Section One: Introduction
Female genital mutilation, a long-standing health concern, is the practice of removing, either partially or totally, women’s genitalia. Included in female genital mutilation (FGM) are all procedures that intentionally cause harm to female genital organs for non-medical purposes (World Health Organization, 2013). FGM is an important health issue because, besides its cultural purpose, its lone effect is to cause the body harm and detriment; there are no known health benefits to this practice (WHO, 2013). United Nations Children’s Fund (2005) explains that FGM is an invariably traumatic procedure that results in both short and long term complications for women. Internationally, female genital mutilation is now recognized as a distinct violation of human rights (Population Reference Bureau, 2010). In the early 1990’s, FGM became widely recognized as a compelling violation by African governments, professional associations, the international community, and women’s organizations (PRB, 2010).
Female Genital Mutilation is usually a practice that is performed on children who are not given a choice if they do or do not want such a procedure done (UNICEF, 2005). G.A.O. Magoha and O.B. Magoha (2000) found that female-child genital mutilation is typically performed from seven days old to 14 years old. Due to the high prevalence rate of FGM in Africa, female children living there are the largest at-risk population (WHO, 2013). The Convention on the Rights of the Child asserted that children should be allowed the opportunity to develop physically in a healthy way, have appropriate medical attention, and be protected from abuse, injury, or violence (UNICEF, 2005). However, women living in Africa are all vulnerable. Female genital mutilation is also traditionally performed on women who are about to be married, pregnant women, and women who have just given birth (WHO, 2013). This practice has been in existence since the fifth century (G.A.O. Magoha & O.B. Magoha, 2000). UNICEF (2005) brings to light that women under the age of 18 cannot give informed legal consent to such a high risk practice. The legality of subjecting children to female genital mutilation makes the practice a chief public health issue. UNICEF (2005) further makes the point that that forced FGM, not allowing women their full liberties and rights, clearly demonstrates discrimination and inequality based on sex. With the above information, the practice of female genital mutilation should be on the forefront of society-wide concerns.
Since women have FGM performed at different times in their lives, the type of mutilation is categorized into the following four groups: clitoridectomy, excision, infibulations, and other. Clitoridectomy is either the partial or total removal of the clitoris (WHO, 2013). When both the clitoris and labia manora are removed it is then classified as excision (WHO, 2013). Infibulation, though, is when the vaginal canal is narrowed by creating a covering seal (UNICEF, 2005). The fourth type is considered the other category that is used to describe any other harmful procedures, such as piercing (UNICEF, 2005).
Bacterial infections, hemorrhaging, severe pain, and shock are the most common short-term complications for all four types of female genital mutilation (WHO, 2013). Delay in wound healing, malnutrition, pelvic inflammatory infection, anemia, and fasciitis are considered intermediate complications (G.A.O. Magoha & O.B. Magoha, 2000). Typically, long-term consequences include infertility, cysts, an increased risk for childbirth complications, and chronic bladder or urinary tract infections (WHO, 2013). Severe dysmenorrhea is one of the most common long-term complications, which is a direct result of obstruction of menstrual flow due to FGM (Jasmine, Christiane, Michel, Oliver, 2011, p. 6). Female genital mutilation can also result in the need for later surgeries in order to have intercourse or give birth to a child (WHO, 2013). Deaths from female genital mutilation primarily result from septic shock, hemorrhagic shock, and tetanus (G.A.O. Magoha & O.B. Magoha, 2000). In a study conducted in Gambia, it was determined that for type one (cutting of the prepuce and citreous) female genital mutilation 23.7% of victims experienced complications (Kaplan et al, 2011, p. 3). 55.0% of participants with type two (excision of the prepuce, citreous, and labia minora) FGM experienced complications and 55.4% of participants with type three (cutting of the external genitalia and stitching the two cut sides together) had complications (Kaplan et al, 2011, p. 3). Female genital mutilation is classified as a violation of human rights due to the preceding harms it can cause the body.
