There have been documented decreases in female genital mutilation (FGM) rates in West Africa – declines not granted by governments, but fought for community by community by survivors, activists, and even former practitioners. 

In July 2025, that fight produced a landmark ruling: the ECOWAS Court of Justice found that Sierra Leone’s failure to protect girls from FGM met the legal threshold for torture.

We have just published a five-country report mapping the movements behind these victories. But we would be remiss not to point out that inside the decline, the practice is changing shape.

FGM is moving into clinics

Globally, UNFPA estimates that 230 million women and girls alive today have undergone some form of FGM.  UNICEF estimates that around 52 million of them, roughly one in four, were cut by health personnel.  

In Guinea, where prevalence remains near 95%, an estimated 15% of procedures are performed by health workers. In Nigeria, the figure is around 13%. 

Cutting also happens at younger ages. In The Gambia, the average age at which girls are cut has fallen from age four to just before age two, in the last three decades. Across the region, a trend is emerging: younger girls, clinical settings, sterile instruments, all giving the illusion of a legitimate, medically approved procedure.

The World Health Organisation (WHO) was alarmed enough to respond. Its 2025 guideline on preventing FGM recommends professional codes of conduct expressly prohibiting health workers from performing the practice, training to equip them as agents of prevention, and sensitive communication approaches to help them decline when families ask.

Those are the right tools. But they are supply-side, aimed at the hands that hold the instruments. They leave an important question unexplored. Why is there a demand side at all?

Why families practice FGM

If you’ve never lived in a community where FGM is practised, you’re probably wondering why parents even cut their daughters. That question assumes that the practice survives because of ignorance or indifference. 

That’s a limited, and implicitly Eurocentric, reading. The practice actually survives on the core values most humans hold about parental love. Those values just operate in a different set of beliefs about what protects a girl and what she requires to thrive.

Cultural belonging is not abstract. It is the difference between being embraced by your own people and being considered a stranger.

In the Sahiyo mini-documentary, Behind the Wall, Gambian lawyer Absa Samba recalls the popular girls at her primary school announcing they would only befriend girls who were pure and clean – meaning, girls who had been cut. 

Unsure of her own status, she went home and asked her mother. She was delighted to be informed that she had undergone FGM. Now confident in her in-group superiority, the next day she joined the popular girls in shaming the uncut.

Their taunt of choice was solima, a Mandinka slur for the uninitiated. “If you’re a solima”, one Gambian woman told Reuters during the 2024 FGM repeal debate, “people will tell you you smell bad; no one will eat the food you cook; no one will be your friend; no one will want you as a wife”. 

The initiation rites that accompany FGM mark a girl as marriageable, respectable and claimed. In Sierra Leone, for example, membership in the powerful women-led Bondo society is virtually impossible for the uncut. An uncut girl learns early what exclusion costs, and families are desperate to prevent their wards from paying that price.  

In many West African communities where FGM is practised, cutting isn’t viewed as an infringement on bodily autonomy but as an act of responsible parenting, securing a daughter’s future in the world. 

Campaigns against it are readily framed by pro-FGM advocates as Western judgement and overreach under the guise of child protection.

Why medicalisation?

Why are they asking doctors and nurses instead of the traditional practitioners, known as ngansingbas, exciseuses and soweis? Belonging explains the ask. 

So why is that demand moving into hospitals? The standard answer is evasion. The belief is that a clinical face makes the practice harder to detect and prosecute. There is truth in that reading, but as clinicians and advocates, we think it misses something, and the miss matters. 

In many practising communities, FGM is understood as a health measure in its own right.  An uncut girl is believed to face itching, infection and poor genital hygiene, and FGM is seen as a way of keeping her clean and disease-free.

The same framing extends to the belief that labial/clitoral excision or “pruning” curbs unbridled sexual desire, and with it, the sexual exploitation, early pregnancy, and sexually transmitted infections that desire is blamed for.

