This article was written by Mary Ann Fahmy, a student in Gavin Yamey’s master’s course, “Global Health Policy: Transforming Evidence Into Policy.” In the piece, she uses Shiffman and Smith’s well-known agenda-setting framework to understand how female genital mutilation/cutting rose up the global health agenda. The framework proposes that health concerns gain global priority based on four factors: “the strength of the actors involved in the initiative, the power of the ideas they use to portray the issue, the nature of the political contexts in which they operate, and characteristics of the issue itself.”
Introduction
Female genital mutilation/cutting (FGM/C) is defined as any procedure that partially or totally removes external female genitalia for non-medical reasons. 1 Although globally recognized as a violation of human rights, it is a cultural practice in about 30 countries, primarily in Africa, the Middle East and North Africa, and Asia. 1 Globally, an estimated 230 million girls and women alive today have undergone the practice and face lifelong physical, psychological, and reproductive consequences. 1
In 1995, The Beijing Declaration and Platform for Action called for ending FGM/C as a global health priority. 2 In 2015, the Sustainable Development Goals reinstated this call and introduced Target 5.3 to eliminate FGM/C by 2030, which helped to institutionalize political commitment, funding, legal reforms, and large-scale prevention programs.2 2 Recent decades have seen measurable progress, including a falling prevalence rate among younger populations, widespread criminalization of FGM/C, and reductions of the practice at the community level. 1,2 In this essay, I explain the rise of FGM/C up the global health agenda through applying Shiffman and Smith’s prioritization framework. 3
Actor power
The movement to end FGM/C was started by African feminists through grassroots activism. Organizations, midwives, and physicians all mobilized to spark conversation about the harms of FGM/C as a public health threat and a women’s rights issue. Grassroots organizations eventually led to international forums, generating recognition of the problem and moral urgency to act. However, legitimacy, funding, and overall prioritization were only sustained once powerful global institutions such as the WHO, UNICEF, the United Nations Population Fund (UNFPA), and the World Bank endorsed the elimination of FGM/C. The 2008 UNFPA-UNICEF Joint Programme targeted funding to eliminate FGM/C and provide support to local, community-based, and survivor-led organizations. 2
Religious authorities, particularly Islamic scholars and institutions, such as Egypt’s Al-Azhar, greatly contributed to the reshaping of the social narrative by declaring FGM/C as incompatible with Islamic teachings. 4 Similarly, several churches denounced any religious justification of the practice. 4 A coalition of grassroots advocates, international institutions, and religious leadership has all contributed towards a shift in social norms, education, commitment, and programmatic expansion across the regions impacted by FGM/C.
Ideas
There are three interrelated domains that created the strategic framing of FGM/C. First, the practice violates several established human rights principles, including bodily integrity, freedom from torture, and gender equality. This framing as a violation of rights aligned with international women’s rights movements and legal instruments, embedding FGM/C elimination within broader struggles against both gender-based violence and patriarchal control. Women’s empowerment became an important pillar in the fight against FGM/C, with specific initiatives aimed at education and community organizations that centered solidarity among women and girls. 1,2
Second, FGM/C was recast as a public health crisis. FGM/C activists educated the public about the obstetric, gynecological, sexual, and mental health repercussions of the dangerous practice, which enabled health institutions to mobilize medical communities in response. Framing FGM/C as a health crisis also established an ethical opposition to the medicalization of FGM/C, reinforcing a zero-tolerance approach among clinicians. 1
A third framing, through a justice-oriented lens, resulted from both the development of a legal framework to help prevent FGM/C and the widespread criminalization of the practice. This framing cast FGM/C as a state responsibility. By 2020, two-thirds of affected countries had enacted laws that prohibited the practice. 2
Issue characteristics
FGM/C causes a huge global burden of disease, with about 230 million girls and women worldwide affected, 1 and the practice is associated with well-documented physical harms and lasting psychological consequences. 1 The WHO has established a classification of FGM/C (Types I-IV) to distinguish procedures by anatomical extent and clinical severity, allowing standardized research, clinical management, and data collection to track progress and encourage accountability. 1
There is substantial evidence that community-based interventions centered on dialogue, collective decision-making, public declaration of abandonment by community groups, and engagement of religious leaders produces sustained reductions in prevalence. 1 For example, community child protection committees in Burkina Faso prevented an estimated 175,700 girls from undergoing FGM/C in 2019 through local surveillance and education initiatives. 2 These characteristics influenced the United Nation’s decision to make FGM/C a global priority.
Political context
International policy and national laws have been central to elevating FGM/C on national and global agendas and sustaining progress toward elimination. At the global level, political recognition of FGM/C as a human rights violation was formalized through resolutions from the World Health Assembly and the United Nations General Assembly. International agreements such as the Convention on the Elimination of All Forms of Discrimination against Women and the Convention on the Rights of the Child have further reinforced state accountability. 1 At the national level, the global movement translated into widespread legal reforms with two-thirds of high prevalence countries enacting legislation prohibiting FGM/C. 1
Conclusions
Several factors contributed to the rise of FGM/C as a global health priority, but the convergence of strategic framing, institutional commitment, and community-based action ultimately proved decisive. Using the lenses and tools of human rights, public health, and justice as the basis for ending FGM/C aligned well with the interests of policymakers and global institutions, leading to political traction and sustainability. However, many organizations, such as UNICEF and the WHO, highlight that durable change comes from community-based initiatives with local leaders, survivors, and families rather than top-down condemnation. 1, 2 At its core, FGM/C is deeply embedded in cultural norms, and true change within this context can only occur within. Strong global health agenda-setting requires political will and funding but succeeds with culturally grounded strategies centering the affected communities.
References
1. World Health Organization. WHO guideline on the prevention of female genital mutilation and clinical management of complications. Geneva: World Health Organization; 2025.
2. United Nations Children’s Fund. A decade of action to achieve gender equality: the UNICEF approach to the elimination of female genital mutilation. New York: UNICEF; 2020.
3. Shiffman J, Smith S. Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet. 2007;370(9595):1370–9.
4. UN Women. As more families report FGM incidents in Egypt, advocacy intensifies, and a new bill seeks to increase penalties [Internet]. New York: UN Women; 2021 Feb 5 [cited 2025].