“Health consequences of female genital mutilation/cutting in the Gambia, evidence into action” was published in Swiss Medical Weekly in 2011. In their evaluation of 871 women, type II was the most prevalent with 229 cases. Of those cases, 55% had some sort of complication directly rising from FGM, 43% of women experienced immediate complications. 87.3% of women had infections, 30.9% had anemia and 41.8% experienced hemorrhaging. 63 out of the 229 women had abdominal scaring and 71 women had late complications.
Female genital mutilation is a worldwide issue that does not attract enough attention in proportion to the amount of people being affected from it. Overall, 30 million females under the age of 15 are still at risk given current trends of genital mutilation (UNICEF, 2013). The World Health Organization (2013) estimates that annually three million girls are at risk for FGM in Africa alone. Moreover, 101 million girls above the age of ten in Africa are estimated to have experienced genital mutilation (WHO, 2013). The World Health Organization (2013) expresses that prevalence rates vary within different areas, with ethnicity being the most decisive factor. Swiss Medical Weekly determined that Somalia had the highest prevalence rate of women undergoing FGM with 97.9% of their population being subjected to such distortion (Jasmine et al, 2011, p. 2). This is followed by 95.8% of women in Egypt and 95.6% of women in Guinea (Jasmine et al, 2011, p. 2). It is estimated that 120 million girls and women have undergone FGM in 29 countries located in Africa, as well as the Middle East (UNICEF, 2013). The violation of human rights that women experience when subjected to female genital mutilation is a pressing public health matter.
Section Two: Etiology
Female Genital Mutilation and Location
Extensive evidence has shown a distinctive correlation between geographic location and magnitude of women experiencing genital mutilation. Female genital mutilation has been assessed by classifying the type of damage to women’s genitalia into three distinctive types and an other category as described in section one (World Health Organization, 2006). Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS), and UNICEF further determine location data (PRB, 2010). Women age 15-49 in C te d’ lvoire, Egypt, Guinea, Sierra Leone, and Somalia have higher than 90% prevalence rates. Eritrea and Mali have prevalence rates in the 80s. Mauritania, Gambia, Ethiopia, and Burkina Faso all have prevalence rates in the 70’s (PRB, 2010). However, the nearby countries of Cameroon, Ghana, Niger, and Uganda have less than a 5% prevalence rate for women age 15-49 (PRB, 2010). World Health Organization (2013) reports that 140 million girls and women currently live with genital mutilation worldwide and of those, 101 million above the age of ten live in Africa. A prospective study conducted by UNICEF (2005) further examined location by breaking down Africa, as a whole, to assess smaller areas’ influences on female genital mutilation. Women living in Guinea, Egypt, Mali, Sudan, Eritrea, and Ethiopia have an 80 % or higher prevalence rate of genital mutilation for women age 15-49 years old (UNICEF, 2005). Through the DHS, MICS, and UNICEF, the Population Reference Bureau (2005) assessed geographic location. They determined that a mere 1.1 % of women between the ages of 35-39 in Somalia have not experienced genital mutilation (PRB, 2010). However, in neighboring Kenya women ages 35-39 have a 35.1 % prevalence rate (PRB, 2010).
Geographic location further affects female genital mutilation based on urban versus rural areas (UNICEF, 2005). Urban centers tend to be progressive and drift away from traditions, where as rural regions hold more tightly to ancestral beliefs (UNICEF, 2005). Out of the 27 countries surveyed, 24 had higher percentages of women in rural regions having experienced genital mutilation (PRB, 2010). The primary region female genital mutilation occurs in is Africa, however, geographic location can be broken down further pin pointing specific areas in Africa.