These are not fringe views. When The Gambia’s Supreme Court heard the challenge to the country’s FGM ban last December, the lead plaintiff, Imam Abdoulie Fatty, testified that the practice is part of cleanliness in Islam.

In a 2019 Egyptian study, mothers and even physicians suggested that clinical cutting was the responsible way to protect a girl from the dangers uncut genitalia are believed to carry. To societies holding these beliefs, FGM is not viewed as a violation. It is seen as a form of preventative care, a momentary discomfort endured for longer-term benefit, in the same vein as vaccination or deworming.

What if anti-FGM messaging (sort of) worked?

It is into these communities, with an existing framework of FGM as healthcare, that decades of anti-FGM messaging were unleashed. It led with the dangers of the blade and the bush. The focus was on unsterile instruments, re-used razors, dirt floors and infection. Parents who love their daughters listened. They didn’t want their children cut with the same razor that had been used on ten other girls.

They didn’t ignore the harm-based messaging; they acted on it. By modifying their existing belief that cutting itself is protection into a new one: that it is only cutting as it is traditionally performed that endangers girls. 

Qualitative research in Nigeria found that parents chose health workers because they considered them more hygienic, skilled, and able to manage emergencies, while some providers presented medicalised cutting as a way to avert serious complications. 

Studies in Guinea and The Gambia likewise found health workers themselves describing medicalisation as safer than cutting by traditional practitioners. 

They heard ‘do it safely’

We got the point but missed the mark. It is clear that somewhere in the decades of campaigning, the core of the matter got muddied. FGM’s cruelty is in the cutting of healthy tissue from a person who did not consent, with physical, sexual and psychological consequences that no sterile environment prevents. 

It is in the gender-based violence of denying women a say in what happens to their bodies and refusing them societal acceptance because they have not participated in a “cultural norm.” 

It is in the patriarchal control underpinning the entire system, so total that women and girls are socialised to barter pleasure for honour but are ultimately denied both. A clinic changes none of this. 

But to FGM-practising communities, updating what has already been marketed as a beneficial hygienic practice into a more sanitary environment is a logical conclusion. The clinic appears to remove infection risks. It shields the family’s privacy from what they perceive to be legal overreach, and it still fulfils the cultural obligation. 

Urbanisation, provider income, health workers drawn from practising communities, and the search for legal cover, also drive medicalisation. But it is a reading that the evidence permits, and more importantly, it is one with consequences for how we work.

What if medicalisation is less a story of communities evading our message than of communities internalising a message that we as anti-FGM advocates failed to phrase fully?

That reading may be uncomfortable for those of us who have spent years crafting these campaigns. But it is also strangely hopeful. If parents have shown they respond to messages about harm, then our task is to clarify what we’re cautioning against.

Torture: Name the brutality 

Health ministries, professional bodies and advocates should stop leading with the dangers of unsafe conditions and start leading with the damage of the cutting itself, in the terms the ECOWAS Court has now made available: FGM is a violation of a girl’s bodily integrity that meets the threshold for torture. 

That holds regardless of who holds the instrument, whether it is a sterilised stainless steel scalpel or a 600-franc razor, and whether the girl is sedated in a hospital bed in Conakry or pinned down on the mud floor of a hut in Kindia. 

Health professionals must frame FGM not as a misunderstood traditional practice that can be refined but as an act of brutality, akin to amputating a perfectly healthy limb. A request in such stark opposition to the Hippocratic Oath that no clinician can ethically perform it.

It’s the cutting, not the setting  

Communities need to understand that no venue sanitises FGM. This is a position on which the WHO and every serious medical authority is unequivocal. Clinicians and the WHO have warned that medicalised procedures may involve deeper or more extensive excision than traditional cutting. Trained hands with proper instruments, working on a child who is anaesthetised rather than struggling, can remove more healthy tissue than traditional cutters.

The evidence here is still thin, resting largely on clinical observation rather than comparative study, and this gap itself deserves research funding. But the outcome is not in doubt: the more healthy tissue removed, the worse the long-term sexual and reproductive consequences, and the less there is for reconstructive surgery to work with.

