic and gender identity within the
Middle East (1,2). Some forms of FGM have also community. In many contexts, social acceptance
been reported in other countries, including is a primary reason for continuing the practice.
among certain ethnic groups in Central and Other reasons include safeguarding virginity before
South America (1). The rise in international marriage, promoting marriageability (i.e.increasing
migration has also increased the number of a girls chances of finding a husband), ensuring
girls and women living in the various diaspora fidelity after marriage, preventing rape, providing
populations, including in Europe and North a source of income for circumcisers, as well as
America, who have undergone or may undergo aesthetic reasons (cleanliness and beauty) (5).
the practice (3,4). Some communities believe that FGM is a religious
requirement, although it is not mentioned in major
It is estimated that over 200million girls and religious texts such as the Koran or the Bible. In
women worldwide are living with the effects fact, FGM predates Islam and is not practised in
of FGM (2), and despite efforts to eradicate the many Muslim countries, while it is performed in
practice, every year some 3million girls and some Christian communities (5).
women are at risk of FGM and are therefore
exposed to the potential negative health Whatever the reason provided, FGM reflects
consequences of this harmful practice (4). deep-rooted inequality between the sexes. This
aspect, and the fact that FGM is an embedded
The World Health Organization (WHO), as part sociocultural practice, has made its complete
of its core mandate to provide assistance to elimination extremely challenging. As such,
Member States in achieving the goal of the efforts to prevent and thus eventually eradicate
highest attainable standard of health for all, FGM worldwide must continue, in addition
issued in 2008 an interagency statement on to acknowledging and assisting the existing
eliminating FGM. The statement describes, population of girls and women already living with
among other things, the negative implications of its consequences whose health needs are currently
the practice for the health and, very importantly, not fully met.
for the human rights of girls and women, and
declared vigorous support for its abandonment 1.3 Health risks from FGM
(1). The aspiration to alleviate the associated
adverse health conditions and to restore violated FGM has no known health benefits, and those girls
human rights constitutes the cornerstone of and women who have undergone the procedure
these guidelines. are at great risk of suffering from its complications
throughout their lives. The procedure is painful
1.1 Types of FGM and traumatic (1), and is often performed under
unsterile conditions by a traditional practitioner
WHO classifies FGM into four types (1), as shown who has little knowledge of female anatomy
in Box1.1. The first image shows unaltered female or how to manage possible adverse events
genitalia for comparison. (6). Moreover, the removal of or damage to
healthy genital tissue interferes with the natural
2 WHO guidelines on the management of health complications from female genital mutilation
Box 1.1: Types of FGM*
Unaltered female genitalia
prepuce
clitoris
labia minora
urethra
labia majora
vaginal introitus
bartholin glands perineum

anus
Type I Partial or total removal of the clitoris (clitoridectomy) and/or the prepuce
FGM Type I FGM Type I
Ia: removal of the prepuce/clitoral hood Ib: removal of the clitoris with
(circumcision) the prepuce (clitoridectomy)
prepuce prepuce
clitoris clitoris
labia minora labia minora

urethra urethra
labia majora labia majora
vaginal introitus vaginal introitus
bartholin glands perineum bartholin glands perineum

anus anus
* Abdulcadir J, Catania L, Hindin MJ, Say L, Petignat P, Abdulcadir O. Female Genital Mutilation: A visual reference and
learning tool for healthcare professionals. 2016 (under review).
(box continues on next page)

Box 1.1: Types of FGM
Type II Partial or total removal of the clitoris and the labia minora, with or without excision of the labia
majora (excision)
FGM Type II FGM Type II
IIa: removal of the labia minora only IIb: partial or total removal of the
clitoris and the labia minora
prepuce prepuce may be affected

clitoris clitoris
labia minora labia minora

urethra urethra

anus anus
FGM Type II
IIc: partial or total removal of

the clitoris, the labia minora and
the labia majora
prepuce
clitoris
labia minora
urethra
labia majora
vaginal introitus
anus
(box continues on next page)

Box 1.1: Types of FGM
Type III Narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning
the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation)
FGM Type III FGM Type III

IIIa: removal and appositioning the labia minora IIIb: removal and appositioning the labia majora
with or without excision of the clitoris with or without excision of the clitoris
infibulation may be a result infibulation may be a result

of the healing and not of the healing and not
necessarily of the stitching necessarily of the stitching
prepuce may be affected prepuce may be affected
clitoris may be affected clitoris may be affected
labia minora labia minora may be affected

urethra urethra
anus anus
Re-infibulation The procedure to narrow the vaginal opening in a woman after she has been
deinfibulated (i.e. after childbirth); also known as re-suturing
Type IV All other harmful procedures to the female genitalia for non-medical purposes, for example:
pricking, pulling, piercing, incising, scraping and cauterization
FGM Type IV
Unclassified.
piercing
prepuce
clitoris
labia minora
urethra
labia majora
vaginal introitus
anus
functioning of the body and may cause several care providers are still often unaware of the
immediate and long-term genitourinary health many negative health consequences and remain
consequences (68) (see Box1.2). The evidence inadequately trained to recognize and treat
indicates that there might be a greater risk of them properly.
immediate harms with typeIII FGM, relative to
types I and II, and that these events tend to be 1.4 FGM and human rights
considerably under-reported (6).
Recognizing the persistence of FGM despite
Regarding the obstetric risks associated with FGM, concerted efforts to eradicate or abandon the
a WHO study group that conducted an analysis practice in some affected communities, and
on FGM in 2006 concluded that women living recognizing the increased need for clear guidance
with FGM are significantly more likely than those on the treatment and care of women who have
who have not had FGM to have adverse obstetric undergone FGM, WHO has developed these
outcomes, and that this risk seems to be greater guidelines to include a focus on human rights and
with more extensive forms of the procedure (9). gender inequality (13).
These adverse outcomes may also affect the health
In December 2012, the Member States of the
of the newborn (10) (see Box1.2).
United Nations (UN) agreed in UN General
For many girls and women, undergoing FGM can Assembly resolution67/146 to intensify efforts to
be a traumatic experience that may leave a lasting eliminate FGM, as a practice that is an irreparable,
psychological mark and cause a number of mental irreversible abuse that impacts negatively on the
health problems (11, 12) (see Box1.2). human rights of women and girls (14).
Given that some types of FGM involve the removal For the past several decades, a diverse group of
of sexually sensitive structures, including the scholars, advocates, legislators and health-care
clitoral glans and part of the labia minora, some practitioners have offered differing views and ideas
women report reduction of sexual response and about how to best respond to this UN resolution.
diminished sexual satisfaction. In addition, scarring One consistent and powerful theme in these
of the vulvar area may result in pain, including conversations is a call for common recognition of
during sexual intercourse (6,11) (see Box1.2). FGM as a denial of girls and womens ability to fully
exercise their human rights and to be free from
In addition to these health risks, a number discrimination, violence and inequality.
of procedures and day-to-day activities may
be hindered due to anatomical distortions, FGM violates a series of well-established human
including gynaecological examinations, cytology rights principles, norms and standards, including
testing, post-abortion evacuation of the uterus, the principles of equality and non-discrimination
intrauterine device (IUD) placement and tampon on the basis of sex, the right to life when the
usage, especially in the case of typeIII FGM. procedure results in death, and the right to
freedom from torture or cruel, inhuman or
Providing exact data regarding the direct health degrading treatment or punishment, as well as the
impacts of FGM has been a challenging task due rights of the child (see Box1.3). As it interferes with
to the small sample sizes and methodological healthy genital tissue in the absence of medical
limitations of the available studies. Despite these necessity and can lead to severe consequences
limitations, over the past decade or so, evidence for a womans physical and mental health, FGM is
of the direct health impacts of FGM has accrued, also a violation of a persons right to the highest
enabling recent systematic reviews and meta- attainable standard of health (1).
analyses to provide summaries of these health
impacts. Box1.2 contains a summary of all health A variety of human rights treaties and agreements
risks related to FGM. have also pronounced FGM to be a manifestation
of violence against girls and women, and a
Although there is evidence showing that these practice that sustains unequal gender norms and
adverse health outcomes are associated with stereotypes that contravene human rights. Human
FGM, and that many communities have started rights treaty monitoring bodies have consistently
to acknowledge this association, in reality health- made clear that harmful practices like FGM
Box 1.2: Health risks of FGM
Risk Remarks
IMMEDIATE RISKS (6, 8)
Haemorrhage
Pain
Shock Haemorrhagic, neurogenic or septic
Genital tissue swelling Due to inflammatory response or local infection
Infections Acute local infections; abscess formation; septicaemia; genital
and reproductive tract infections; urinary tract infections
The direct association between FGM and HIV remains

unclear, although the disruption of genital tissues may
increase the risk of HIV transmission.
Urination problems Acute urine retention; pain passing urine; injury to
the urethra
Wound healing problems
Death Due to severe bleeding or septicaemia
OBSTETRIC RISKS (9, 10)
Caesarean section
Postpartum haemorrhage Postpartum blood loss of 500 ml or more
Episiotomy
Prolonged labour
Obstetric tears/lacerations
Instrumental delivery
Difficult labour/dystocia
Extended maternal hospital stay
Stillbirth and early neonatal death
Infant resuscitation at delivery
SEXUAL FUNCTIONING RISKS (6, 11)
Dyspareunia (pain during sexual There is a higher risk of dyspareunia with type III FGM
intercourse) relative to types I and II (6).
Decreased sexual satisfaction
Reduced sexual desire and arousal
Decreased lubrication during sexual
intercourse
Reduced frequency of orgasm or
anorgasmia
Box 1.2: Health risks of FGM
Risk Remarks
PSYCHOLOGICAL RISKS (12)
Post-traumatic stress disorder (PTSD)