Female Genital Mutilation and Societal Environment
World Health Organization (2013) recognizes female genital mutilation as a societal construct. It is common practice for women to undergo genital mutilation in order to conform to the traditional practices of their culture (WHO, 2013). A review study published in Swiss Medical Weekly explains that women who do not experience genital mutilation are often stigmatized, excluded from society, and shamed (Jasmine et al, 2011). With an increase of African immigrants to Europe, Swiss Medical Weekly published a study to give practitioners fuller knowledge of the complicated aspects of female genital mutilation (Jasmine et al, 2011). Researchers determined that women undergo genital mutilation to ensure control of sexuality, honor to the community, and chastity (Jasmine et al, 2011).
World Health Organization (2013) is careful to make the distinction that even though genital mutilation holds a sacred place in societies, it is not associated with any religious practices. Rather, it is viewed as a symbol of femininity and modesty (WHO, 2013). After mutilation women are considered “clean” or “beautiful”, because their “male” body parts have now been removed (WHO, 2013).
G.A.O. Magoha and O.B. Magoha published a study in the East African Medical Journal (2000) that assessed ritual and cultural indications for female genital mutilation. They found that in Africa it might have come about as a substitute for human sacrifice. However, even though the reason for FGM traditionally may have been as a substitute for human sacrifice, to preserve virginity, or due to thinking that the clitoris would grow long like a penis, the practice is persevered in many cultures today. G.A.O. Magoha and O.B. Magoha (2000) found that girls would be considered women after the practice was performed. Some illiterate African women believe that female genital mutilation is a universal practice in which every female takes part (G.A.O. Magoha and O.B. Magoha, 2000).
A prospective analysis by UNICEF (2005) determined that in countries with high prevalence rates, it was almost always done to uphold tradition. In Sudan it was determined that 70 % of women reported justifying female genital mutilation because it is a traditional, cultural practice (UNICEF, 2005). Female genital mutilation is an act supported by many traditional communities in Africa, making one’s societal environment a crucial risk factor in women’s predisposition to experiencing genital mutilation.
Female Genital Mutilation and Socioeconomic Status
The multifaceted aspects of socioeconomic status play a distinctive role in the prevalence of female genital mutilation. Women’s access to education, ability to be monetarily independent, and socioeconomic status influence their likelihood of undergoing genital mutilation (UNICEF, 2005). UNICEF’s data depicts that families of higher socioeconomic status are more likely to have women attend college, affording them knowledge about the affects of genital mutilation (UNICEF, 2005). Women afforded the opportunity to have some form of education decreases their chances of undergoing mutilation (UNICEF, 2005).
The World Health Organization (2006) conducted a prospective study of female genital mutilation in African regions to evaluate the different pieces of socioeconomic status. They collected data from 28,393 women from Burkina Faso, Ghana, Kenya, Nigeria, Senegal, and Sudan. Participating women filled out surveys regarding their personal characteristics as well as their obstetric and medical histories and then these same women had a medical examination by a trained study midwife. Monetary socioeconomic status showed families classified with high income had extremely low prevalence rates of genital mutilation at only 3 % (WHO, 2006). Families with medium incomes had a prevalence rate of 61 % (WHO, 2006). Access to education is a key factor often directly resulting from a person’s socioeconomic status. Women with tertiary education had a low prevalence rate of only 8 % (WHO, 2006). Women with secondary education had a 25% prevalence rate and women with primary education had a 35% prevalence rate (WHO, 2006). The incremental increases demonstrate the direct correlation of education level and prevalence rates of female genital mutilation. In regards to female genital mutilation, higher socioeconomic status is associated with a protective factor for women experiencing genital mutilation (WHO, 2006).
