• child abuse
• epidemiology
• ethics
• forensic medicine
• anthropology

It is heartening that the number of children presenting with female genital mutilation (FGM) in the UK is less than expected from the estimates.1 This is against a decade of changes to legal frameworks, including introducing FGM Protection Orders (FGMPOs) to protect girls and women at risk, alongside educational efforts to increase public awareness by a range of stakeholders.

It is possible that FGM is abandoned after migration to the UK1 and that anti-FGM measures need to be proportionate to the empirical evidence of the risk of FGM in the UK. However, there remain widespread concerns connected to discrimination towards women and girls of which FGM is one facet.

A criminal conviction for FGM in England in 2019 focused on witchcraft, rather than the injury and the harm that the girl sustained. In immigration cases, the home office appears to expect medical examinations to prove whether women and girls have had FGM or not, and in family law cases there are concerns that the approach to FGMPOs might have led to disengagement from some individuals, with concerns of a lack of state support to accompany legal measures. The most successful changes appear to be through education and public health prevention strategies. However, we note this with cautionary optimism due to a lack of empirical research, which is clearly imperative.

Using a disease progression model, we suggest that the study1 is visualising the interconnection of legislation and health measures with education campaigns.2 Interventions can include ‘upstream’ or ‘downstream’ approaches. Downstream approaches are individualised, catering to specific needs. Upstream approaches are system-wide, such as the introduction of FGMPOs. While often seen as a heavy-handed approach by policy-makers, the effectiveness of upstream interventions improves over time, as resistance to change fades and subsequent generations grow up with changes normalised.3

Upstream interventions tend to be cheaper with better health outcomes.4 This may offer reassurance to the longitudinal effectiveness of anti-FGM measures. However, it would be unwise to suggest that effectiveness increases over time without additional interventions.

The use of legislation and government policies to change individuals’ and communities’ behaviours, attitudes and practices towards FGM is under-researched. The distance between on-the-ground impact through education and a legislative response can affect the success not just of eradication of FGM but also the wider necessary reduction in gender inequality. While the improvement of law was useful in 2012, the inflammatory and hyperbolic language centring on one conviction means the application of legal mechanisms risks becoming a barrier to reaching the United Nations ‘Sustainable Development Goals to eradicate FGM’. Upstream interventions are considered more effective in terms of their longevity and equitability. Recognising that legislation alone is not sufficient to achieve the desired outcome but that health, education and law combined have the potential to end FGM in our generation is important.