The 4 ‘E’s Of FGM Eradication – My Paper On The Economics Of FGM, At The UN Geneva IAC Meeting

The Inter-African Committee on Harmful Traditional Practices affecting Women and Girls (the IAC) held an International Conference to End FGM at the United Nations in Geneva on 10 and 11 May 2016. The theme was ‘From Goals to Action: Working Together to Bridge Gaps‘. I spoke on the Economics of FGM. My main point? … that ending FGM will be achieved most quickly if we fully engage economic analysis of the wider contexts and use that analysis to inform Public Health budgets and strategies, with top-level leaders who accept direct accountability for delivery.

 

The Economics of Female Genital Mutilation: a draft agenda for research and action

Hilary Burrage, IAC Geneva, 11 April 2016

Abstract:

Female genital mutilation is a long entrenched facet of the economic infrastructure of many traditional societies.  It is also hugely expensive, both in the usual financial sense of expenditure and opportunity costs, and in the sense of tragic costs to human life and well-being.

This paper will explore some ideas around what is currently acknowledged about the economics of FGM at the local, national and international levels. The focus will then turn to what has not as yet been explored in significant depth.

What are the consequences of FGM in terms of human resources squandered through ill-health and early death?  How much diversion of individual nations’ economic investments, and of global humanitarian effort, does FGM incur? What other fiscal and welfare detriments do the costs of FGM impose?

Looking forwards, what economic and other trade-offs might be required to end FGM, as our knowledge of the economic bases develops and impacts of this traditional harmful practice are fully identified?

Rather than asking how many years it will take to end FGM, should we be asking how much economic and other resource investment (from many parties) is required to make FGM history?

Already Engagement, Education and Enforcement are widely understood to be important elements in the eradication of FGM.  Is a fully informed Economic approach the missing component, the ‘fourth E’, in bringing FGM finally to an End?

 

There are four ‘E’s’ which together comprise a realistic route to the Eradication of female genital mutilation.  They are Engagement, Education, Enforcement and Economics.

This paper will outline an agenda for taking forward the last and least discussed of these elements, which is Economics.

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Writing in her book, Cutting the Rose, (p.174), Efua Dorkenoo asserted that

‘Aid donors have a right and duty to become involved in [FGM] prevention and to place pressure on the relevant governments to undertake effective measures to eradicate it.
‘In areas where more than 50% of the female population undergo genital mutilation, [thereby] placing extra burdens on already inadequately resourced health care and delivery, aid given towards health programmes should be tied to proven measures taken by governments to abolish female genital mutilation.’

That view, from one of the most significant advocates against FGM ever, was written in 1994.  Since then wider public awareness and understandings of this harmful traditional practice have developed very considerably.

We now know that the incidence of FGM around the globe is actually increasing.  Yes, rates (percentage of women and girls ‘cut’ in various countries) are in many cases dropping, but the absolute numbers undergoing FGM are increasing because of the ever-growing youth population.

Given that alarming fact, there is surely now a case for suggesting that a proportion of all financial aid (or of matched national funds) should be allocated to the eradication of FGM. Further, to avoid any questions about imperialist duplicity, the same proportionality of funding should in logic be allocated by Western governments to their own FGM eradication budgets.

The essential message must be that no society anywhere will tolerate FGM or any parallel harmful traditional practices. In this, careful consideration of economics could be a powerful tool; everywhere in the world finance talks in a way that no other language can.

FGM is patriarchally entrenched Big Business

Female genital mutilation is a trans-global for-profit business. It is often organised by formal agencies (eg the Sowei / Sande Society) with millennia of tradition behind them.  Even where the operators are independents their acts are intended to assist in the transfer of wealth or other resources between generations, bolstered by centuries of folklore, belief and custom.

Within such communities silence is the norm; by powerful convention no-one can easily or safely question the act, even if they somehow thought to do so.  The excisors have a huge interest in continuing their work – goat farming and the other proposed alternative economic activities offer neither the status nor the income – and the economic prospects for a girl and her family (no male to support her, no bride price) may also be dire if FGM is not accepted.

‘Human rights’ is not a much considered concept within traditional societies,[1] where unquestioning compliance with collective thinking holds sway in the perceived interests of the group.  In these contexts FGM is a given, just as in first world contexts it may become a marker of the ‘other’, of the difference which those displaced by the diaspora may seek to establish and maintain.

And so FGM continues, a vehicle for the financial supremacy of powerful men and for the imposition on women of dependency throughout their lives.  That women are often the inflictors of the physical damage is part of this balance of power; they are the instrument of economic forces more compelling than any sort of resistance they might muster even if they should think to do so.

Nor is the issue of economic (dis-)empowerment related ‘only’ to FGM.  Tragically, there are plenty of other harmful traditional practices (beading, breast ironing etc), as well as overt transactions such as human trafficking – second only to drugs as a global criminal activity – and child brides and sexual exploitation, which also secure the economic interests of powerful individuals, at the pinnacle almost always men, over less advantaged members of society.