Anxiety disorders
Depression
LONG-TERM-RISKS (6, 8)
Genital tissue damage With consequent chronic vulvar and clitoral pain
Vaginal discharge Due to chronic genital tract infections
Vaginal itching
Menstrual problems Dysmenorrhea, irregular menses and difficulty in passing
menstrual blood
Reproductive tract infections Can cause chronic pelvic pain
Chronic genital infections Including increased risk of bacterial vaginosis
Urinary tract infections Often recurrent
Painful urination Due to obstruction and recurrent urinary tract infections
constitute a form of discrimination based on sex, not used to perform this practice, as is the case
gender, age and other grounds (19). Several regional with medicalization of FGM. The obligation to
human rights agreements also take up the issue, fulfil requires states to take appropriate legislative,
especially the Protocol on the Rights of Women administrative, budgetary, judicial and other
in Africa (the Maputo Protocol), which mandates actions to prevent and eliminate FGM. Finally, the
legal prohibition of harmful practices such as FGM obligation to protect requires states to ensure
(20). For a comprehensive list of international and that third parties do not violate the rights of girls
regional human rights treaties and consensus and women and that protective measures are in
documents providing protection and containing place, such as health, legal and social services.
safeguards against FGM, please see Annex1. This means that states must set in place systems
and structures to support women and children
The UN Convention on the Elimination of All Forms who are victims of harmful practices by ensuring
of Discrimination against Women (CEDAW) and the access to immediate support services, including
UN Convention on the Rights of the Child (CRC) medical, psychological and legal services, as well
further called for an end to the practice, as have as emergency medical services (19).
a variety of other UN human rights treaty bodies
(19). They have clarified that states obligations to The right to health means that states must
respect, fulfil and protect the rights of girls and generate conditions in which everyone can be
women require that they take action to ensure as healthy as possible. Despite some progress,
that girls and women can live free from harmful governments face persistent challenges in meeting
practices, such as FGM. their international obligations within their national
laws and policies related to FGM. These range from
The obligation to respect requires states to refrain failing to fully implement and enforce existing
from interfering directly or indirectly with the laws, failing to foresee and address unintended
enjoyment of rights. In the case of FGM, it may consequences of laws and policies, and taking
require states to ensure that the health system is misguided actions that may increase the practice,
such as the medicalization of FGM (see section1.5), about the associated health risks of FGM is an
which is often instituted as a harm-reduction important part of its elimination, it is not sufficient
measure (13). Health interventions targeted at to eradicate a practice strongly based on cultural
women suffering from FGM-related complications beliefs and deeply embedded in societal traditions.
can contribute, from within the health system, to
the safeguarding and restoration of a number of As an additional side-effect of the health
health-related human rights. In order to achieve risk approach to FGM, some professional
this, appropriate evidence-based clinical guidance organizations and governments have increasingly
accompanied by adequate training of health- supported less radical forms of cutting (e.g.the
care providers is a key requirement. While the pricking of the clitoris), performed under hygienic
promotion and protection of human rights is and medically controlled conditions; such harm-
ultimately the responsibility of governments, it reduction strategies are an attempt to reduce
is clear that health-care providers have a critical the risk of severe complications arising from
role to play in ensuring that efforts to eradicate the procedure when carried out in precarious
FGM and provide care for women living with conditions.
FGM are accomplished with the utmost attention These circumstances paired with the fact that
and consideration of girls and womens human a number of health-care providers still consider
rights (13). certain forms of FGM not to be harmful and a large
proportion of them are unable or unwilling to
1.5 Medicalization of FGM state a clear position when confronted with crucial
The medicalization of FGM refers to situations in issues like requests for performing FGM or re-
which the procedure (including re-infibulation) is infibulation (5) have contributed to increasing the
practised by any category of health-care provider, popularity of medicalized FGM across Africa and
whether in a public or a private clinic, at home or in the MiddleEast. In addition, the involvement of
elsewhere, at any point in time in a womans life. health-care providers in performing FGM is likely
This definition was first adopted by WHO in 1997 to confer a sense of legitimacy on the practice
(21), and reaffirmed in 2008 by 10 UN agencies and could give the impression that the procedure
in the interagency statement, Eliminating female is good for womens health, or at least that it is
genital mutilation (1). The interagency statement harmless (21).
strongly emphasizes that regardless of whether
Efforts to stop this unintended consequence were
FGM is carried out by traditional or medical
initiated by WHO in 1979 at the first international
personnel, it represents a harmful and unethical
conference on FGM, held in Khartoum, Sudan,
practice, with no benefits whatsoever, which
where WHO established that it is unacceptable
should not be performed under any circumstances.
to suggest that performing less invasive forms
Communities may be increasingly turning to of FGM within medical facilities will reduce
health-care providers to perform the procedure health complications. Since then, this position
for a combination of reasons. An important has been endorsed by numerous other medical
contributing factor is the fact that FGM has been professional associations, international agencies,
addressed for years as a health issue, using what is nongovernmental organizations (NGOs) and
known as the health risk approach. This approach governments. The condemnation of medicalization
has involved locally respected health experts of FGM was further highlighted and reiterated in
expressing concern about the health risks of FGM, the 2008 interagency statement on the elimination
in the form of a didactic and factual delivery of of FGM (1). It has been recognized that stopping the
messages (22). In several high-prevalence countries, medicalization of FGM is an essential component
this approach unfortunately did not result in of the holistic, human-rights-based approach
individuals, families or communities abandoning towards the elimination of the practice: when
the practice, but began to shift it from traditional communities see that health-care providers have
circumcisers to modern health-care practitioners taken a stand in favour of the abandonment of the
in the hope that this would reduce the risk of procedure and have refrained from performing
various complications (21,22). This brought to light it, this will foster local debate and questioning of
the problem that although providing information the practice.
Box 1.3: Human rights violated by the practice of FGM
HUMAN RIGHT RATIONALE
Right to the highest Because FGM can result in severe physical and mental harm and
attainable standard of because it constitutes an invasive procedure on otherwise healthy
health tissue without any medical necessity, it is seen as a violation of the
right to health. The International Covenant on Economic, Social
and Cultural Rights recognizes the right of all human beings to the
highest attainable standard of physical and mental health(15).
Right to life and physical FGM can cause severe physical and mental damage, sometimes
integrity, including resulting in death. As such, it interferes with a womans right to
freedom from violence life and physical integrity and freedom from violence. The right to
physical integrity includes the right to freedom from torture, inherent
Right to freedom dignity of the person, the right to liberty and security of the person,
from torture or cruel, and the right to privacy. This category of rights is protected by
inhuman or degrading various human rights instruments including: the Universal Declaration
treatment of Human Rights, Articles 1 and 3; the International Covenant on
Economic, Social and Cultural Rights, Preamble; the International
Covenant on Civil and Political Rights (ICCPR), Preamble and Article 9;
and the Convention on the Rights of the Child (CRC), Article 19 (1518).
Right to equality and FGM perpetuates the fundamental discriminatory belief of the
non-discrimination on subordinate role of girls and women, which fits within the definition of
the basis of sex discrimination against women. This refers to any distinction, exclusion
or restriction made on the basis of sex which has the effect or purpose
of impairing or nullifying the recognition, enjoyment or exercise by
women, irrespective of their marital status, on a basis of equality of
men and women, of human rights and fundamental freedoms in the
political, economic, social, cultural, civil or any other field (19).
Rights of the Child Because FGM is predominantly performed on girls under the age
of 18, the issue becomes fundamentally the protection of the
rights of children. The Convention on the Rights of the Child (CRC)
acknowledges the role of parents and families in making decisions
for children, but places the ultimate responsibility for protecting the
rights of a child in the hands of the government (Article 5). The CRC
also established the best interests of the child standard in addressing
the rights of children (Article 3). FGM is recognized as a violation of that
best interest standard and a violation of childrens rights. In addition,
the CRC mandates governments to abolish traditional practices
prejudicial to the health of children (Article 24) (18).
On this basis, WHO has issued within these with requests from parents or family members to
guidelines a guiding principle statement against perform FGM on girls, or requests from women
the medicalization of FGM, aiming to stop this to perform re-infibulation after delivery. Technical
practice (see section3.1). One fundamental knowledge about how to recognize and manage
measure needed to tackle this situation is the complications of FGM, including suitable obstetric
creation of protocols, manuals and guidelines to care and how to counsel women on FGM-related
guide health-care providers in dealing with issues issues, must be provided in order to emphasize
related to FGM, including what to do when faced the health-care providers role as a caregiver
rather than a perpetrator (21). Therefore, adequate 1.6 Objectives of the guidelines
training becomes not only a preventive measure,
1.6.1 Why these guidelines were developed
but also an urgently needed tool for coping
with the reality that millions of women have Following the publication of the 2008 interagency
already undergone FGM and must live with its statement on elimination of FGM co-signed by
consequences. WHO and nine UN partner agencies (1), the UN
General Assembly resolution 67/146 of December
In the course of developing these guidelines (see 2012, Intensifying global efforts for the elimination
Methods, section 2.1), the Guideline Development of female genital mutilations, called on Member
Group (GDG) noted that an increasingly relevant States to:
issue related to FGM is female genital cosmetic
. . . protect and support women and girls
surgery (FGCS). Although parallels may exist
who have been subjected to female genital
between FGM and FGCS procedures (which
mutilations and those at risk, including by
include labial reduction or vaginal tightening developing social and psychological support
because of social, cultural and community norms services and care, and to take measures to
that promote a particular aesthetic of female improve their health, including sexual and
beauty and appropriate female bodies), critical reproductive health, in order to assist women
differences are evident. FGM as described by and girls who are subjected to the practice;
the WHO classification (1) and referred to within
and to:
this document is the result of a procedure that is
performed on individuals without full informed . . . develop, support and implement
consent, and who may face profound direct or comprehensive and integrated strategies for
indirect coercion to take part in these procedures, the prevention of female genital mutilations,
which are done in the absence of any potential including the training of social workers,
medical benefit. The underlying reasons for medical personnel, community and religious
performing FGM in the context discussed leaders and relevant professionals, and
to ensure that they provide competent,
within these guidelines perpetuate deep-rooted
supportive services and care to women
inequality between the sexes and constitute
and girls who are at risk of or who have
human rights violations, as described above
undergone female genital mutilations, and
and noted in the 2009 UN report to the General
encourage them to report to the appropriate
Assembly on the Girl Child: FGM is perpetrated authorities cases in which they believe
without a primary intention of violence but is de women or girls are at risk (14).
facto violent in nature (23).
Since the release of the interagency statement and
Thus, although outside of the immediate the resolution, significant efforts have been made
scope of these guidelines, the GDG thereby to counteract FGM, through (i)research to generate
differentiated FGM from FGCS. In the event further evidence to inform both policy and health
that FGCS is requested by an individual who is interventions; (ii)working with communities on
fully autonomous and able to give consent, the prevention strategies; (iii)advocacy; and (iv) passing
individual should be given complete preoperative of laws. The last involves enabling legislation
counselling, including a discussion of normal against FGM and focuses primarily on punitive
measures against practitioners and community
variation and physiological changes over the
members who perform FGM, as well as parents
lifespan, as well as the possibility of unintended
who support or condone it. Laws against FGM
consequences of cosmetic surgery to the genital
exist in more than half of the countries where
area. The lack of evidence regarding outcomes FGM is a traditional practice, as well as in many
and the lack of data on the impact of subsequent of the countries with communities of immigrants
changes during pregnancy or menopause should from countries where FGM is practised. While
also be discussed and considered part of the legal prohibitions create an important enabling
informed consent process (24). environment for abandonment efforts, and
criminal prosecutions can send a strong message of health. This is especially relevant with regard
against the practice, if these are not combined to the efforts to stop medicalization, placing
with education and community mobilization, the emphasis on the role of health workers
they risk placing health-care practitioners in the as caregivers who must not also become
position of enforcers of punitive policies, potentially perpetuators of a harmful practice.
damaging their relationships with their clients and
1.6.2 Purpose of these guidelines
limiting their capacity to engage in rights-based
and gender-equality-promoting health practices The main purpose of these guidelines is to provide
(13). A framework that includes preventive measures evidence-informed recommendations on the
to promote abandonment, as well as punitive management of health complications associated
measures for those who engage in the practice, with or caused by FGM.
has been shown to have a positive effect when
coupled with community-based work (21). The guidance provided covers selected topics
related to FGM that were considered critically
In spite of the positive signs resulting from these important by an international, multidisciplinary
efforts, prevalence of the practice in many areas group of health-care providers, patient advocates
remains high and millions of women live today and other stakeholders. These guidelines, therefore,
with the negative health consequences of FGM do not include all reported FGM-related health
(1). In this regard, the development of pertinent, conditions, but this should on no account be taken
evidence-based clinical guidelines for health to indicate that those conditions are not also real or
workers is of key importance. First and foremost, important.
guidelines help guide clinical decision-making and
ensure the delivery of standardized, quality health Additionally, these guidelines, and in particular the
services to girls and women currently suffering knowledge gaps it identifies, may be used as a
complications of FGM. blueprint for the design of research protocols that
could further enrich the scarce evidence currently
Secondly, guidelines serve as an important basis available on the management of health conditions
for both pre- and in-service medical training that may arise from FGM.
programmes, which are urgently needed not
only in countries with a high prevalence of FGM, 1.6.3 Target audience
but also in high-income countries that are home These guidelines are intended primarily for health-
to growing diaspora communities of people care professionals involved in the care of girls and
who have migrated from regions where FGM is women who have been subjected to any form of
widespread. As a result, health-care providers FGM. These health-care professionals may include,
across the globe, many of whom have received among others, obstetricians and gynaecologists,
little or no formal education on the issue of FGM, surgeons, general medical practitioners, midwives,
may find themselves ill-prepared to make sensitive nurses and other country-specific health cadres.
enquiries about FGM and to treat and care for girls Health-care professionals involved in the
and women with FGM-related complications (25). provision of mental health care and educational
Further, the development of guidelines offers a interventions, such as psychiatrists, psychologists
unique opportunity to systematically review the and social workers, are also part of the target
available evidence in specific areas of interest, and audience. This document also provides guidance
in this way to identify and target critical research for policy-makers, health managers and others in
gaps that are crucial to expanding our knowledge charge of planning, funding and implementing
in any given scientific field. pre- and in-service professional training, and for
those responsible for developing training curricula
Lastly, the technical knowledge conveyed within in the areas of medicine, nursing, midwifery and
these guidelines on how to recognize and manage public health.
complications of FGM makes it clear that the
procedure is inherently harmful to the health of
girls and women and, what is more, that it is a
violation of several human rights, including the
human right to the highest attainable standard
2. Methods
This document was developed according to of interest in the WHO handbook for guideline
the standards and requirements specified in the development (26). None of the meeting participants
WHO handbook for guideline development, second declared a conflict of interest that was considered
edition (26). In summary, the process included: significant enough to pose any risk to the guideline
(i)identification of critical research questions development process or to reduce its credibility. A
and outcomes; (ii)commission of systematic summary of the DOI statements and how conflicts
reviews to experts; (iii)retrieval of evidence; of interest were managed is included in Annex3.
(iv)quality assessment and synthesis of the
evidence; (v)presentation of the evidence using 2.3 Identification of priority
a structured approach; and (vi)formulation of research questions and outcomes
recommendations. scoping exercise
2.1 Guideline contributors After an initial scoping review of the available
literature, the WHO Steering Group identified
The guideline development process was guided and drafted a list of potential priority questions
by three main groups (a detailed description and outcomes related to health complications
of their roles is available in Annex2). The WHO from FGM using the population, intervention,
Steering Group, comprising a core group of comparator, outcome (PICO) format. This
WHO staff members and consultants from the preliminary list was then presented to the GDG
Adolescents and at-Risk Populations team within during the first guideline development meeting
the Department of Reproductive Health and held in Geneva, Switzerland, in February 2015.
Research, led the guideline development process. Based on the outputs of this meeting, an online
The Guideline Development Group (GDG), scoping survey containing the updated list of
formed of 15 external (non-WHO) international potential research questions was prepared in
stakeholders, including health-care providers, order to obtain input. Survey participants were
researchers, health programme managers, human asked to rate the importance of the questions
rights lawyers and womens health advocates, on a scale from 1 to 9 and to provide input on
advised on the content of the guidelines and the selection and rating of the outcomes. In this
formulated the evidence-based recommendations. context, questions that scored between 7 and 9
Finally, an External Review Group (ERG) of were ranked as critical, while those with a score
relevant international stakeholders reviewed the between 4 and 6 were considered as important,
final guideline document to identify any factual but not critical. The questions that scored lower
errors and commented on the clarity of the than 4 were not considered to be important for
language, contextual issues and implications for the purposes of these guidelines. A web annex
implementation. containing the scoping survey and the complete
list of questions is available upon request.
2.2 Declaration of interests by
The survey was sent out electronically to
external contributors
international experts in the field of FGM nominated
All GDG members and other external contributors by members of the GDG. In an effort to include
were required to complete a standard WHO as many respondents as possible, a public link
Declaration of Interest (DOI) form before engaging to the survey, was included on the Department
in the guideline development process and taking of Reproductive Health and Research website.
part in any of the guideline meetings. Before Provided that all 33 potential questions were ranked
finalizing experts invitations to participate in either as critical or important, but not critical by
the development of the guidelines, the WHO survey respondents, and given that the number of
Steering Group reviewed all the DOI forms using systematic reviews that could be commissioned
the criteria for assessing the severity of a conflict was limited due to resources, the WHO Steering
Group agreed to include the 11 most highly rated criteria for inclusion and exclusion of studies
questions in the scope of the guidelines. were reported using the PRISMA Guidelines and
flow diagram, and are described in the individual
Given that the initial search for articles performed systematic reviews. There were no restrictions on
by the systematic review team revealed a paucity language or publication dates.
of robust studies pertaining to almost all relevant
research topics, the WHO Steering Group, in
2.5 Quality assessment, synthesis
conjunction with the systematic review lead
and grading of the evidence
investigator and the guideline methodologist (see
Annex2), revised the list of questions in an effort The external team of systematic reviewers
to broaden their scope. Thus, complying with the performed a quality assessment of the body of
priority topics selected by survey participants, evidence using the Grading of Recommendations
a number of questions that shared the same Assessment, Development and Evaluation (GRADE)
intervention were identified and merged into methodology.6 Following this approach, the
a broader research question that included the quality of evidence for each outcome was rated
common intervention and an expanded list of as high, moderate, low or very low, based
outcomes. Both the original and prioritized lists of on the following set of pre-established criteria:
research questions are available upon request. (i)limitations in the study design and execution;
(ii)inconsistency of the results; (iii)indirectness;
2.4 Evidence retrieval (iv)imprecision; and (v)publication bias (26).
A systematic and comprehensive retrieval of In the final step of the assessment process, GRADE
evidence was conducted to identify published profiler software was used to construct GRADE
studies concerning the FGM-related health evidence profiles (or summary of findings tables)
complications prioritized during the scoping for each priority research question for which
exercise. None of the priority questions could be evidence was available; these tables include the
answered using an existing, recent systematic assessments and judgements relating to the
review (published less than two years prior) of elements described above and the illustrative
currently available publications. Therefore, to comparative risks for each outcome and are
inform the development of the recommendations, available in the Web Annex: GRADE tables.7
10 new reviews were commissioned from an
external team of systematic reviewers from 2.6 Qualitative research and
the Nigerian Branch of the South African human rights evidence
Cochrane Centre.
To obtain evidence on the values and preferences
A standard protocol was prepared for each of girls and women living with FGM and
systematic review, containing the PICO question health workers who provide health care to this
and the criteria for identification of studies, population, four additional systematic reviews of
including search strategies, methods for assessing qualitative research were carried out by an external
risk of bias and the plan for data analysis. The WHO consultant in collaboration with the WHO Steering
Steering Group and the guideline methodologist Group. These reviews focused on the contexts and
reviewed and endorsed the protocols before conditions surrounding:
the team of reviewers carried out each review.
medical/surgical interventions
To identify relevant studies, systematic searches
of several electronic databases were conducted, psychological interventions
including MEDLINE, CENTRAL via CSRO, CINHAL counselling interventions and
Plus (EBSCOhost), Web of Science, SCOPUS,
health information interventions.
PILOT, African Index Medicus, LILACS, PsycINFO
(EBSCOhost), POPLINE, WHOLIS via LILACS, ERIC
(EBSCO host), NYAM Library, ClinicalTrials.gov, 6 Further information available at:
African Journals Online (AOL) and Pan African http://www.gradeworkinggroup.org/
Clinical Trials Registry. The search strategies 7 Available at: http://www.who.int/reproductivehealth/
employed to identify the studies and the specific topics/fgm/management-health-complications-fgm/en/
Each of these four qualitative systematic reviews

