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The Many ‘E’s Of FGM Eradication – And Why They All Lead Via ‘Economics’ And ‘Epidemics’ To Public Health

April 24, 2018

I was pleased to be invited to speak at the second University of Salford ONECPD Conference on Zero Tolerance for Female Genital Mutilation.  I originally intended my presentation to be on The 4Es of Eradication but further events and consideration suggest there are at least 7 Es….  and that they all point the same way:  The largely missing element in current eradication strategies is Public Health.
In this post I explain why I see that discipline or framework as critically important if we are to eradicate FGM forever.

The fundamental question for those who seek FGM eradication is not, ‘How long will it take?’, but rather, ‘What resources and leadership are required, finally to make FGM history?’

University of Salford                                                                                24 April 2018

Zero Tolerance for Female Genital Mutilation Conference

Hilary Burrage

The Many ‘E’s of FGM Eradication – and why they all lead via ‘Economics’ and ‘Epidemics’ to Public Health

The original introduction to this talk posed several questions:

  • Rather than asking how long, how many years, till FGM eradication?, is a fully informed economic approach the missing component in bringing FGM finally to an end?
  • We know already that community Engagement, Education programmes and legal Enforcement are critical to FGM eradication.

Now it’s important to ask, what about the Economics?

Why is Economics less considered?

  • The financial drivers of FGM are usually acknowledged – bride price, ‘purity’, status and income for mutilators (‘cutters’) etc.

But what of the socio-economic impacts on whole communities?

What’s the real cost to, and of, women who have had FGM, whether in ‘traditional’ communities of in the diaspora?

And what is the cost also to their national economies?

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Previously I’ve focused as above on 4 ‘E’s’ of Eradication:

Engagement –  seeking ways wherever possible to work alongside the practising community, rather than against them

Education – not only about the human body and the ways in which FGM harms it, but also, very importantly, the education of the whole child, both girls and boys, in their family and community contexts

Enforcement – how to frame and when to involve the powers of the state to stop FGM


Economics – an emphasis not ‘only’ on the moral and ethical issues around FGM eradication, but on the huge financial and resources burden which this harmful traditional practice creates.

But more recently I’ve added a few more ‘E’s  to the list:

Empathy – the necessary tacit mutuality between those who seek overtly to end FGM and those who would like to see it end, but don’t want, or in truth fear, to say so

Empowerment – the recognition that education and the avoidance of FGM are elements in self-determination for women who choose to live their lives freely in the modern world with which their traditional communities interface


Epidemic – perhaps a rather surprising final ‘E’-word, but one which has become prominent in my thinking on how to make FGM history.

Joining the budgetary dots
Whilst the essential goodwill required to make FGM history cannot be quantified, every other aspect of the road to eradication has measurable costs.

The cost-benefit analysis can be said in any given situation where FGM occurs to comprise the costs of allowing it to continue (and the immediate personal financial and status benefits to ‘cutters’ and others involved) set against the costs of abolition and then the benefits of achieving abolition.

On one hand we have the very substantial price to be paid when FGM continues:

  • Lives may be lost (both the victim herself, and also any children she may bear who die after difficult deliveries).
  • Potential and talent which would contribute to the community may be wasted because FGM is often followed by early marriage (in reality, socially sanctioned juvenile rape) and girls receive no further formal education of the sort necessary for coping with the modern world.
  • The physical and psychological health of female members of the community is compromised, sometimes, severely, so they may not be able to contribute as they would otherwise to caring for their families and to the running of their local economy.
  • Additional costs arise because health problems (both the women and sometimes their children) require care which would normally be provided within the family; and if it is not given people may even die. (In some traditional communities a young child whose mother has died has a far greater risk him/herself of death than do other infants.)
  • FGM causes much marital friction and break-ups, with inevitable extra costs, occur as a result of it. Husbands may seek ‘solace’ elsewhere and women may be abandoned and become destitute, especially if the FGM results also in obstetric fistula.
  • Where support systems are in place, already over-stretched health services are faced with even more demands on their resources.
  • And finally, the costs of enforcing the law which prohibits FGM is high whilst it is still prevalent – just as the costs of failing to do so are significant, not least because flouting the law also has cost implications.

On the other hand, if and when FGM is eradicated, none of the costs above will pertain.  If these costs were assessed for their monetary value, it would surely become obvious that the economic case for eradication – along always with the vital moral and health cases – is irrefutable.

FGM is an epidemic
Cressida Dick, the Metropolitan Police Commissioner (and thereby the most senior Police officer in the UK) has recently demanded that knife crime in London be regarded as an epidemic. Law enforcement agencies alone cannot address all the issues which must be resolved for the current lethal crime wave to be brought to a halt. A more holistic public health approach is, she says, required.

On a much larger scale, FGM occurs in many parts of the world, and it harms millions of people – both direct victims and those indirectly affected – every year.  It too is by any measure an epidemic.

The most critical aspect of these considerations is however also the simplest:

If people stopped performing FGM, all the other difficulties which follow would also cease to be a problem … just as the same applies to knife crimes and other acts of violence.

In other words, these lethal phenomena are the result of human agency and human volition.  The triggering factors are deep and complex, but they are all the outcomes of the beliefs and actions of real people.

These are epidemics resulting solely from social behaviour. Whilst great skill is required to support those who have already experienced FGM, there is no need when it comes to eradication strategies to draw particularly on highly technical medical knowledge. Instead, what is required is an understanding of the many threads, social, psychological and economic, which together enable knife crime and FGM, amongst other seriously damaging behaviours.

Conformity to the group, fear of what others may do to non-conformers, a restricted repertoire of responses to complex situations, and a greater reverence towards group norms rather than the formalised state, all play a part in crimes such as FGM, as do the outcomes such as post traumatic stress disorder and denial of the criminal nature of the act was which, most probably, prompted if not delivered by the victim’s closest family.