Wider economic contexts

To date the focus of economic attention, such as it is, has been largely on the immediate transactions arising from FGM. The ‘business’ of delivering FGM, the inter-generational passing of wealth and perhaps the procuring of safeguards in parental old age are fairly widely acknowledged.

Less acknowledged has been the damage to entire communities which arises from FGM, but there are some, such as Navi Pillay, the United Nations High Commissioner for Human Rights, who in 2014 noted that FGM generates ‘profoundly damaging, irreversible and life-long physical damage,’ and increases the risk of neonatal death for babies born to women who have survived it:

‘When FGM is eradicated, communities are healthier. Freed of the terrible pain and trauma that FGM creates, girls and women are more able to develop their talents and use their skills. Economic, social and political development can surge forward.’

Even before then, in 2007, Dr. Gebreselassie Okubagzhi of the World Bank Group insisted at the UNFPA Global Consultation on FGM that ‘an analytic study [of FGM] to compile data on economic cost implications is critical… for launching effective community and international advocacy.’

From Medicine to Public Health

Unsurprisingly, those most likely to have addressed FGM in the usual settings – and to know the realities of FGM – are medical personnel, often midwives.  Their focus is primarily the woman who has experienced (or perhaps may be at risk of experiencing) the harm, and her unborn or infant child.  This emphasis is critical in terms of immediate human need, but it may sometimes result in putting aside other wider issues.  When a clinician is treating a patient, and especially a pregnant one, that must be the problem to address.

But wider perspectives are also now advocated.  Human rights and sometimes criminal lawyers have been at the forefront of this move, and more recently there has also been an emphasis on what community activists and schools can do to help prevent the hurt in the first place. For these reasons it could be said that Eradication is now centred on the ‘three Es’ of Engagement, Education and Enforcement.

To these however should be added a fourth ‘E’ – Economics.

With this addition the ‘four Es’ can deliver a realistic way forward to Eradication.  Combined, the elements suggest a proper agenda for action.  Together they encompass the package of understandings, the essential paradigm, of one of the least visible and most important medical disciplines – that of Public Health.

The Public Health approach brings together all aspects of FGM eradication, and acknowledges the contribution of each (medical, legal, community, education etc).  What must always inform the Public Health approach is, however, a clear understanding of how available resources – funds, personnel, knowledge, skills, equipment, logistics, goodwill etc – can most effectively be allocated to make FGM history.

To do that it is necessary to understand the economics of FGM and its eradication; but our knowledge of this agenda is far from complete.

An agenda for the economics of FGM

It is important to establish at the start that measuring economic impacts does not in any way imply a reduction in the critical importance rightly attached to the human costs of FGM.  Human rights and personal health / well-being stand alone, whatever other factors are considered.

Having fully affirmed the constant criticality of human rights and well-being however, elements of the Economics / Public Health agenda which should also be considered include the following:

• Overt direct costs:

How much of a given family or community economy is taken by activities and wealth investment / transfer directly concerned with FGM?  And what are the paybacks?

To be clear about what to do to stop FGM, we need to know not only the direct economic costs, but also the perceived ‘benefits’, so these can be delivered in other ways.  How, for instance, can girls be protected and given status in adulthood, without FGM? – We all know of ways this may be achieved, but the resources, financial and otherwise, to achieve this on a large scale are not as yet unquantified.

For instance, many organisations which deliver Alternative Rites of Passage (ARPs), even where these have been proven to be effective (which is not everywhere; much depends on local customs and beliefs), must expend a lot of energy and time on raising charitable donations for their work.

• Covert / less evident direct costs:

What are the personal and family outcomes of FGM?  What are the impacts on personal health, both physical and psychological?  How much damage – recognised or not – may be done to family relationships by inflicting FGM?  What are the costs, or economic and other benefits, and to whom, of this practice? How ready for change is the community? What will deliver ‘readiness to change’?

We know that FGM may cause death and very severe ill health to both mothers and their children – obstetric fistula, post-traumatic stress disorder and constant, life-long infections are immensely damaging; and for every case of infant mortality there may be ten instances of morbidity.  But what other aspects of FGM must also be investigated regarding personal impacts? What are the economic impacts on the community?

Whilst there have been occasional efforts to establish the economic costs of eg obstetric and maternal outcomes, very little has been quantified beyond that.

• Indirect local / community costs:

Does activity around FGM consume time, energy and other resources which would otherwise benefit other parts of the local economy?  (eg child nurturing, production of food and other domestic requirements, developing local social or for-profit enterprises…)

How ‘effective’ is FGM (along forced or early marriage, or child marriage / licensed paedophilia) as a method of inter-generational wealth transfer?  How do these transfers uphold or damage the interests of women, girls and less advantaged male members of the community?