Box 2.1. Factors considered while
aimed to: (i)understand stakeholder experiences
formulating each recommendation and
and perceptions of the interventions; (ii)identify
best practice statement
and summarize contextual barriers and facilitators
to implementation of the interventions; and
Quality of the available evidence
(iii)explore how the context and conditions of
implementation relate to the outcomes reported in Balance between benefits and harms
the effectiveness reviews.
Values and preferences of girls and women
Given that the provision of health services to living with FGM, and of health-care providers
women living with FGM should be accomplished
with the utmost care and consideration of girls Resource implications
and womens human rights, two literature reviews Priority of the addressed health problem
were commissioned from an external group of
human rights experts to better understand the Equity and human rights issues
public health and human rights/gender equality
Acceptability of the proposed intervention
linkages that pertain to FGM. These two reviews
sought to identify evidence on: (i)interventions Feasibility of the proposed intervention
to address and/or promote gender equality and
human rights in the context of FGM programmes
and policies; and (ii)how specific manifestations of Using each draft statement as a starting
gender inequality and neglect/violations of human point, participants could decide to
rights affect and are affected by FGM. recommend, recommend against, or not
make a final recommendation or best practice
The evidence obtained from the above-mentioned
statement. Additionally, before issuing a final
reviews helped inform the GDG about the values
recommendation, the strength of each issued
and preferences and human rights and equity
statement was agreed upon. The GDGs use of
issues, which constituted important considerations
the different categories for the strength of a
in deciding on the direction and strength of the
recommendation is explained in Annex4.
issued recommendations.
Best practice statements were issued when the
2.7 Formulation of available direct evidence was of low quality or
recommendations absent, and the contents of the recommended
statement were based on sound practical
Prior to the second guideline development
judgement, in addition to being supported by
meeting, which took place in September 2015,
human rights and equity principles, public health
the guideline methodologist in conjunction with
or medical practice, and when they were judged to
members of the WHO Steering Group formulated
carry little to no risk of harm to health.
an initial draft statement for each priority question,
which served as a blueprint for each of the finalized The final adoption of each best practice
recommendations and some of the best practice statement and recommendation and its
statements. During the September meeting, strength was decided by consensus, which was
all draft statements, evidence summaries and defined as the agreement of all the participants.
corresponding GRADE tables (where evidence was Unanimous agreement was reached for all but
available) were presented to the GDG members. one recommendation. This recommendation
Before issuing a final recommendation or best was put to vote and stood by simple majority.
practice statement, participants discussed the This situation was recorded as such in the text
presented evidence and systematically reviewed accompanying the recommendation. WHO staff at
each proposed draft statement considering a set of the meeting, external technical experts involved
established criteria (see Box2.1). in the collection and grading of the evidence, and
observers were not eligible to vote.
2.8 Document preparation and Review Group (ERG) for peer review (for a full list
peer review of the ERG members, please see Annex2). The
WHO Steering Group carefully evaluated all the
Following the GDG meeting, members of the input from the ERG members, which was limited
WHO Steering Group prepared a draft of the to correction of factual errors and language clarity,
full guideline document containing all the and provided responses to each of their comments
recommendations and best practice statements and then sent these responses back to each
formulated by the GDG as well as the key points external reviewer. No major disagreements arose
of the deliberations and decisions of the meeting during this process and no modifications were
participants. The draft guidelines were then sent made to the direction, strength or content of the
electronically to all GDG members for further recommendations.
comments before being sent to the External
3. Guidance
During the guideline development meeting 3.2 Recommendations and best

in September 2015, the participants adopted practice statements
three guiding principle statements, five
recommendations and eight best practice The recommendations contained in these
statements covering health interventions for guidelines were issued after consideration of the
preventing and treating health risks of FGM. existing evidence (when available) and its quality,
in addition to a series of factors as mentioned in
3.1 Guiding principles section 2: Methods (see Box2.1).
Decades of prevention work undertaken by local In general, the quality of evidence was low
communities, governments, and national and across most recommendations and best practice
international organizations have contributed to statements, and for a number of topic areas no
a reduction in the prevalence of FGM in some evidence was available. Despite the low quality or
areas (1). However, the overall rate of decline in non-existence of the evidence, some interventions
prevalence of FGM has been slow. Therefore, all were endorsed and labelled as best practice
recommendations and best practice statements statements if they were supported by the GDGs
issued in these guidelines are framed by the sound practical judgement. These statements
following three guiding principles that reflect the were also required to carry little to no risk of harm
stance of WHO and a wider group of UN agencies8 to health, and be supported by internationally
and the Guideline Development Group (GDG) recognized human rights standards and principles.
with regard to FGM and the need to end this The justification for each of these decisions was
harmful practice. recorded, along with key issues that need to be
considered for implementation. The corresponding
Guiding principles research gaps identified in each topic area were
also included. Where clinical recommendations
I Girls and women living with FGM have were based on indirect evidence (i.e. evidence that
experienced a harmful practice and should be was not directly from the population of women
provided quality health care. living with FGM), this was labelled accordingly.
3.2.1Deinfibulation
II All stakeholders at the community,
(recommendations 13 and best
national, regional and international level practice statements 12)
should initiate or continue actions directed
towards primary prevention of FGM. Deinfibulation is a minor surgical procedure carried
out to re-open the vaginal introitus in women
III Medicalization of FGM (i.e. performance living with typeIII FGM. In order to achieve this, a
of FGM by health-care providers) is never trained health professional performs an incision
acceptable because this violates medical of the midline scar tissue that covers the vaginal
ethics since (i) FGM is a harmful practice; introitus until the external urethral meatus, and
(ii) medicalization perpetuates FGM; and eventually the clitoris, are visible. The cut edges
(iii) the risks of the procedure outweigh any are then sutured, which allows the introitus to
perceived benefit. remain open. This procedure is performed to
improve health and well-being, as well as to allow
intercourse and/or to facilitate childbirth.
8 OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNFPA,