Medicalisation also carries a danger beyond the procedure room, one the WHO has warned of since 1997. The credibility of health systems normalises FGM. It entrenches the practice by appearing to legitimise it. 

Every clinician who cuts lends the white coat’s authority to the idea that FGM is a health service. For families who already conflate circumcision with care, that authority reads as confirmation. That is a threat to girls and the standing of the profession.

Professional misconduct

Medical and dental councils, nursing and midwifery boards and the bodies that license private clinics across West Africa should issue explicit, written directives to every professional on their registers. 

They should say that performing, assisting with, referring for or supervising any form of FGM, including re-infibulation, is professional misconduct, regardless of the family’s request or the setting. 

The consequences should be stated in advance and applied fully, such as suspension on first report, removal from the register on proof, loss of the facility’s operating licence where a clinic has permitted it, and automatic referral to the police where national law criminalises the practice. 

Regional bodies such as the West African Health Organisation and the West African College of Physicians should ask their member councils to adopt a common standard, so that a practitioner struck off in one country cannot simply re-register in the next. The message to the profession must be as unambiguous as the message we are asking the profession to deliver to families.

Equip health workers as messengers

In a trial across Kenya, Guinea and Somalia, patients of health workers trained in person-centred communication on FGM became significantly more opposed to the practice, and were more likely to say they would not cut their daughters, than patients of untrained colleagues.

This tells us that we might have found new messengers in a more effective medium. Think about it. The anti-FGM message arrived in FGM-practising communities on radio, on billboards, emblazoned across T-shirts at protest marches. However necessary its intent, it was perceived as uninvited and unsolicited. 

Doctors and nurses, approached for clinical cutting, hold a different position entirely. They do not knock on a family’s door. The family comes to them, request in hand. Often themselves respected members of FGM-practising communities, they are being invited into the very conversation campaigners have spent years trying to start. 

The WHO’s sensitive communication guidance recognises this opportunity when it asks health workers to decline the request for FGM and explain its risks. 

The instinct is right, but it courts a familiar trap. A catalogue of risks is easily misheard. These families are at the hospital precisely because they believe risk is best managed by clinicians. 

So equip health workers to speak less about risk, which can be mitigated, and more about harm, which parents have a duty to prevent. 

Train them to say that cutting causes the very problems it claims to prevent, from infections to sexual dysfunction to complications during childbirth; that their medical training cannot erase the physical and psychological trauma of FGM; and that an uncut girl is already clean, healthy and equipped to thrive. 

Use the authority of the white coat not simply to “do no harm” but to deter others from it.

Test the messaging

Medicalisation didn’t emerge in a vacuum, and it won’t recede in one either. The WHO’s guidelines concede that the effect of health-sector interventions on medicalisation is an open research gap. 

Why don’t we widen the frame? We have barely studied how anti-FGM messages are actually metabolised inside communities, and what alternatives to cutting best satisfy the cultural belonging need. 

Those are not two gaps but one, and funders should resource them in tandem. This will only happen when they  stop pigeonholing FGM as a niche African practice that can be modernised and urbanised away, and start seeking to understand it with the same nuance and depth they give to other forms of gender-based violence. Because that is what it is.

The transnational movement to end FGM across West Africa has shown that rates can decline. Medicalisation shows us where the next front is. It was never about the bush or the blade but the violence.

Famia Nkansa is the communications lead for Purposeful, an Africa-rooted global hub for girls’ organising and activism.

Dr Bintu Mansaray is executive director of the Institute of Gender and Children’s Health Research in Sierra Leone.

Dr Frances Wurie is an obstetrician-gynaecologist at The Woman’s Place in Sierra Leone.

Image Credits: Thomas Triebel, UNFPA, UNFPA, Rugiatu Neneh Kamara/ Amazonian Initiative Movement , Rugiatu Neneh Kamara/ Amazonian Initiative Movement, IFPMA, Amnon Shavit / Wikimedia Commons.