To what extent do these costs vary between different communities?  Are there any general measures which might be adopted, or factors for investigation identified, to assist in calibrating the impacts of FGM and other HTPs on local economies?

• Ownership of resources:

Resources come in many different forms.  Sometimes they are physical, sometimes knowledge and skills, sometimes money (as we discuss above) or something else.

Physical resources

– In many cases FGM is connected with ownership of, or the ‘right’ to access, material things.  Amongst these may be food (e.g. ‘uncut’ women may not prepare it) and land (in some communities only after FGM is a woman deemed adult and thereby entitled, for instance, to a plot of land for agriculture or farming).  There are doubtless also other resources of this sort, associated with FGM, which need to be considered as well.

Anthropologists can tell us much about women and food preparation or land ownership, but only occasionally, as in Hazel Barrett’s research, is such information linked in with FGM practices.  To disconnect FGM from these significant resource disentitlements we must understand these factors and find ways of removing the obstacles to ownership and more equitable economic standing.

Knowledge and skills / education

– A combination of FGM-induced ill-health, forced ‘child marriage’ and in some places the absence of hygiene provision for girls during menstruation has ensured that in many communities schooling and education beyond the early years is unusual.   The criticality of this general issue has been emphasised by the World Bank, which stresses also that girls without much education are particularly vulnerable to abuse and poor life-chances.

There are many other formal and informal elements also at play in this matter, but the economic case for the entitlement of girls and boys together to a full, formal education has as yet not always (despite the entreaties of leaders such as Mme Pillay, and some excellent programmes in the field) been made clearly where it matters most – at the local level, to parents and community leaders.

This is as important in Western countries as in developing nations. At present school drop out in places such as the UK is not considered in the context of the possibility of FGM, even in communities where it is known to have occurred.

Nor is it in all locations made clear what young people will need to know, if they are to grow up healthy and therefore best able to support their communities and wider society in adulthood.  Further economic analysis in the overt context of FGM and related HTPs is important to inform the way/s forward, to bring together with greater frequency campaigns against FGM and wider education policies.

• Medical and social support costs:

The level of formal health and welfare care for women and children affected by FGM varies enormously between different parts of the world, but informal traditional care takes a toll on the resources of communities just as formal, professionally skilled care does.  Given that some 200 million women have been affected by FGM – some very seriously – these costs must be enormous.

Further, FGM has produced a distortion in various parts of the world of clinical care.  As the World Health Organisation repeatedly reminds us, the ‘medicalization’ of FGM is in their view the greatest threat to eradication.  FGM provides a source of income not only to traditional midwives and others in communities, but also to trained personnel who can make it seem ‘acceptable’ because they adopt sterile techniques and use anaesthesia.  Whilst the moral and ethical issues are clear to most external observers at least, the distortions of the relevant health economies which probably occur because of medicalization have yet to be addressed adequately.

The professional medical care of women with significant long-term FGM-induced conditions is a complex business.  Indeed, a move from illicit medicalization to the professionally appropriate care of survivors might, with the right drivers, provide another way forward for clinicians tempted to earn an extra penny.  Where skilled care is provided for survivors it may – in an ideal world – include the treatment of infections, help with infertility and / or contraception, reconstruction (still rare), psychological or psychiatric treatment, family reconciliation, the treatment and counselling of children and much else.

The list is long, but the prospects for the (potential, if not usually delivered) care which would be required to deliver good health and enable these women to be economically productive members of their communities has been barely discussed in general debate.   This must change.

• Diversion of resources:

There are many local, national and international agencies which try to prevent FGM happening and to deliver care to those who have experienced it.  The cost of these services is clearly very high, however extensive or otherwise the service may be, and regardless of whether it is supplied by the nation state or an NGO, national or international.

Evaluation is now progressing – see for instance UNFPA-UNICEF Joint Programme, including the 2012 UNICEF Report and Analysis and the UNFPA Report on Demographic Perspectives of 2015) – but overall costs, inclusive of all the factors above, are not generally examined or aggregated in a meaningful manner, nor are they always benchmarked for efficacy.  The economics of FGM encompasses more than the straightforward figures which indicate levels of expenditure on FGM eradication and alleviation programmes.

Those on the ground face the grim realities experienced by people they know; it is inevitable that thinking tends still to focus on ‘aid’ rather than on ‘investment’ – on how, as it is imperative must happen, to alleviate death and morbidity, pain and suffering. For very good reasons the emphasis day to day is on the humanitarian aspects, rather than the economic case for eradication which in fact lies behind the data.  But day to day considerations are not the same as strategic programmes.

• Politics and policies:

Economics can never be the first consideration in tackling FGM, but it is a very important one.