UNHCR, UNICEF, UN Women (formerly UNIFEM). See list of
acronyms for full agency names.
Recommendation 1: Deinfibulation is recommended for preventing and

treating obstetric complications in women living with type III FGM
Strength of recommendation: Strong (very low-quality evidence)
SUMMARY OF EVIDENCE (SEE WEB ANNEX: GRADE TABLES)
The evidence was extracted from a systematic review investigating the effects of deinfibulation
for preventing and treating obstetric complications in women with type III FGM (27). The review
included four casecontrol studies: two conducted in the United Kingdom (28, 29) and two in Saudi
Arabia (30, 31).
Two studies compared women with type III FGM. One group had deinfibulation during labour and
the other laboured and delivered without deinfibulation (28, 29). The studies found better obstetric
outcomes among women who underwent deinfibulation during labour, compared with women
who remained infibulated. Caesarean section and postpartum haemorrhage rates were statistically
significantly lower in women with deinfibulation (very low-quality evidence).
Two studies compared women with type III FGM who underwent deinfibulation during labour to
women who had never undergone FGM (therefore, non-infibulated) (30, 31). Both groups had similar
rates of episiotomy and duration of second stage of labour. Rouzi et al. (2001) further showed, when
comparing women with deinfibulation to women who had not undergone FGM, that their mean
amount of blood loss, length of maternal hospital stay (in days), and rates of caesarean section, vaginal
lacerations, and newborns Apgar scores at 1 and 5 minutes were not statistically different (very low-
quality evidence).
Additional evidence from a WHO collaborative prospective study carried out in six African countries
shows a potentially causal, dose-response risk between increasingly extensive types of FGM
and adverse obstetric and neonatal outcomes, with greater risk for adverse reproductive health
outcomes with FGM types II and III (9). The evidence further suggests that FGM does not impact fetal
development (no association between FGM and birth weight), but has an impact on delivery, with
higher rates of fresh stillbirths among women living with FGM (9).
RATIONALE
Considering the potential doseresponse relationship described between the types of FGM and
the risk of obstetric complications, and based on the clinical benefits described within the evidence
reviews, which in addition show that when using women who were never infibulated as controls,
performing deinfibulation during vaginal delivery is a management option that does not increase the
likelihood of superimposed obstetric complications, the GDG recommended reversing typeIII FGM
through deinfibulation for preventing and treating obstetric complications.
In addition the GDG noted:
Based on the causal relationship between typeIII FGM (infibulation) and a number of health
complications identified by the WHO collaborative prospective study carried out in six African
countries (9), deinfibulation can be considered as a surgical procedure that can re-open the narrowed
introitus, restoring the anatomy of the pelvic outlet (to the extent possible). This may contribute to
a reduction of overall health-care costs by encouraging a trial of labour (rather than using history
of FGM alone as the indication for caesarean section), or avoiding severe perineal injury due to
spontaneous lacerations or episiotomy performed at the time of delivery. Both caesarean section and
repair of third- and fourth-degree lacerations require significantly higher levels of surgical skill and
may themselves have longer-term adverse outcomes resulting in higher health-care costs (e.g. care
and management of urinary incontinence due to pelvic floor instability, conditions that may arise as a
result of perineal lacerations).
In addition to being medically unnecessary, FGM interferes with healthy genital tissue and can lead
to severe consequences for a womans physical and mental health. Its practice has therefore been
considered by international and regional human rights bodies as a violation of a persons right to the
highest attainable standard of health. When performed with informed consent, restoring the anatomy
and physiology (to the extent possible) through deinfibulation may therefore be seen as a necessary
part of upholding a womans right to health and ensuring access to health-care goods and services
needed by women to enjoy the full extent of this right.
IMPLEMENTATION REMARKS
Providers conducting deinfibulation must be adequately trained on how to carry out this surgical
procedure. Nonetheless, the relatively simple nature of this surgical procedure would allow for the
training of mid-level health workers to perform deinfibulation, with the consequent reduction of the
required human and financial resources.
Available qualitative evidence shows that the lack of knowledge among health workers regarding
deinfibulation is not only an important reason why providers may avoid performing deinfibulation,
even in contexts in which it has been requested, but it also affects women who describe the
providers inexperience as a significant source of fear (32). The GDG therefore noted that adequate
health-care provider training is a crucial and urgently needed step in the implementation of this
recommendation.
Recommendation 2: Either antepartum or intrapartum deinfibulation is

recommended to facilitate childbirth in women living with type III FGM,
depending on the context
Strength of recommendation: Conditional (very low-quality evidence)

Given that both antepartum and intrapartum deinfibulation appear to be comparable in terms of
obstetric outcomes, the decision about the timing of the procedure should be based on the following
contextual factors:
preference of the woman
access to health-care facilities
place of delivery
health-care providers skill level.
SUMMARY OF EVIDENCE (SEE WEB ANNEX: GRADE TABLES)
Evidence on the timing of deinfibulation for childbirth in women with type III FGM was extracted
from a systematic review investigating the effects of antepartum or intrapartum deinfibulation on
the outcomes of childbirth (33). The review included five retrospective, observational studies: two
conducted in the United Kingdom (29, 35), two in Saudi Arabia (30, 31), and one in Sweden (34).
The analysis was limited to the two casecontrol studies (29, 35) that directly compared the timing
of deinfibulation antepartum and intrapartum. The findings show that duration of labour, perineal
lacerations, postpartum haemorrhage, and rates of episiotomy were not significantly different based
on the timing of deinfibulation (very low-quality evidence).
RATIONALE
According to the available evidence, obstetric outcomes appear comparable irrespective of the timing
of deinfibulation antepartum or intrapartum between women living with typeIII FGM who are
deinfibulated and women who present in labour with no infibulation (low certainty).
Given the above, and due to the paucity of direct evidence on womens preferences regarding the
timing of deinfibulation, members of the GDG considered that the decision should be founded on the
following contextual factors.
1. Preference of the woman: Women should be consulted on their preferences. For example, if a
client places high importance on the postoperative aesthetic results, antepartum deinfibulation
should be preferred in order to allow adequate healing time and optimal aesthetic results.
2. Access to health-care facilities: In settings where women may encounter unintended delays
while reaching health-care facilities due to difficult access, antepartum deinfibulation should
be preferred.
3. Place of delivery: Given that deinfibulation should be carried out by a trained health-care provider,
in contexts where home deliveries are common, antepartum deinfibulation should be prioritized.
The same applies to settings where the health-care facility has a high patient load.
4. Health-care providers skill level: Anatomical conditions like tissue oedema and distortion
during labour may pose difficulties for less-experienced health-care professionals performing
intrapartum deinfibulation. In this case, antepartum deinfibulation should be preferred.
In settings with experienced, well-trained providers, intrapartum deinfibulation is an
acceptable procedure.
The available qualitative evidence suggests a lack of clarity on the responsibility for various tasks along
the care continuum among health-care providers caring for women living with FGM (32), which may
represent a barrier to identifying women who are in need of deinfibulation to prevent FGM-related
obstetric risks. In this regard, the GDG emphasized the importance of establishing a clear referral
pathway, in particular for pregnant women living with typeIII FGM, and encouraged efforts to define
the roles and responsibilities of health-care personnel within the client continuum of care from
antenatal care to the postpartum period.
Recommendation 3: Deinfibulation is recommended for preventing and treating

urologic complications specifically recurrent urinary tract infections and
urinary retention in girls and women living with type III FGM
The GDG could not reach consensus regarding the strength of this recommendation. Therefore, it was
put to the vote: among 12 of the 14 attending GDG members who were eligible and opted to vote on
this topic, 11 voted for strong while 1 voted for conditional.9
Strength of recommendation: Strong (no direct evidence)
SUMMARY OF EVIDENCE
A systematic review investigating the effects of deinfibulation on the prevention or treatment of

recurrent urinary tract infections (UTIs) and urinary retention among women who have undergone
typeIII FGM (infibulation) was carried out to help inform this recommendation (36). The authors found
no studies that met the inclusion criteria; therefore direct evidence on the effects of deinfibulation on
restoring normal function is at present not available.
RATIONALE
Additional evidence from a systematic review that explored the effects of FGM on physical health
outcomes confirms that reduced urinary flow beneath the infibulation scar can result in symptoms
of urinary obstruction, which may lead to recurrent UTIs due to stasis of urine, conditions which
commonly appear in this population (6).
Based on the above evidence and the clinical experience of medical practitioners within the GDG, the
group further emphasized that several urological conditions normally treated with low-complexity
medical procedures among women with no FGM (i.e. catheterization for acute urinary retention or prior
to elective and/or emergency caesarean section) cannot easily be treated with these same procedures in
the presence of typeIII FGM (infibulation). This may turn health conditions of low complexity into serious,
potentially fatal situations that could be averted if deinfibulation was performed in a timely manner. Thus,
despite the lack of direct evidence on the effects of deinfibulation on restoring normal function, the GDG
relied on expert opinion and recommended deinfibulation for treating urinary conditions among girls and
women living with typeIII FGM. With this recommendation, the GDG aimed to prevent severe negative
health outcomes due to complications related to urological conditions in the context of infibulation.
The GDG further endorsed this intervention, based on the fact that FGM violates a series of well-established
human rights principles, norms and standards, including the principles of equality and non-discrimination
on the basis of sex, the right to life and bodily integrity, the right to the highest attainable standard of health
and the right to freedom from torture or cruel, inhuman or degrading treatment or punishment. Therefore,
based on the human rights argument addressed in recommendation No.1, the GDG also highlighted
that the restoration of the anatomy and physiology (to the extent possible) through deinfibulation should
be seen not only as a treatment for urological health complications, but also as an attempt to reinstate a
violated human right, in particular the right to the highest attainable standard of health.
Providers conducting deinfibulation must be adequately trained on how to carry out this surgical
procedure. The training of mid-level health workers to perform deinfibulation represents an acceptable
approach that can lower the costs of the intervention and increase access to the procedure.
9 The GDG member who voted for a conditional recommendation did so given the urgent need for robust studies that
directly examine deinfibulation for the treatment of urologic conditions in this population.
Best practice statement 1: Girls and women who are candidates for
deinfibulation should receive adequate preoperative briefing
Evidence on values and preferences of women who underwent deinfibulation suggests that some
women may report initial discomfort with the postoperative appearance of deinfibulated labia (32).
Therefore, in addition to obtaining preoperative consent, when counselling women with a history
of FGM, health-care personnel should always provide balanced, unbiased counselling on expected
benefits and potential risks associated with a procedure in a clear preoperative briefing. In the context
of deinfibulation, this briefing should include information regarding the anatomical and physiological
changes that can be expected after deinfibulation (i.e.faster micturition, increased vaginal discharge).
Best practice statement 2: Girls and women undergoing deinfibulation should

be offered local anaesthesia
As with any other surgical procedure, the GDG noted that irrespective of the timing, deinfibulation
should be carried out under local anaesthesia. However, given that local anaesthesia may not be
readily available in some low-resource settings, in situations in which deinfibulation may be critical
for the progression of labour or in the event of a life-threatening condition, deinfibulation should
be carried out regardless of the unavailability of local anaesthesia. For example, this may be done to
relieve obstructed second stage of labour to deliver the fetal head, similar to performing an episiotomy.
Research implications
Recognizing the importance of deinfibulation in preventing complications and improving birth outcomes
for women with typeIII FGM, research is needed on how to ameliorate the practice around deinfibulation
among different cadres of providers in a range of clinical settings and cultural contexts. Many providers are
not well informed about how and when to deinfibulate women, and there are many gaps in evidence on
how to improve practice in this regard.
Some specific research gaps identified include the following:
Research to understand the factors that promote uptake of or act as barriers to deinfibulation is
urgently needed, in particular regarding:
womens knowledge and acceptance of the deinfibulation procedure
male partners views and knowledge on the surgical procedure
content and quality of existing deinfibulation training programmes for health-care providers.
Additional research is needed regarding urological consequences, not only to understand the risk
of urological complications among women with typeIII FGM, but also to understand the effects of
deinfibulation on urologic outcomes, particularly on recurrent UTIs and urinary retention. Establishing
whether women with typeIII FGM are at an increased risk of urological complications can be done
through retrospective studies and will be an important step in justifying the need for deinfibulation to
reduce urological complications. In addition, evaluating long-term clinical outcomes of women who
have undergone deinfibulation will provide much needed evidence on the role of deinfibulation in
improving health and reducing urological complications of women with typeIII FGM.
There is a need for additional research to determine how to best inform women on deinfibulation
options during pregnancy or childbirth, which will inform how to improve uptake of deinfibulation. In
particular, research is needed to compare deinfibulation outcomes not only between the ante- and
intrapartum periods, but also among different time points within the antepartum phase.
3.2.2 Mental health (recommendation anxiety disorders including post-traumatic stress