Section Three: Recommendations
Female genital mutilation is an operation that cannot be reversed; therefore, primary intervention is critical for women to not undergo genital mutilation. Primary interventions would have to take place before women or young girls are mutilated. Breaking down female genital mutilation’s foundational causes, as described in the etiology section, would be an effective way to reduce prevalence rates. The three primary causes of FGM are women’s location, societal environment, and socioeconomic status. Women’s location and socioeconomic statues are factors that would be challenging to alter. However, location in terms of where to focus interventions is vital. 101 million women above the age of ten in Africa have had genital mutilation (WHO, 2013). With the World Health Organization (2013) reporting that 140 million women worldwide have FGM there is a distinct region of needed intervention. Somalia, Guinea, Djibouti, and Egypt have the highest prevalence rates of over 90% of their populations (UNICEF, 2013). Efforts in these countries would span a population where almost every woman is affected by genital mutilation. The Lancet (Wairagala Wakabi, 2007) reports that in the past two years concerted efforts in Africa have had success by educating local communities about how female genital mutilation is harming communities and individuals. Kady Bah Faye, Tostan spokesperson, said that in Senegal more than 1,800 communities where excision is practiced have publicly abandoned the practice in the past 9 years from educational efforts (Wairagala Wakabi, 2007). Tanzania has also seen the benefits of awareness campaigns with a prevalence rate dropping from 18% to 15% from 1996 to 2005 (The Lancet, 2005). Targeted educational efforts in Africa have proven to be effective ways of decreasing the prevalence rate of female genital mutilation in Africa.
Focusing interventions on women’s societal environment would be another effective way to decrease prevalence rates. Women attribute the purpose of having genital mutilation performed to their ancestral traditions. Female genital mutilation is a deeply ingrained tradition that can be difficult to break. Given the pan-societal value of female genital mutilation, interventions would have to take place for individuals, at- risk groups and the population as a whole. Kenya’s director of medical services, James Nylikal, explained to The Lancet (Wairagala Wakabi, 2007) that the major restriction in combating the practice is the deep rootedness it has in some cultures, with girls having few rights, and parent’s who will reject daughters that go uncircumcised. tIndividual women would need information about the harmful effects of genital mutilation. They would need to see genital mutilation as a choice that is purely theirs. Yes, there would be repercussions of not having the procedure, but individuals would need to understand the benefits of the alternative.
Addressing the at-risk group of primarily girls, and some women, in Africa would also be a key aspect of interventions. Women would be able to band together in choosing not to have genital mutilation. They could serve as a support network for one another and empower other members of the at-risk group to decide not to have genital mutilation. The third group that would have to be addressed in a comprehensive intervention model is the African population at large. Female genital mutilation is widespread issue that is often influenced by population’s traditional views. Educating African populations about the risk, harms, and effects of female genital mutilation would demonstrate the impact their views are having on the women of the population. Tostan has found it effective to avoid encouraging that countries eradicate the practice, but rather focus on educating the community about democracy and human rights, so that they can understand the dangers of FGM and decrease the practice by formulating a different perspective on the issue (Wairagala Wakabi, 2007) Tostan has been so successful in using role playing, having women share their perspective on the practice and including both sexes in the conversation, that WHO and UNICEF have named it the model program (Wairagala Wakabi, 2007).
Effective interventions to lower female genital mutilation prevalence rates would have the platform of being primary interventions through education. With the highest prevalence rates in Africa, efforts need to be directed at clusters of high female genital mutilation there. Informational efforts would be the most operational if designed to specifically target individual African females, the cumulative female population, and the population at large. Efforts working with people of low socio-economic status and in areas where the societal environment supports the practice would have the most profound effect. While female genital mutilation has been withstanding the test of time, increasing knowledge about the practice stresses that women should have the opportunity to give informed consent.
Section Four: Implementation
Effectively implementing a process to reduce female genital mutilation is built up from an examination of what has already been tried. In July of 2005, five organizations: Population Council, The Manoff Group, PATH, Family Health International, and the Population Reference Bureau collaborated to research what the most effective ways to promote the abandonment of female genital mutilation are (Feldman-Jacobs & Ryniak, 2006). This study defined success in two ways: having a tangible impact on improving ones quality of life and whether the technique was economically, culturally, socially, and environmentally sustainable. They concluded that The Navrongo Health Research Center, IntraHealth International, and Tostan were the most effective projects.