The prime consideration must always be the prevention of the harm FGM inflicts on women and children and their wider communities, but this does not lessen the need for a comprehensive ‘Economics of FGM’.[2]  At last there is a real concern to address and stop the epidemic of FGM which increasingly we recognise to be a source of pain and distress across the globe.

This concern has not however always translated into a dialogue about the overall costs (as above) and value-for-money of expenditure which such serious issues surely demand.  Nor do we see much consideration of the lost opportunities, for instance, to address issues such as malaria or clean water, because resources must instead be allocated to the eradication and treatment of FGM.[3]

Similarly, although figures for expenditure on FGM issues in traditionally practising countries and communities are quite often now forthcoming, there remain questions about real levels of domestic spending in the Western world, where FGM also occurs.  But better resourced Western nations, perhaps more easily than in developing ones, are well positioned to develop possible methodologies for measuring FGM resource investment and outcomes which might inform future programmes.

…..

The world has finally realised that FGM is a needless, massive, epidemic of pain and misery which can be eradicated simply by people refusing any more to do it.  Policies and logistics to deliver that refusal are becoming clear.  Increasingly, Public Health and political will are being aligned.

Next required is a shift in the way we think about the Economics – the fourth ‘E’ in Eradication – which underpin #EndFGM strategies.

The big question now should not be ‘how long?’.  Instead, we must ask, ‘how much?’  How many resources of what sort will it take, finally, to deliver?

The resources required for FGM eradication are not ‘handouts’. They are fundamental investments in all our futures.

NOTES

[1]   *Not of course a phenomenon only of pre-literate communities.  As just one example, when speaking about dissent in 2015 President al-Sisi of Egypt – a nation with a very high rate of FGM despite sporadic legislation forbidding it – told a US congressional delegation visiting Cairo that issues of human rights and civil liberties in his country should not be approached from a ‘Western perspective’.

[2] This topic is considered in more detail in my book, Eradicating Female Genital Mutilation (Chapter 2: Socio-economic Analysis), Ashgate / Routledge, 2015.

[3] The recent challenges for health care of Ebola illustrate this point well. Understandably, the emphasis was on this terrible disease, but the upshot was that other health issues were put aside.

…

Khady Koita, Godfrey Williams-Okorodus, Comfort Effiom, [Hilary], Nikki Denholm, Lorraine Koonce Farahmand, Sylvia Perel-Levin, speaking at the session on Session V of the IAC conference, 11 May 2016, UN Geneva. Photo courtesy of Kaillie Winston.

 

Read more about FGM and Economics

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Books by Hilary Burrage on female genital mutilation

For more detail and discussion of female genital mutilation please see my textbook, which considers in some detail the situation globally, but also explores the issues relating specifically to Western nations:  Eradicating Female Genital Mutilation: A UK Perspective (Ashgate/Routledge, 2015). My second book, Female Mutilation: The truth behind the horrifying global practice of female genital mutilation (New Holland Publishers, 2016), contains narrative ‘stories’ (case studies) from about seventy people across five continents who have experienced FGM, either as survivors and/or as campaigners and activists against this harmful traditional practice.

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FURTHER INFORMATION AND ACTION

There is a free FGM hotline for anyone in the UK: 0800 028 3550, or email:fgmhelp@nspcc.org.uk

The (free) #NoFGM Daily News carries reports of all items shared on Twitter that day about FGM – brings many organisations and developments into focus.

Also available to follow at no cost or obligation is the #NoFGM_USA Daily News.

Twitter accounts:@NoFGM_UK  @NoFGMBookUK @FemaleMutlnBook  @FGMStatement  @NoFGM_USA @NoFGM_Kenya  @NoFGM_France  @GuardianEndFGM [tag for all: #NoFGM] and @StopMGM.

Facebook page: #NoFGM – a crime against humanity

More info on FGM here. Email contact: NoFGM email

[NB The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, which has a primary focus on FGM, is clear that in formal discourse any term other than ‘mutilation’ concedes damagingly to the cultural relativists – though the terms employed may of necessity vary in informal discussion with those who by tradition use alternative vocabulary. See the Feminist Statement on the Naming and Abolition of Female Genital Mutilation,  The Bamako Declaration: Female Genital Mutilation Terminology and the debate about Anthr/Apologists on this website.]

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PLEASE NOTE:

This article concerns approaches to the eradication specifically of FGM.  I am also categorically opposed to MGM, but that is not the focus of this particular piece.

Anyone wishing to offer additional comment on more general considerations around infant and juvenile genital mutilation is asked please to do so on the relevant dedicated thread, originally developed in June 2012:

The Other FGM Debate: Is Male Circumcision (MGM) Also Child Abuse?

Pending further notice (of a planned new blog, sometime after February 2016), discussion of the general issues re M/FGM will not be published unless they are posted on this dedicated page.  Thanks.