4 and best practice statement 3) disorder (PTSD) among this population, following
the FGM procedure (12, 3741). These data suggest
Girls and women living with FGM are more likely to that FGM and its associated health risks are
have a psychiatric diagnosis than women without psychological stressors that can lead to a variety
FGM (11). This has been further detailed in several of negative psychiatric outcomes, including the
studies that have documented depression and above-mentioned conditions.
Recommendation 4: Cognitive behavioural therapy (CBT) should be considered

for girls and women living with FGM who are experiencing symptoms consistent
with anxiety disorders, depression or post-traumatic stress disorder (PTSD)
Strength of recommendation: Conditional (no direct evidence)
CBT may be considered provided that:
a psychiatric diagnosis of anxiety disorder, depression or PTSD has been established, and
it is offered in contexts where individuals are competent (i.e. trained and supervised) to provide
the therapies.
In resource-constrained settings, stress management may be the most feasible treatment option (42).
Further information available at: http://www.who.int/mental_health/emergencies/mhgap_module_
management_stress/en/
SUMMARY OF EVIDENCE
A systematic review investigating the effects of CBT for PTSD, depression or anxiety disorders in girls
and women living with FGM was conducted to help inform this recommendation (43). The authors
found no studies that met the inclusion criteria and therefore direct evidence could not be used for
this recommendation.
RATIONALE
CBT represents an evidence-based treatment that can effectively reduce or resolve symptoms of
PTSD, depression and anxiety disorders associated with other conditions, including survivors of
torture and war and victims of sexual violence (4446). Given existing evidence on the beneficial
effects of psychological treatment with CBT for these disorders in other populations, the GDG
agreed it would be reasonable to assume that this intervention can also benefit girls and women
living with FGM. As the indirect evidence refers only to these three psychiatric conditions, the GDG
felt a conditional recommendation was warranted and noted that it should apply exclusively to girls
and women living with FGM with a confirmed psychiatric diagnosis and be delivered by adequately
trained individuals.
From a human rights point of view, the right to the highest attainable standard of health, as recognized
under international and regional standards, includes the right to a state of complete physical, mental
and social well-being. The right has been interpreted to include:
[T]he creation of conditions which would assure to all medical service and medical attention in the
event of sickness, both physical and mental, including the provision of equal, timely access to basic
preventive, curative, rehabilitative health services . . . which would also include appropriate mental
health treatment and care (47).
Regarding the feasibility of this intervention, and in particular the shortage of health-care personnel
adequately trained to deliver CBT in most low- and middle-income countries, the GDG recommended
consulting the Assessment and management of conditions specifically related to stress: mhGAP intervention
guide module, which contains a number of interventions for clients presenting with PTSD that can
be safely delivered by community health workers, including psycho-education and alternative
stress management techniques (e.g. breathing exercises, progressive muscle relaxation) (42). Further
information available at: http://www.who.int/mental_health/emergencies/mhgap_module_
management_stress/en/
Additionally, the GDG discussed evidence from supplementary studies that support the use of Internet-
based CBT (i.e. psychological self-help programmes mediated via the Internet) as an efficacious
treatment for individuals with a confirmed primary diagnosis of PTSD (48). Because web-based
programmes can be accessed anonymously and anywhere a computer is available, these services have
the potential to surmount stigma, as well as geographical and financial barriers to accessing mental
health treatment (49), making them a plausible therapeutic option for this population.
Best practice statement 3: Psychological support should be available for girls

and women who will receive or have received any surgical intervention to
correct health complications of FGM
Available qualitative evidence on values and preferences of girls and women living with FGM from two
studies conducted in Gambia and among migrant populations in Norway and the Netherlands shows
that women may experience several negative psychological outcomes secondary to the performance
of FGM, including anxiety, fear, sense of betrayal, pain and anger (50). This is additionally supported by
evidence from a meta-analysis which shows that women living with FGM have a higher risk of having
a psychiatric diagnosis compared to women with no FGM (11). The former explains why psychological
support interventions may be especially needed among this population, particularly in the context of
stressful life events that may remind the client of the initial trauma caused by the FGM procedure, such
as surgical procedures to correct FGM-related complications.
There is no direct evidence on the effect of psychological interventions on post-operative outcomes

for girls/women undergoing a procedure to manage health complications associated with FGM. As a
result, the GDG considered indirect evidence on the effects of psychological interventions on recovery
from surgery in other populations, including abdominal and hernia surgeries (5152). The GDG noted
the benefits of psychological support in terms of postoperative pain, recovery and psychological well-
being, when offered as an adjunct to surgical procedures.
Supported by the indirect evidence and the fact that psychological support includes activities
that range from special programmes to quite simple, inexpensive modifications of or additions
to required medical procedures, including the provision of procedural information or emotional
support, the GDG considered that the intervention should be available to women undergoing surgical
procedures to correct complications from FGM.
From a human rights perspective, the GDG strongly emphasized that the right to the highest
attainable standard of health includes the right to a state of both complete physical and mental health,
together with social well-being (47). This recommendation would therefore stand in accordance with
the realization of the right to health of girls and women living with FGM.
POLICY AND PROGRAMMATIC REMARKS
Regarding the human resources needed to provide psychological support in the context of surgical
procedures to correct health complications from FGM, the GDG acknowledged that delivering mental
health interventions can rely heavily on health personnel rather than on technology or equipment, and
that most low- and middle-income countries have insufficient trained and available human resources.
In this regard, based on guidance on task shifting from the Mental Health Gap Programme (mhGAP)
(53), the GDG suggested that some of the priority interventions can be delivered by community health
workers, after specific training and with the necessary supervision. Further information available at:
http://www.who.int/mental_health/emergencies/mhgap_module_management_stress/en/ (42).
Research implications quasi-experimental designs include reduced

emotional distress, improved coping mechanisms,
The increased risk of adverse mental health effects improved understanding of anatomy and health
from FGM suggests that women with FGM may risks associated with FGM, as well as understanding
need additional psychological support in general the risks and benefits of a surgical procedure to
and when seeking surgical intervention related address the health complications of FGM.
to complications from FGM. However, there is a
need for additional epidemiological research to In particular, further research is needed to examine
demonstrate the influence of FGM on specific the effectiveness of CBT for treating PTSD and
mental health effects. In addition, there is a need depression symptoms among girls and women
for evidence regarding what type of psychological living with FGM. Specific outcomes that can be
intervention would be the most helpful to girls and measured include reduced PTSD symptomatology,
women living with FGM. improved functioning, reduced emotional distress
and depression.
Development and testing of the content of
psychological support and health education as In addition, more evidence is needed on modes
well as modes of delivery of such interventions are of delivering CBT (i.e. through trained health-
important steps in developing evidence-based care providers or community-health workers or
best practice. Whether psychological support is through self-help programmes via the Internet,
provided by lay providers, psychologists or other where appropriate) in order to determine the
providers, the content and delivery will vary. effectiveness and acceptability of different delivery
Some outcomes that can be assessed through methods.
interventions research using experimental or
3.2.3 Female sexual health only certain aspects of reproductive health such
(recommendation 5) as being able to control ones fertility through
access to contraception and abortion, and being
The achievement of the highest attainable standard free from sexually transmitted infections (STIs),
of health also comprises the right to sexual health. sexual dysfunction and sequelae related to sexual
Sexual health is widely understood as a state of violence or FGM but also the possibility of having
physical, emotional, mental and social well-being pleasurable, safe sexual experiences, free of coercion,
in relation to sexuality and it encompasses not discrimination and violence (54).
Recommendation 5: Sexual counselling is recommended for preventing or

treating female sexual dysfunction among women living with FGM
Strength of recommendation: Conditional (no direct evidence)
This is conditional because there is a general lack of direct evidence regarding the use of sexual counselling
specifically among women living with FGM, and it is anticipated that this topic will be highly sensitive.
SUMMARY OF EVIDENCE
A systematic review investigating the effects of sexual counselling for treating or preventing sexual
dysfunction in women living with FGM was conducted to help inform this recommendation (55). The
authors found no studies that met the inclusion criteria and therefore direct evidence could not be used.
RATIONALE
Current evidence from a systematic review that looked at the effects of FGM on the sexual functioning
of women substantiates the proposition that a woman whose genital tissues have been partly
removed is more likely to experience increased pain and reduction in sexual satisfaction and desire
(56). In this regard, the GDG underlined that surgery alone in particular clitoral reconstruction does
not treat all aspects of sexual dysfunction that may occur among women living with FGM (57), and
other medical interventions such as the use of genital lubricants have not been extensively studied.
What is more, studies show that the use of gels may not be acceptable among women and their
partners, depending on personal sexual practices and the degree to which men exercise influence
in determining whether and how these products are used (58). Given the above, and in recognition
that womens sexuality is multifactorial and depends, among other things, on the interaction of
anatomic, cognitive and relational factors, the GDG noted that offering treatment alternatives for sexual
dysfunction in this case sexual counselling to this population should be seen as a priority.
Based on clinical experience and indirect evidence that supports sexual counselling as an effective
treatment for sexual dysfunction in other populations, including patients with breast cancer and
cardiovascular disease (5962), the GDG considered the intervention to be beneficial, provided it is
adequately adapted to different countries and cultural contexts. The GDG agreed that in order to avoid
unintended adverse effects, like intimate partner violence or social stigma, characteristics such as
clients age, marital status and potential inclusion of the male partner must be taken into consideration
when offering sexual counselling to women living with FGM.
Additionally, according to General Recommendation No.24 on Article12 of the Convention on the