The Navrongo Health Research Center was established in 1988 in northern Ghana. In 1992 the Ministry of Health adopted it (Feldman-Jacobs & Ryniak, 2006). The Navrongo FGM Experiment came into fruition in 1999 as a dual operation to take action against female genital mutilation and collect research on the controversial practice. Their funding sources are Maata N Tuda, the Swiss Embassy, Accra, GNADO, ActionAid, and USAID. They have 10 full-time staff members and 85 community change agents. They are able to remain operational with a budget between $116,00 and $238,200. The researchers were able to compare and test anti-FGM interventions in African communities.
Through their work, the researchers developed a project that is culturally sensitive, specifically crafted for the local areas, and sustainable (Feldman-Jacobs & Ryniak, 2006). The experiment took place in six villages located in the eastern area of the Kassena-Nank-ana district. Societal support for female genital mutilation remains strong in these regions. Researchers concluded a 93% decreased risk for female genital mutilation with their intervention technique (Feldman-Jacobs & Ryniak, 2006). The three reasons that make the project notable in its success is a multi-phased approach, systematic intervention, and having a scientific evaluation. The multi-phased approach was broken down as follows: a diagnostic phase to asses and understand the extent of FGM, a pilot phase to engage the community through participatory learning in the planning of intervention techniques, and the experimental phase in which interventions were introduced to communities over a duration of time. The systematic intervention uses the identified key lines of societal support for the practice and develops strategies to meticulously approach these hurdles. Finally, the scientific evaluation allowed for hard data to be measured and indicate the effectiveness of the intervention strategies. Concluding thoughts from the Navrongo staff include the effectiveness of having female genital mutilation become a normalized discussion for the community to have and the usefulness of being able to change techniques when the statistical analysis was showing ineffectiveness (Feldman-Jacobs & Ryniak, 2006).
IntraHealth International was founded in 1979 at the University of North Carolina Chapel Hill School of Medicine (Feldman-Jacobs & Ryniak, 2006). In 1997, The National Committee on Traditional Practices of Ethiopia became a chapter of IntraHealth International and began the study entitled, “A Five-Dimensional Approach for the Eradication of Female Genital Cutting (FGC) in Ethiopia”. Intra Health has 2.5 paid staff and runs on a $80,000 per year budget. Their funding source is from USAID. Currently, their working languages are English, Amharic, and local languages (Harari, Oromiffa, and Somali). They began their work with the following four objectives: 1) identify current knowledge, practices, and attitudes about female genital cutting, 2) develop a way for community leaders to advocate against female genital cutting, 3) increase knowledge and change attitudes of community members, and 4) to monitor, as well as evaluate, the intervention’s impact in order to understand what knowledge gaps are present (Feldman-Jacobs & Ryniak, 2006).
Their work was focused on the communication of information, laws, religion, gender roles, and health consequences (Feldman-Jacobs & Ryniak, 2006). In an evaluation of their work, researchers found that when the Ethiopian parliament made a penal code for FGC to be punishable by law, it increased intervention success rates. An 83-person consensus of prominent national and religious leaders against female genital mutilation brought about large numbers of cessation against the practice. Educating community members through their five-dimensional approach (communication of information, laws, religion, gender roles, and health consequences) with workshops, training events, public declarations, educational materials, and mobilization activities greatly decreased prevalence rates. They were able to have 2,252 community members ban the practice with public declarations and had public promises to cease the practice by seven well-known circumcisers, who had been performing the operation for more than 15 years. Their largest lessons learned in order to have successful interventions were as follows: ensue the transfer of project ownership to the community, emphasis on stopping the demand for genital mutilation, design activities based on community needs, recommendations, and strengths, bridge information gaps between different community members (i.e. fathers, brothers, sisters, older women, younger women, etc.), respect socio-cultural values, and mobilize/train individuals in the community who have diverse backgrounds (health providers, teachers, religious leaders, traditional birth attendants, etc.) (Feldman-Jacobs & Ryniak, 2006).