The underlying theme in FGM is patriarchy, led by economics.  It is very much in the interests of some powerful men that women and girls are subjugated to them. Dominant men’s wealth and influence are consolidated by ensuring that women and girls are chattels, to be bought and sold on the market via the agency of others (women, usually) who derive some reflected status and power themselves from helping to maintain that patriarchy.

In FGM we have congruence of some of the most powerful elements of any society.

FGM is patriarchy incarnate: the literal imposition of (some) men’s will onto women’s bodies.

Placed in this context, it is evident that the medical care of affected girls and women, and better education, however well delivered, will not alone suffice to eradicate FGM.

To address these matters adequately will require a better understanding of the underlying forces at play – essentially, the economics which results in FGM – and a clear grasp of the resources needed to bring the practice to an end – the financial costs and economic resourcing required, and the human resources and political leadership from the top which would make collaboration effective.

To summarise:

  • Serious assessments of the economics of eradication, as well as of FGM itself, must be undertaken.
  • The resources required must be made available under the leadership and supervision of a person with an over-arching policy for eradication.

Public health
One public service which the state in almost all nations provides is Public Health.  It is this service which we might most realistically expect to cost and support co-ordinated efforts to eradicate FGM.  Public health can provide an overarching framework for action, and strategies for delivery.

This is one summary of the responsibilities of a Public Health Officer:

  • Coordinate or combine the resources of health care institutions, social service organizations, public safety personnel, or other agencies to enhance the community health.
  • Design or use monitoring tools, like as screening, lab records, and vital information, to recognize health risks.
  • Develop tools to address behavioural causes of diseases.
  • Direct or control prevention programs in specialized areas such as aerospace, work-related, infectious disease, and environmental medicine.
  • Assess the effectiveness of recommended risk reduction actions or other interventions.
  • Recognize groups at threat for specific preventable diseases.
  • Carry out epidemiological research of acute and chronic diseases.
  • Prepare precautionary health reports which include problem explanations, analyses, alternate solutions, and suggestions.
  • Deliver details about potential health risks and possible treatments to the media, the public, other health care experts, or local, state, and national health regulators.
  • Manage or coordinate the work of doctors, nurses, statisticians, or other staff members.
  • Educate or train medical team regarding precautionary medicine problems.
  • Design, implement, or assess health service delivery systems to enhance the health of specific communities.

Here surely is the best fit for delivering the eradication of FGM and other harmful practices.

An overview
It is important to note that none of the Public Health responsibilities above diminishes in any way the criticality of specific and specialist efforts to address the challenges of FGM.

Still required at every stage are the skills, in-depth knowledge and active involvement of community activists, medical personnel, legal and enforcement agencies and education specialists, as well as supportive media and other agencies.  Market segmentation – with different people / organisations addressing the diverse needs and concerns arising from the many different aspects of FGM and its eradication – remains a prime (and as yet under-considered) requirement for strategies, but some body or agency has to take cognisance of, and responsibility for, the overall framework.

Nor does the proposal that FGM eradication be led by Public Health in any way excuse those in senior political positions of their responsibility to accept that, ultimately, the buck stops with them. Policy requires serious political backing if it is to achieve its objectives.

Every nation or administrative region where FGM occurs needs one, named, person at the highest political level who has oversight and control of the budgets, other resources and personnel involved.

Sadly, in recent years in the UK at least, Public Health has become something of a Cinderella service (the same applies in the USA); and sadly also we in the UK must note that the programme of national government leadership in FGM services (the Female Genital Mutilation Prevention Programme) came to an end in March 2018.

It is time for those who lead Public Health to step up to the mark, as Cressida Dick demands, whether the challenge be knife crime or FGM or any other similar issue.  Multi-agency liaison alone is not enough.

To make FGM history requires oversight and co-ordination of budgets and resources, and top-level political courage to acknowledge where ultimate responsibility for women and children’s safety lies.

Let’s ask not, ‘How long will it take to eradicate FGM?’  That question side-steps the real issues.

Rather, we need to ask, ‘How much money, what resources and top-level leadership, are required to achieve eradication?’

When we can answer that second question honestly,
we will be quite a way along the route to making FGM history.



Read more about FGM and Economics

Your Comments on this topic are welcome. 
Please post them in the box which follows these announcements…..

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Books by Hilary Burrage on female genital mutilation

18.04.12 FGM books together IMG_3336 (3).JPG

Eradicating Female Genital Mutilation: A UK Perspective (Hilary Burrage, Ashgate / Routledge 2015).
Full contents and reviews   HERE.
FEMALE MUTILATION: The truth behind the horrifying global practice of female genital mutilation  (Hilary Burrage, New Holland Publishers 2016).
Full contents and reviews   HERE.


There is a free FGM hotline for anyone in the UK: 0800 028 3550, or

Details of NHS Specialist Services for FGM here.

More info and posts on FGM here.

Activists, service providers and researchers may like to join the LinkedIn group Female Genital Mutilation (FGM): Information, reports and research, which has several hundred members from around the world.

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

Email contact: via Hilary


[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.]


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 via these relevant dedicated threads.

Discussion of the general issues re M/FGM will not be published unless they are posted on these dedicated pages. Thanks.

4 Comments leave one →
  1. April 29, 2018 21:53

    I agree with you dear Hillary a public health is THE Key issue for eradicating FGM.

  2. May 1, 2018 15:18

    Well done to expand the E’s to empathy and epidemic. Your comparison to knife violence viewed through the lens of public health also illuminates FGM and how best to address it. A feminist discussion of ‘patriarchy incarnate’ is long-overdue.

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