Elimination of All Forms of Discrimination against Women (CEDAW), parties should ensure, without
prejudice or discrimination, the right to sexual health information, education and services for all girls
and women (63, 64). In this regard, offering sexual counselling helps promote the fulfilment of the right
of girls and women living with FGM to a healthy sexual life.
Research implications Studies are needed on the efficacy of available

surgical and non-surgical treatment options for
Establishing whether FGM increases risks of pain girls and women with FGM experiencing both
during intercourse and other forms of sexual acute and chronic vulvar and clitoral pain (see also
dysfunction is an important step in developing section3.3.1).
interventions. In addition, more research is needed
to investigate the efficacy of sexual counselling In addition, there is a need for research to assess
interventions in treating sexual dysfunction among the efficacy of sexual therapy independent of
women living with FGM. and in conjunction with clitoral reconstruction
in improving sexual health among women living
with FGM.
3.2.4 Information and education (best practice statements 48)
Best practice statement 4: Information, education and communication (IEC)

interventions regarding FGM and womens health should be provided to girls
and women living with any type of FGM
WHO defines IEC interventions as a public health approach aiming at changing or reinforcing health-
related behaviours in a target audience, concerning a specific problem and within a pre-defined
period of time, through communication methods and principles (65).
In this regard, a recent systematic review that included five studies conducted in African countries (66)
investigated the effects of providing information and education interventions involving FGM and
health-related topics to girls and women living with any type of FGM (see Web Annex: GRADE tables).
The review concluded that IEC interventions appear to have positive effects on girls and women living
with FGM and other community members by reducing:
the willingness of women to recommend FGM for their daughters;

the shyness among women to discuss FGM; and
new cases of FGM among girls aged 510 years, two years after women and men attended
educational sessions.
This systematic review identified a number of IEC interventions that were carried out within
communities with high prevalence of FGM such as:
participatory educational modules on womens health, basic hygiene, problem-solving and

human rights issues (6770);
targeted advocacy against FGM (67,71);
mass media campaigns to stimulate and publicize dialogue around FGM and its associated
harmful effects (67,71); and
community-based initiatives to mobilize groups to create public declarations against FGM (68).
It was noted, however, that programmes that empower women, particularly adolescent girls and
young women, by encouraging them to learn about their bodies and to exercise their rights, remain
extremely rare (72). According to UN estimates, the vast majority of adolescents and young people
lack access to information and education about their bodies and about the negative consequences
associated with FGM (73).
Therefore, supported by the evidence and the fact that the provision of education and information to
girls and women is in line with international human rights, norms and standards and constitutes an
important measure for reducing inequalities, the GDG agreed that this type of educational intervention
should be encouraged and further developed in countries where FGM is either practised or present.
The GDG noted that although specific IEC interventions cannot be recommended at present, due to
the paucity of evidence, this should constitute an important research priority.
However, the GDG emphasized the importance of ensuring adequate content of the IEC interventions
in order to avoid unintended adverse effects, such as recreating trauma, particularly among girls and
women diagnosed with PTSD.
Therefore, educational interventions should be:
evidence-informed and scientifically accurate

non-prejudicial
non-judgemental
sensitive and respectful
non-stereotypical
based on adolescents evolving capacities (when provided to this group).
The GDG noted that well-designed, effective IEC programmes can be resource-intensive, mainly
due to the human resources required to implement them and the time required for effective
knowledge shifting to occur. Although these associated costs will vary depending on the nature of the
intervention, ways of lowering expenditures should be sought during the design of such programmes.
This may include adapting existing programmes to local contexts and using innovations, including
digital health strategies, for example.
Best practice statement 5: Health education and information on deinfibulation

should be provided to girls and women living with type III FGM
Health education is the provision of accurate and truthful information so that a person can become
knowledgeable about a subject and make an informed decision (74). In the case of deinfibulation for
girls and women living with typeIII FGM, health education aims to provide scientific, non-coercive
information to help clients understand the surgical procedure, its benefits and also its potential
associated complications.
Health education on deinfibulation should contain the following:
a description of the surgical procedure;

health benefits of deinfibulation;
potential immediate and long-term adverse surgical outcomes;
anatomical and physiological changes clients may experience after the procedure;
information on adequate postoperative care; and
information about the health consequences of re-infibulation and the benefits of not
re-infibulating.
The GDG emphasized that providing health education and information on deinfibulation to women
living with FGM may serve two purposes. Firstly, to guarantee the clients principle of autonomy,
expressed through free, full and informed decision-making, which is a central theme in medical ethics,
and is embodied in human rights law. Respecting autonomy in decision-making requires that any
counselling, advice or information provided by health workers or other support staff be non-directive,
enabling individuals to make decisions that are best for themselves (63).
Secondly, informing girls and women about the health effects of deinfibulation and also the
implications of re-infibulation may contribute to reducing the requests for re-infibulation, a procedure
that has been increasingly banned in several countries. This was supported by available evidence
extracted from a systematic review investigating the impact of counselling before deinfibulation on
client satisfaction and the rate of requests for re-infibulation among women with typeIII FGM (75)
(see Web Annex: GRADE tables). The only study meeting the inclusion criteria was an abstract from a
prospective casecontrol study (76). This study reported reduced rates of requests for re-infibulation
among women with typeIII FGM post-delivery after receiving antenatal counselling prior to
deinfibulation, although these results did not reach statistical significance (very low-quality evidence).
Available qualitative evidence indicates that the fact that women may delay seeking care and may
be ashamed to publicly discuss problems related to FGM represents a potentially important barrier to
the intervention (77). Consequently, the GDG emphasized the importance of developing strategies for
reaching out to this population, in addition to designing health education programmes that are easily
accessible and provide a welcoming environment.
Best practice statement 6: Health-care providers have the responsibility to

convey accurate and clear information, using language and methods that can be
readily understood by clients
Individuals have the right to be fully informed by appropriately trained personnel (63). This signifies
that health-care providers have the responsibility to convey accurate, clear information, using language
and methods that can be readily understood by the client (e.g.with the assistance of an interpreter if
necessary) together with proper, non-coercive counselling, in order to facilitate full, free and informed
decision-making (78).
Best practice statement 7: Information regarding different types of FGM and the
associated respective immediate and long-term health risks should be provided
to health-care providers who care for girls and women living with FGM
Caring for girls and women living with FGM requires knowledgeable health-care providers, adequately
trained to identify, treat or refer clients who may present with a range of health complications due to
different types of FGM. Although evident, this requirement is in many cases not fulfilled, as expressed
by the available qualitative evidence discussed by the GDG.
Evidence from a knowledge, attitudes and practices (KAP) study on FGM carried out among Flemish
midwives (79) and a systematic review on context and conditions surrounding health information
interventions on FGM highlighted the emotional distress experienced by health-care professionals
caring for women with FGM, mainly due to lack of provider training and skills to manage the care of
these clients (80). Providers also mentioned a feeling of low competence in handling discussions about
FGM with women, and openly indicated their need for more information on the subject. Consequently,
women report experiences of poor communications with health workers, which are exacerbated
by their own feelings of shyness while discussing FGM. These studies therefore indicate that both
providers and clients need informational interventions and that the provision of knowledge may offer
mutual benefits for both client and provider.
In addition, the GDG discussed available evidence extracted from a systematic review investigating
the effects of providing information about the consequences of FGM to health-care providers caring
for girls and women living with FGM (81) (see Web Annex: GRADE tables). The only study that could
be included was a controlled before-and-after study conducted in Mali that reported statistically
significant improvement of providers ability to name any type of FGM after attending training sessions
that involved the provision of information on female anatomy, FGM and the prevalence of FGM in
Mali and other regions (82). A positive trend was observed with regard to the effects of the training on
health-care providers knowledge about immediate and long-term risks of FGM, although these results
did not reach statistical significance (very low-quality evidence).
The GDG concluded that improving health-care providers abilities to correctly identify and record the
different types of FGM, in addition to adequately recognizing the associated health complications,
constitutes a fundamental step towards improving the quality of health care, with the additional
benefit of strengthening the capacity of monitoring FGM.
The GDG stressed that regular, ongoing capacity-building programmes on FGM should be seen as a
priority for health personnel, both in high-FGM-prevalence countries and countries that are home to
diaspora communities affected by FGM. Unfortunately, despite a few encouraging examples in some
African countries (83,84), FGM is rarely covered in detail in the training curricula of nurses, midwives,
doctors and other health-care professionals. The GDG suggested this best practice statement could
serve as a cornerstone for the development of core curricula for both academic and in-service training
in an effort to fill gaps in professional education.
Finally, in order to lower the possible costs associated with the intervention, as for best practice
statement No.4, the GDG encouraged considering the adaptation of existing programmes to local
contexts and the use of emerging innovations, including digital health strategies, for example.
Best practice statement 8: Information about FGM delivered to health workers

should clearly convey the message that medicalization is unacceptable
The GDG expressed concern about increased medicalization being a potential unintended effect of
providing information about FGM to health workers. To avoid this, all provided information should:
specifically address medicalization and its risks;

contain scientifically accurate and evidence-based content;
also target non-medical staff, who in certain settings perform some health-care tasks; and
be delivered in local languages (i.e.proper translations) in order to ensure adequate
comprehension.
Research implications 3.3 Interventions for which no

