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Girls today are less likely to undergo female genital mutilation than 30 years ago. But with the practice still near-universal in some countries, activists say the goal to end FGM in a decade will be tough.
For Lisa Camara, a new mother from The Gambia, it was a decision that goes against generations of practice in her community. Just five years old when she was cut, the National Coordinator for the NGO Safe Hands for Girls is determined that girls born today should not suffer as she did. "I know that my daughter will never be cut."
Female genital mutilation, or FGM, refers to any kind of deliberate cutting or removal of parts of the female genitalia for non-medical reasons. It affects three quarters of women in The Gambia, and in some countries, the practice is almost universal. Across the world at least 200 million girls and women have been cut.
Read more: Helping survivors of FGM in Africa
For many, being cut is a rite of passage that ensures their acceptance into society. But it can also cause pain, infections and health issues that can continue throughout a woman's life. Those who have been cut have a greater risk of infertility and are twice as likely to die in childbirth. The practice itself can also be fatal. Just last month, a 12-year-old girl died in Egypt after her parents took her to a doctor for the procedure.
The UN aims to end FGM by 2030. But efforts to stop the practice will need to increase significantly to achieve that.
"I hope that I can protect more girls," said Camara. "Working on the ground and coming from a practicing community, I know the odds of that happening, ending FGM by 2030, are very, very slim."
While the vast majority of the girls and women who undergo FGM are sub-Saharan African, it is also practiced elsewhere, including in Egypt, Yemen, Iraq, Indonesia and parts of southern Asia. Girls from some diaspora communities in Europe and North America are also at risk of being cut.
Read more: Female genital mutilation feels 'like living in a dead body'
FGM, which is also referred to as FGC by groups who prefer the more neutral term 'cutting' to 'mutilation', is usually connected to traditional, cultural and religious beliefs. Some communities see it as a way of safeguarding girls' virginity, curbing their sexuality, or even protecting them from rape.
"In Gambia, it is considered an Islamic religious obligation, even though it is not," Camara said. There is no verse in the Quran that supports the practise. "In a country that is more than 90% Muslim, it's going to be very hard for people to abandon their obligations."
'Girls ask their mothers to cut them'
Mariam Dahir, a doctor and anti-FGM activist in Somaliland, said communities there see genital cutting as necessary for social acceptance: "The girl can't be married; she can't be a woman, unless she is going through this practice."
That social pressure helps to explain why so many people believe the practice should continue. In both Somalia and The Gambia, almost two thirds of women support some form of cutting, according to the UN.
"I have seen many times that young girls ask their mothers to cut them, because they really want to look like their peers," said Dahir.
Different communities practice different kinds of FGM. Some partially or totally remove the external clitoris while others cut parts of the labia as well. FGM can also involve the edges of the vulva being sewn together, leaving just a tiny opening for urine and menstrual blood. This is also known as infibulation. Other harmful procedures covered by the term FGM can include scratching, piercing or stretching.
In Somalia, the prevalence of FGM has remained constant at around 98%. But Dahir explains that attitudes have changed. In the past, most Somali communities practiced infibulation. That is now much less common, and the first two types, which involve cutting but not sewing up the genitalia, are more widespread.
"Somehow the messaging and the awareness raising is getting through but still, they want to cut, still, they want to touch the girl," said Dahir. "This is exactly a patriarchal community – they don't want the girl to live the way that she is."
Dahir, who was part of a team that worked to draft a law banning FGM that will soon be submitted to lawmakers in Somaliland, said education is the best way to fight FGM. The self-declared state is internationally seen as an autonomous region of Somalia, one of six African countries where FGM is practiced and still effectively legal.
But banning FGM may not in itself stop girls being cut.
When The Gambia introduced a law banning FGM in 2015, it enabled activists to go into communities and talk about it, but it did not stop the practice, said Camara. There have so far been no prosecutions. "The law has driven the cut underground. Now babies are being cut when they are just months old."
In some countries, girls are cut when they are older, and may have more chance to escape, Camara said. "In Gambia you don't get the chance to get away, you are cut before you even understand what this process means."
'Change is happening'
More than 24 million people in almost 9,000 communities have committed to abandon FGM, according to UNICEF, which says that girls today are one third less likely to be cut than 30 years ago.
"Change is happening, but it's not happening fast enough," says Ebony Ridell Bamber, head of advocacy and policy at Orchid Project, a UK-based NGO working towards ending FGM. "We really need to escalate progress and scale up the work to end this practice."
One development hindering progress towards ending FGM is the shift in some countries towards medicalization of the practice. In Egypt, Sudan and Indonesia, the majority of girls who undergo FGM are cut by a health practitioner.
"In some countries, after childbirth, you can have FGC carried out as part of the birth package," said Ridell Bamber. "It really contributes to legitimizing and entrenching the practice even further."
Dahir has seen a move towards medicalization in Somaliland too. "In our last research, we discovered that 20 percent of the cutters are health workers. The trend now is changing from the traditional cutter to the midwives and doctors." Dahir works with student health workers to raise awareness. "[They] must know that FGM is a human rights violation, and this must be included in the code of conduct."
Both Camara and Dahir are skeptical that the goal to end FGM by 2030 could be achieved in their countries. But both are buoyed by the changes in attitude they have seen.
"In the next 10 years or so, when my generation and even younger people get married, that is the time you will get the real numbers, then you will know how effective the countries have been in practice," said Camara.
She's particularly proud that she could protect her daughter and niece from being cut, even while her grandmother still supports the practice.
Camara suffered complications when giving birth because she was cut as a child, but is not angry about what happened to her. "I cannot change the way I am. All I can do is protect the other people and make sure they get to enjoy what I have not enjoyed."