Tostan established their roots in 1991 with their Community Empowerment Program in Senegal (Feldman-Jacobs & Ryniak, 2006). Since then, they have spread to six other countries. With a mission, “to empower African communities to bring about positive sustainable development through a comprehensive non-formal education program in local languages” they work to decrease prevalence rates of female genital mutilation. Tostan has 59 paid staff and runs on a budget between $3,000 and $5,000 per year. Wolof, Fulani, Fulani, Mandinka, Malinke, Serere, Bambara, Sonine, Diola, Moore, Soussou, and Arabic are their current working languages. Tostan funding comes primarily from private contributors, government partners, multilateral organizations, and foundations. Their method of reduction involves over 200 sessions in five modules. This program is taught over two to three year periods.
Their community based ownership program has six essential characteristics: respectful—teaching methods are formed around African tradition of respectful discussion, practical—participants implement projects and use their knowledge to solve problems, holistic—it is comprehensive, covering health, hygiene, and literacy, learner-centered—games, song, and theater are used to involve participants with little schooling, trusting—program believes that people will come to the right conclusions given adequate information, trustworthy—information is credible and a sense of trust is built within the program (Feldman-Jacobs & Ryniak, 2006). Tostan staff note four main strong suits of their program. Tostan used to primarily work with adults, however, involving adolescents filled a communication gap and they found higher success rates with this inclusion method. Allowing for participants to make public declarations brought the issue to the forefront of communities. It created an environment where people had to pay attention to the issue. Also noted is the idea of a community having a tipping point. This is where the change reaches a critical mass of people who support not subjecting women to female genital mutilation anymore and the idea becomes a concept of the past. Their fourth successful strategy is the mapping of communities. Tostan works with communities to map networks of local communities before the project starts. This is crucial because it shows which areas have values that align with anit-FGM on both political and religious levels. Having a map allows community members to see if they marry someone of another area if their anti-female genital mutilation stance will be supported there or if they will be in the minority. Tostan is now working to strengthen their program to be able to have other organizations adopt their strategies (Feldman-Jacobs & Ryniak, 2006).
Female genital mutilation has long been overlooked due to its pervasive interconnectedness within African cultures. However, it is emerging, with justified reasons, on the forefront of concerns centering around human rights violations. The international community and many African governments are publicly declaring FGM a practice that women should not be subjected to. Reviewing organizations’ implementation methods to decrease female genital mutilation offers invaluable insights into effective measures.
The Navrongo Health Research Center, IntraHealth International, and Tostan have found ways to achieve a decrease in female genital mutilation prevalence rates in Africa and have common themes of what they each found effective. Integrating interventions within a community wide approach is a concept all three organizations found extremely effective. By ensuring that interventions are viewed within the public arena, the efforts to decrease FGM are not a disreputable topic, but rather they are opened up to community questions, concerns and thoughts. Interventions were still able to target individuals, the at-risk group, and the entire community to provide a cross-community approach. Having interventions in native languages and presented in ways that uneducated people can understand allowed the organizations to reach the greatest number of people. IntraHealth International found that collecting data during the intervention phase was helpful in order to have measurable ways that interventions were either effective or were not positively impactful.
A project would be operational on a budget around $50,000, depending on scale. A staff between 10 and 20 would be needed to run the project, train community volunteers, and manage interventions. Staff would also be able to play an integral role in advocating for African governments to speak out against the practice of FGM and create laws to protect women. A project focusing on education would be the most effective and respectful way to engage in conversations with populations that support female genital mutilation. Female genital mutilation is deeply ingrained in African cultures, however, with growing international and in-country support the practice is starting to become a way of the past that is no longer tolerated.
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