recommendations were issued
There is a need for more rigorous evaluation of
training and education interventions aimed at In addition to the topics covered by the
clients and providers. recommendations and best practice statements
issued and included in these guidelines, the GDG
For example, while there are several promising
discussed the results of two additional systematic
community-based IEC interventions aimed at
reviews during the guideline development
improving knowledge, changing norms and
meeting. These reviews investigated the effects
reducing FGM, the lack of rigorous evaluations of
of surgical and non-surgical interventions for
the effectiveness, acceptability and sustainability
the treatment of vulvar pain (vulvodynia) and
of these interventions has resulted in a knowledge
clitoral pain, and the safety and efficacy of clitoral
gap. Evidence is needed on whether a particular
reconstruction in girls and women girls living
programme or approach has achieved its intended
with FGM.
outcomes before it can be recommended or scaled
up. Incorporating an evaluation component into Due to lack of evidence (in the case of
existing programmes and/or testing community- interventions for treating vulvodynia and clitoral
based interventions through experimental or quasi- pain) and safety concerns (in the case of clitoral
experimental research designs is an important step in reconstruction), the GDG decided not to issue any
designing evidence-based IEC programmes to reduce recommendations regarding these interventions at
FGM in communities with a high prevalence of FGM. present and strongly encouraged further research
in these areas.
In addition, training and education aimed at
providers should assess how to improve providers Nonetheless, in recognition of the clinical
knowledge about types of FGM and health importance of vulvodynia and clitoral pain and the
consequences, their attitudes regarding FGM, and increasing interest and advertisement for clitoral
their manner of interacting with clients. reconstruction as a strategy to restore sexual
pleasure and female identity, the GDG considered it
Further, more rigorous evaluations are needed on
relevant to include a brief discussion of both topics
how education interventions aimed at health-care
within these guidelines, as provided in this section.
providers impact clients experiences and their
interactions with providers. This can be done by 3.3.1 What are the treatment alternatives
assessing client satisfaction during an evaluation for vulvodynia and clitoral pain in girls and
or through more experimental research designs in women with any type of FGM?
which client outcomes are compared among those A systematic review investigating the effects of
treated by providers who received specialized surgical and non-surgical interventions for the
training and those who did not. treatment of vulvodynia and clitoral pain in girls
Health education surrounding surgical intervention and women living with FGM was presented to
is a necessary component in informed care, but help inform this discussion. The authors found no
evidence on outcomes of these health education studies that met the inclusion criteria therefore
sessions is crucial for improving the content and direct evidence was not available.
delivery of these health education interventions Given the current lack of direct evidence in this
for clients. In particular, two key outcomes were topic, the GDG agreed that vulvodynia and
identified as research priorities by the GDG client clitoral pain should be alleviated based on clinical
satisfaction and the rate of requests for re-infibulation. judgement and client preferences. Some available
Additional outcome measures that can be explored treatment alternatives include:
include impact of health education interventions on
womens knowledge about anatomy, health effects use of water-soluble lubricants during sexual
of FGM, and health benefits of deinfibulation. There intercourse
is also a need for evidence on how male partner easing pressure on the vulvar area (i.e. avoid
involvement in the health education process can activities like bicycling)
impact womens satisfaction with services, and their
rate of requests for re-infibulation. local anaesthetics (i.e. lidocaine gel).
In addition, the GDG emphasized that several Three studies reported complication rates that
potential adverse events are associated with fluctuated between 5.3% and 23.6% (8688). These
surgical interventions (i.e.pain, additional scarring complications included postoperative readmission
and bleeding) and stated that unless a clear direct rates up to 5.3% and reoperation rates between
cause for pain (e.g.scar tissue, clitoral neuroma, 3.7% and 4.2%. One study reported reduced
abscess, cyst) is identifiable, surgical procedures clitoral response in 12 out of 53 women who had
should be avoided. experienced regular orgasms preoperatively (87).
In the case of asymptomatic women living with The available evidence shows that reconstructive
FGM who request surgery, the GDG expressed clitoral surgery may improve chronic clitoral pain
strong reservations about performing any kind of as well as dyspareunia symptoms among women
surgical intervention and agreed that in situations who have had clitoral tissue excised or damaged
where interventions are performed on the basis due to FGM. While these results may appear
of clinical judgement, the management of these promising, the GDG expressed considerable
cases should always start with the least invasive apprehension regarding the methodological
procedure available. limitations of the included studies, in particular
the large or unknown loss to follow-up and the
3.3.2 What is the role of clitoral
use of non-validated scales for measuring clitoral
reconstruction?
function, in addition to the unacceptably high
The GDG discussed available evidence from a rates of reported complications. The GDG also
systematic review that examined the safety and stated concern regarding the possibility of further
efficacy of clitoral reconstruction in women who damage to neighbouring structures such as the
had undergone FGM (57). urethra and the clitoral neurovascular bundle, with
the consequent deterioration of clitoral function as
The evidence for all measured outcomes was rated reported in two of the included studies.
as being of very low quality; all studies presented
serious risk of bias due to participant selection, The GDG further cautioned that endorsing clitoral
high loss to follow-up and the use of non-validated reconstruction in the absence of conclusive
scales for assessing clitoral function (see Web evidence of benefit could lead to the exploitation
Annex: GRADE tables). of expectations that cannot be met for many
women living with the consequences of this
One casecontrol study carried out in Egypt harmful practice, who in recent years have
reported improved sexual function at six months increasingly taken interest in the procedure as a
after surgery (85), and three additional prospective potential means of improving their sexual well-
cohort studies carried out in France and Burkina being. It was also noted that a recommendation
Faso described slight or real improvement in in favour of this procedure could not be
clitoral pleasure postoperatively (8688). None of implemented equitably because the procedure is
the above-mentioned studies used validated scales not yet available in the majority of countries with a
for measuring the described outcomes. One study high prevalence of FGM.
showed at least slight improvement in chronic
vulvar pain symptoms and dyspareunia among
women at one year of follow-up (87).
4. Dissemination and implementation
The dissemination and implementation of these policy and health systems strengthening tools
guidelines are crucial steps for improving the will be developed based on the recommendations
quality of health care and health outcomes for and best practice statements contained in
girls and women living with FGM. The WHO these guidelines.
Department of Reproductive Health and Research
has adopted a formal Knowledge-to-Action (KTA) 4.2 Implementation of the
framework for the dissemination, adaptation and guidelines
implementation of guidelines.10 In addition to
this KTA framework, the actions described in this The successful introduction into national
section will further facilitate these processes. programmes and health-care services of evidence-
based policies related to interventions to improve
4.1 Dissemination of the health outcomes among girls and women living
guidelines with FGM relies on well-planned and participatory,
consensus-driven processes of adaptation
The recommendations and best practice and implementation. These may include the
statements contained in these guidelines will be development of new national guidelines or
translated into Arabic and French and disseminated adaptation of existing national guidelines
with the cooperation of a broad network of or protocols using these WHO guidelines as
international partners, including: WHO country a reference.
and regional offices; ministries of health; WHO
collaborating centres; professional associations; The recommendations and best practice
other UN agencies, particularly the United Nations statements contained in these guidelines should
Population Fund (UNFPA) and the United Nations be adapted into locally appropriate documents
Childrens Fund (UNICEF); and NGOs. They will also that can meet the needs of each country and its
be available on the WHO website11 and in the WHO health services, while taking the availability of
Reproductive Health Library (RHL).12 In addition, human and financial resources into account; this
an executive summary aimed at clinicians and should include national policy as well as local
a wide range of policy-makers and programme clinical guidance. In this context, modifications may
managers will be developed and disseminated be limited to conditional recommendations, and
through WHO country offices and their respective justification for any changes should be made in an
partners, focusing particularly on countries with explicit and transparent manner.
high prevalence of FGM. An important requisite for the implementation
A series of systematic reviews, which were of the recommendations and best practice
the result of the scoping exercise carried out statements contained in this document is the
in preparation for the development of these creation of an enabling environment for their use
guidelines, will be published in a peer-reviewed (i.e.availability of medical supplies and a private
journal. Lastly, a package of practical tools area for talking with clients while providing
including a clinical handbook, job aids and training psychological support), paired with adequate
curricula for health-care providers, and health training of health-care practitioners and managers
to enable the use of evidence-based practices. In
this process, the role of local professional societies
10 Further information on the KTA Framework is available is also important, and an inclusive and participatory
at: http://www.who.int/reproductivehealth/topics/best_
process should be encouraged.
practices/greatproject_KTAframework/en/
11 These guidelines, including all language versions and
web annexes, will be available at: http://www.who.int/
reproductivehealth/topics/fgm/management-health-
complications-fgm/en/
12 RHL is available at: http://apps.who.int/rhl/en/
4.3 Monitoring and evaluating the the proportion of women living with typeIII
impact of the guidelines FGM who received deinfibulation before or
during childbirth;
Ideally, implementation of the recommendations
the proportion of women living with typeIII
and best practice statements contained in these
FGM who requested re-infibulation after
guidelines should be monitored at a health-care
being deinfibulated to facilitate childbirth;
facility level. Interrupted time-series of clinical
audits or criterion-based clinical audits could be the proportion of health-care providers
used to obtain data related to changes in the care who perform any form of FGM, including
that is given to girls and women who experience re-infibulation;
health complications from FGM. Clearly defined the proportion of women living with FGM
review criteria and monitoring and evaluation who were provided with information
indicators are needed and could be associated about the health risks associated with the
with locally agreed targets. Final selection of practice; and
indicators in each country context should consider
measurability and feasibility. The following list the number of medical and allied health
includes several suggested indicators: faculties that implemented undergraduate
and postgraduate training on FGM,
the number of countries establishing primary including identification of types of FGM,
care guidelines on management of health health risks associated with it, prevention
complications from FGM, and changes and management of health complications
in national and health-care guidelines in from FGM, and the risks associated with the
accordance with WHO guidelines; medicalization of the practice.
the proportion of health-care providers
trained: 4.4 Updating the guidelines
to identify the different types of FGM These guidelines will be updated following
to know the prevalence and health risks of the identification of new evidence that
the procedure indicates a need to change one or more of the
recommendations. Given that the evidence for
to prevent and manage complications all recommendations was either of low quality
of FGM; or non-existent, new recommendations or a
the proportion of health-care facilities change in the published recommendations may
that have carried out an institution-wide be warranted before the end of the usual five-year
assessment of all policies, protocols and period. The WHO Steering Group will continue to
practices that impact girls and women follow the research developments in the field of
living with FGM, including adequate referral FGM, particularly in the areas that were identified
pathways, human resources, training as research priorities during the retrieval and
provided to health workers, and available examination of evidence for these guidelines.
written policies and protocols distributed
WHO welcomes suggestions regarding additional
to decrease medicalization of the practice
topics for inclusion in the updated guidelines.
and to prevent and manage complications
Please send your suggestions by email to:
among girls and women who have
[email protected]
undergone FGM;
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Annex 1: International and regional human rights treaties

and consensus documents providing protection and
containing safeguards against female genital mutilation
International treaties Convention on the Rights of the Child, adopted
20 November 1989. General Assembly Resolution
Universal Declaration of Human Rights, adopted 44/25. UN GAOR 44th session, Supp. No.49. UN
10December 1948. General Assembly Resolution Doc. A/44/49 (entry into force, 2September 1990).
217. UN Doc. A/810. http://www.ohchr.org/en/professionalinterest/
http://www.un.org/en/universal-declaration- pages/crc.aspx
human-rights/
Committee on the Elimination of All Forms
Convention relating to the Status of Refugees, of Discrimination against Women. General
adopted 28July 1951 (entry into force, 22April 1954). Recommendation No.14, 1990, Female
http://www.unhcr.org/pages/49da0e466.html circumcision; General Recommendation No.19,
Protocol relating to the Status of Refugees, adopted 1992, Violence against women; and General
31January 1967 (entry into force, 4October 1967). Recommendation No.24, 1999, Women and health.
https://treaties.un.org/pages/ViewDetails. http://www.un.org/womenwatch/daw/cedaw/
aspx?src=TREATY&mtdsg_no=V- recommendations/recomm.htm
5&chapter=5&lang=en Human Rights Committee. General Comment
International Covenant on Civil and Political Rights, No.20, 1992. Prohibition of torture and cruel
adopted 16December 1966 (entry into force, treatment or punishment.
23March 1976). http://www.ohchr.org/EN/HRBodies/Pages/
https://treaties.un.org/Pages/ TBGeneralComments.aspx
ViewDetails.aspx?src=IND&mtdsg_no=IV- Human Rights Committee. General Comment
4&chapter=4&lang=en No.28, 2000. Equality of rights between men and
International Covenant on Economic, Social and women. CCPR/C/21/rev.1/Add.10.
Cultural Rights, adopted 16December 1966 (entry http://www.ohchr.org/EN/Issues/
into force, 3January 1976). Education/Training/Compilation/Pages/b)
http://www.ohchr.org/EN/ProfessionalInterest/ GeneralCommentNo28Theequalityofrights
Pages/CESCR.aspx betweenmenandwomen(article3)(2000).aspx
Convention on the Elimination of all Committee on Economic, Social and Cultural

Forms of Discrimination against Women, Rights. General Comment No.14, 2000. The right
adopted 18December 1979 (entry into force, to the highest attainable standard of health.
3September 1981). UNDoc.E/C.12/2000/4.
http://www.un.org/womenwatch/daw/cedaw/text/ http://www.refworld.org/pdfid/4538838d0.pdf
econvention.htm Committee on the Rights of the Child. General
Convention against Torture and Other Cruel, Comment No.4, 2003. Adolescent health and
Inhuman or Degrading Treatment or Punishment, development in the context of the Convention on
adopted and opened for signature, ratification and the Rights of the Child. CRC/GC/2003/4.
accession by General Assembly resolution 39/46 of http://www.ohchr.org/Documents/Issues/Women/
10December 1984 (entry into force, 26June 1987). WRGS/Health/GC4.pdf
http://www.ohchr.org/EN/ProfessionalInterest/
Pages/CAT.aspx
Regional treaties Consensus documents

European Convention for the Protection of Human United Nations General Assembly, Declaration on
Rights and Fundamental Freedoms, adopted the Elimination of Violence against Women, UN
4November 1950 (entry into force, 3September Doc. A/RES/48/104 (1993).
1953). http://www.un.org/documents/ga/res/48/
http://www.echr.coe.int/Documents/Convention_ a48r104.htm
ENG.pdf
World Conference on Human Rights, Vienna
American Convention on Human Rights (entry into Declaration and Plan of Action, June 1993. UN Doc.
force, 18July 1978). DPI/ 1394-39399 (August 1993).
http://www.oas.org/dil/treaties_B-32_American_ http://www.ohchr.org/EN/ProfessionalInterest/
Convention_on_Human_Rights.htm Pages/Vienna.aspx
African Charter on Human and Peoples Rights Programme of Action of the International
(Banjul Charter), adopted 27June 1981. Organization Conference on Population and Development,
of African Unity. Doc. CAB/LEG/67/3/Rev. 5 (1981), Cairo, Egypt, 513September 1994. UN Doc. A/
reprinted in 21 I.L.M. 59 (1982) (entry into force, CONF.171/13/Rev. 1 (1995).
21October 1986). https://www.unfpa.org/sites/default/files/event-
https://treaties.un.org/doc/Publication/UNTS/ pdf/PoA_en.pdf
Volume%201520/volume-1520-I-26363-English.pdf
Beijing Declaration and Platform for Action
African Charter on the Rights and Welfare of the of the Fourth World Conference on Women,
Child, adopted 11 July 1990. Organization of African Beijing, China, 415September 1995. UN Doc. A/
Unity. Doc. CAB/LEG/24.9/49 (entry into force, 29 CONF.177/20.
November 1999). http://www.un.org/esa/gopher-data/conf/fwcw/
http://www.refworld.org/docid/3ae6b38c18.html off/a--20.en
Protocol to the African Charter on Human and UNESCO Universal Declaration on Cultural Diversity,
Peoples Rights on the Rights of Women in Africa, adopted 2 November 2001.
adopted 11July 2003, Assembly of the African http://unesdoc.unesco.org/
Union (entry into force, 25November 2005). images/0012/001271/127162e.pdf
http://www.achpr.org/instruments/women-
protocol/ Convention on the Protection and Promotion
of the Diversity of Cultural Expressions, adopted
October 2005 (entry into force, March 2007).
http://unesdoc.unesco.org/
images/0014/001429/142919e.pdf
United Nations Economic and Social Council

(ECOSOC), Commission on the Status of Women.
Resolution on the Ending of Female Genital
Mutilation. March 2007. E/CN.6/2007/L.3/Rev.1.
http://www.un.org/womenwatch/daw/csw/
csw52/AC_resolutions/Final%20L2%20ending%20
female%20genital%20mutilation%20-%20
advance%20unedited.pdf
Annex 2: Guideline contributors
The guideline development process was guided by also ensured that the guideline decision-making
three main groups: processes had incorporated contextual values
and the preferences of potential users of the
WHO Steering Group recommendations, health-care professionals and
policy-makers. It was not within the groups remit
The WHO Steering Group, comprising a core group to change the recommendations formulated by
of WHO staff members and consultants from the the GDG. The members of the ERG are presented
Adolescents and at-Risk Populations team of the on the next pages of this annex.
Department of Reproductive Health and Research,
led the guideline development process. The Lists of names of external experts
group was in charge of the scoping review for the
involved in the preparation of the
guidelines, drafting the PICO questions (population,
intervention, comparator, outcome), and overseeing
guidelines
the evidence retrieval and writing of the guidelines. Guideline Development Group (GDG)
The Steering Group was also in charge of selecting
the members of the collaborating groups, and Dr Jasmine Abdulcadir
organizing the guideline development meetings. Chief Resident
The members of the Steering Group are presented Department of Gynaecology and Obstetrics
on the next pages of this annex. Geneva University Hospital
Faculty of Medicine
Guideline Development Group University of Geneva
30 Bld de la Cluse
(GDG)
1211 Geneva
The WHO Steering Group invited 15 external Switzerland
international stakeholders to form the GDG,
Ms Joya Banerjee
including health-care providers, researchers,
Yale Global Health and Justice Partnership Fellow
health-care programme managers, human rights
Yale University
lawyers and womens health advocates. This
170 15th Street
was a diverse and gender-balanced group, who
New York, NY 11215
advised on the contents of the guidelines, helped
USA
define the research questions and outcomes that
guided the evidence synthesis, collaborated on the Dr Owolabi Bjalkander
interpretation of the evidence, and formulated the Department of Public Health Sciences
evidence-based recommendations. The members Global Health Division (IHCAR)
of the GDG are presented on the following pages Karolinska Institutet
of this annex. Widerstrmska Huset
Tomtebodavgen 18A
External Review Group (ERG) 17177 Stockholm
Sweden
This group included three technical experts
and other stakeholders with an interest in Dr Susana Fried
the health of girls and women living with Yale Global Health and Justice Partnership Fellow
FGM. The ERG was geographically balanced Yale University
and gender representative, and no member 170 15th Street
declared a conflict of interest. The group New York, NY 11215
reviewed the final guidelines document to USA
identify any factual errors and commented on
the clarity of the language, contextual issues
and implications for implementation. The group
Professor Adriana Kaplan Marcusn Professor Olayinka Olusola Omigbodun

Fundacin Wassu Professor of Psychiatry
Universitat Autnoma de Barcelona College of Medicine
Mdul de Recerca A Campus Bellaterra University of Ibadan
08193 Barcelona 200010 Ibadan
Spain Nigeria
Professor Joseph Karanja Professor Gamal Serour

Professor of Obstetrics and Gynaecology Director
Associate Professor
International Islamic Center for Population Studies
Department of Obstetrics and Gynaecology
and Research
University of Nairobi
Al Azhar University
Kenyatta National Hospital Campus SE1 8ST Maadi
PO Box 19676 Egypt
Nairobi
Kenya Professor Moustapha Toure
Chef du Service de
Dr Morissanda Kouyat Gynecologie Obstetrique
Executive Director of Inter-African Committee (IAC) Hpital du Mali
ECA Africa Hall Bamako
Menelik Road Mali
PO Box 3001
Dr Ingela Wiklund
Addis Ababa
Board Member
Ethiopia
International Confederation of Midwives
Professor Els Leye Baldersgatan 1
Professor and Senior Researcher SE-114 27 Stockholm
International Centre for Reproductive Health Sweden
University of Ghent Guideline/GRADE Methodologist
De Pintelaan UZ P114
9000 Ghent Professor Caitlin Kennedy14
Belgium Associate Professor
Department of International Health
Professor Martin M. Meremikwu13 Johns Hopkins Bloomberg School of Public Health
Professor of Paediatrics 615 N. Wolfe Street, Room E5033
Department of Paediatrics Baltimore, MD 21205
University of Calabar Teaching Hospital USA
PMB 1115 Systematic Review Group
Calabar, Cross River State
Nigeria Mr Ekpereonne Esu
Department of Public Health
Dr Nawal Nour College of Medical Sciences
Director, Department of Obstetrics and University of Calabar
Gynecology PMB 1115, Calabar
Director, African Womens Health Center Cross River State
Director, Ambulatory Obstetrics at Brigham and Nigeria
Womens Hospital
Dr Uduak Okomo
Associate Professor, Harvard Medical School
Vaccine and Immunology Theme
African Womens Health Center
Medical Research Council Unit
75 Francis Street Atlantic Boulevard, Fajara
Boston, MA 02115 PO Box 273
USA Banjul
The Gambia
13 Systematic review team coordinator 14 Also a member of the GDG

Dr Babasola Okusanya Ms Marycelina H. Msuya

Department of Obstetrics and College Lecturer
Gynaecology Kilimanjaro Christian Medical University
College of Medicine PO Box 2240
University of Lagos Moshi
Private Mail Bag 12003 Kilimanjaro
Lagos Tanzania
Nigeria
WHO Secretariat
Dr Helen Smith
WHO Steering Group
Senior Research Associate
Centre for Maternal and Newborn Health Department of Reproductive Health and
Liverpool School of Tropical Medicine Research
Pembroke Place
Liverpool, L3 5QA Dr Ian Askew
United Kingdom Director
Adolescents and at-Risk Populations
UN Partners
Dr Lale Say
Dr Nafissatou J. Diop Coordinator
Senior Adviser
Coordinator UNFPAUNICEF Joint Programme on Dr Doris Chou
Female Genital Mutilation/Cutting Medical Officer
Accelerating Change Coordination Team
Dr Michelle Hindin
UNFPA
Scientist
New York
USA Dr Christina Pallitto
Scientist
Mr Cody Donahue
Child Protection Specialist Dr Karin Stein
UNFPAUNICEF Joint Programme on Female Consultant
Genital Mutilation/Cutting
Accelerating Change Coordination Team Office of the Director
UNICEF Mr Rajat Khosla
New York Human Rights Advisor
USA
Department of Gender Equity and Human Rights
External Review Group (ERG)
Dr Veronica Magar
Professor Pascale A. Allotey Team leader
Professor of Public Health
Head Global Public Health Department of Maternal, Newborn, Child and
School of Medicine and Health Sciences Monash Adolescent Health
University Dr Anthony Costello
Building 3 Room 02-03 Director
Malaysia
Dr Comfort Momoh
FGM Public Health Specialist
Guys and St Thomas NHS Foundation Trust
African Well Womens Clinic
8th Floor c/o Antenatal Clinic
Lambeth Palace Rd
London, SE1 7EH
United Kingdom
Annex 3: Summary of declared interests from Guideline

Development Group (GDG) members and how they were
managed
Name and expertise contributed to Declared interest(s) Management of

guideline development conflict(s) of interest
Dr Jasmine Abdulcadir None declared Not applicable

Role: Content expert and end-user
Ms Joya Banerjee None declared Not applicable
Role: Gender expert
Dr Owolabi Bjalkander None declared Not applicable
Dr Susana Fried None declared Not applicable
Role: Human rights expert
Professor Adriana Kaplan Marcusn None declared Not applicable
Professor Joseph Karanja None declared Not applicable
Professor Caitlin Kennedy None declared Not applicable
Role: Methodologist
Dr Morissanda Kouyat None declared Not applicable
Role: Consumer representative
Professor Els Leye i. Her institution has The conflict was not
Role: Content expert and end-user received grants for considered serious
research. enough to affect GDG
membership
ii. She was a member of the
FGM risk estimations in the
European Union (EU).
Professor Martin M. Meremikwu None declared Not applicable
Dr Nawal Nour None declared Not applicable
Professor Olayinka Olusola None declared Not applicable
Omigbodun
Professor Gamal Serour None declared Not applicable
Professor Moustapha Toure None declared Not applicable
Dr Ingela Wiklund None declared Not applicable
Annex 4: Factors considered while rating the quality of

the evidence
Each recommendation contained in these Implications of a conditional

guidelines encompasses a direction (in favour or recommendation:
against) and, as discussed in this annex, the degree
of strength: strong or conditional. For clients Most people in this situation would
want the recommended course of action, but
The Guideline Development Group (GDG) used the many would not.
following different categories for the strength of a
recommendation:15 For clinicians Different choices will be appropriate
for different clients, who will require assistance in
Strong recommendations mean the GDG is arriving at a management decision consistent with
confident that the desirable effects of adherence their values and preferences.
to a recommendation outweigh the undesirable
effects. For policy-makers Policy-making will require
substantial debate and involvement of many
Conditional recommendations mean the GDG stakeholders.
concludes that the desirable effects of adherence
to a recommendation probably outweigh the
undesirable effects, but is not confident of that
conclusion.
Implications of a strong
recommendation:
For clients Most people in this situation would
want the recommended course of action and only
a small proportion would not.
For clinicians Most clients should receive the

recommended course of action.
For policy-makers The recommendation can be

adopted as a policy in most situations.
15 WHO handbook for guideline development, 2nd ed.

Geneva: World Health Organization; 2014 (http://www.
who.int/kms/handbook_2nd_ed.pdf).
For more information, please contact:
Department of Reproductive Health and Research
World Health Organization
Avenue Appia 20, CH-1211 Geneva 27, Switzerland
Fax: +41 22 791 4171
E-mail: [email protected]

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WHO guidelines on the management of health complications from female genital mutilation i

WHO guidelines on the

I. World Health Organization.

ISBN 978 92 4 154964 6

Subject headings are available from WHO institutional repository

World Health Organization 2016

Printed by WHO Document Production Services, Geneva, Switzerland.

Editing and layout: Green Ink (www.greenink.co.uk).

Noun Project icons: Gregor renar, Rflor.

Acronyms and abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Executive summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

Annex 2: Guideline contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Annex 4: Factors considered while rating the quality of the evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Web Annex: GRADE tables available online at:

Acronyms and abbreviations

CBT cognitive behavioural therapy

CEDAW Convention on the Elimination of All Forms of Discrimination against Women

CRC Convention on the Rights of the Child

DOI declaration of interest

ERG External Review Group

FGM female genital mutilation

GDG Guideline Development Group

GRADE Grading of Recommendations Assessment, Development and Evaluation

HRP UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and

IEC information, education and communication

NGO nongovernmental organization

PICO population, intervention, comparator, outcome

PTSD post-traumatic stress disorder

UNAIDS Joint United Nations Programme on AIDS

UNDP United Nations Development Programme

UNECA United Nations Economic Commission for Africa

UNESCO United Nations Educational, Scientific and Cultural Organization

UNFPA United Nations Population Fund

UNHCR United Nations High Commissioner for Refugees

UNICEF United Nations Childrens Fund

UNIFEM United Nations Development Fund for Women (now UN Women)

UTI urinary tract infection

WHO World Health Organization

Terms associated with female genital mutilation (FGM):

Infibulation (type III FGM)

Cognitive behavioural therapy (CBT)

Information, education and communication (IEC)

Summary of the recommendations (R) and best practice statements (BP)

FEMALE SEXUAL HEALTH

INFORMATION AND EDUCATION

Female genital mutilation (FGM) comprises 1.2 Reasons why FGM is

Box 1.1: Types of FGM*

Unaltered female genitalia

bartholin glands perineum

FGM Type I FGM Type I

labia minora labia minora

bartholin glands perineum bartholin glands perineum

(box continues on next page)

Box 1.1: Types of FGM

FGM Type II FGM Type II

prepuce prepuce may be affected

labia minora labia minora

bartholin glands perineum bartholin glands perineum

IIc: partial or total removal of

bartholin glands perineum