Debating medicalization of Female Genital Mutilation/Cutting (FGM/C): learning from (policy) experiences across countries

The medicalisation of female genital cutting in Kenya: a threefold exposition

In Kenya, the prevalence of Female Genital Cutting (FGC) is slowly decreasing. Simultaneously, the practice is increasingly being performed by healthcare providers rather than traditional circumcisers, which may pose the risk of legitimising the practice. To date, the underlying mechanisms remain poorly understood. Using the 1998, 2008-09, and 2014 Kenyan Demographic Health Surveys, this study aims to enhance understanding by mapping both FGC prevalence and medicalisation rates across birth cohorts and ethnic groups. Additionally, the study delves into data from the Kisii community, where FGC medicalisation is particularly high, to examine the association between medicalisation and a mother's social position, as she is typically the primary decision-maker regarding the practice. Findings reveal that the coexisting trends of decreasing prevalence and increasing medicalisation exhibit significant ethnic variation. Among the Kisii, greater wealth is associated with higher odds of a medicalised cut compared to a traditional cut, while higher education and media use are linked to higher odds of not undergoing cutting at all compared to a medicalised cut. Our findings nuance the international community's premise that the medicalisation of FGC hinders the eradication of the practice.

Rethinking the Definition of Medicalized Female Genital Mutilation/Cutting

In 2015, the international community agreed to end Female Genital Mutilation/Cutting (FGM/C) by 2030. However, the target is unlikely to be met as changes in practice, including medicalized female genital mutilation/cutting (mFGM/C), challenge abandonment strategies. This paper critically reviews the current World Health Organization (WHO) definition of mFGM/C to demonstrate that mFGM/C, as currently defined, lacks detail and clarity, and may serve as an obstacle to the collection of credible, reliable, and comparable data relevant to targeted FGM/C prevention policies and programs. The paper argues that it is necessary to initiate a discussion on the revision of the current WHO definition of mFGM/C, where different components (who-how-where-what) should be taken into account. This is argued by discussing different scenarios that compare the current WHO definition of mFGM/C with the actual practice of FGM/C on the ground. The cases discussed within these scenarios are based on existing published research and the research experience of the authors. The scenarios focus on countries where mFGM/C is prevalent among girls under 18 years, using data from Demographic Health Surveys and/or Multiple Indicator Cluster Surveys, and thus the focus is on the Global South. The paper places its arguments in relation to wider debates concerning female genital cosmetic surgery, male genital circumcision and consent. It calls for more research on these topics to ensure that definitions of FGM/C and mFGM/C reflect the real-world contexts and ensure that the human rights of girls and women are protected.

The feasibility, acceptability, appropriateness and impact of implementing person-centered communication for prevention of female genital mutilation in antenatal care settings in Guinea, Kenya and Somalia

BACKGROUND

There is limited evidence on how to engage health workers as advocates in preventing female genital mutilation (FGM). This study assesses the feasibility, acceptability, appropriateness and impact of a person-centered communication (PCC) approach for FGM prevention among antenatal care (ANC) providers in Guinea, Kenya and Somalia.

METHODS

Between August 2020 and September 2021, a cluster randomised trial was conducted in 180 ANC clinics in three countries testing an intervention on PCC for FGM prevention. A process evaluation was embedded, comprising in-depth interviews (IDIs) with 18 ANC providers and 18 ANC clients. A qualitative thematic analysis was conducted, guided by themes identified a priori and/or that emerged from the data.

RESULTS

ANC providers and clients agreed that the ANC context was a feasible, acceptable and appropriate entry point for FGM prevention counselling. ANC clients were satisfied with how FGM-related information was communicated by providers and viewed them as trusted and effective communicators. Respondents suggested training reinforcement, targeting other cadres of health workers and applying this approach at different service delivery points in health facilities and in the community to increase sustainability and impact.

CONCLUSION

These findings can inform the scale up this FGM prevention approach in high prevalence countries.

Qualitative study of the roles of midwives in the provision of sexual and reproductive healthcare services in the Somaliland health system

OBJECTIVES

To explore midwives' perspectives in providing sexual reproductive healthcare services in the Somaliland health system.

METHODS

An exploratory qualitative design using focus group discussions (n=6) was used. The study was conducted in the capital of Somaliland, Hargeisa, at six maternal and child healthcare centres that provide sexual and reproductive healthcare (SRH) services. Qualified midwives (n=44) who had been working in the maternal and child health centres for a minimum of 1 year were recruited to participate, and only one did not participate due to illness.

RESULTS

The results showed that Somaliland midwives face multiple challenges from a lack of formal arrangements, primarily written guidelines and policies, that explicitly define their role as healthcare professionals, which impact the quality of care they provide. They also reported feeling unsafe when practising according to their professional scope of practice due to challenging cultural norms, customary traditions and Somaliland's legal system. Finally, the midwives called for support, including training, institutional protection and psychological support, to enhance their ability and fulfil their role in SRH services in Somaliland.

CONCLUSION

Midwives are essential to the provision of equitable SRH services to women and girls, yet are not fully supported by policies, laws or institutions, often living in fear of the consequences of their behaviours. Our research highlights the importance of understanding the context of Somaliland midwifery in order to better support the development of the midwifery workforce, stronger governance structures and midwifery leadership. Appropriately addressing these challenges faced by midwives can better sustain the profession and help to improve the quality of care provided to women and girls and ultimately enhance their reproductive health outcomes.

Knowledge, attitudes, and practices of female health care service providers on female genital mutilation in Somalia: A cross-sectional study

BACKGROUND

Despite a strong international standpoint against female genital mutilation, the prevalence of female genital mutilation in Somalia is extremely high.

OBJECTIVES

This study assessed the knowledge, attitude, and practice of female genital mutilation among female health care service providers in order to formulate appropriate policies and programs to eliminate this harmful practice.

DESIGN

Facility-based cross-sectional survey conducted in 2019 among female doctors and nurses working in Banadir Hospital, Mogadishu, Somalia.

METHODS

A total of 144 female health care service providers were randomly selected, and data were collected through a pre-tested, semi-structured questionnaire. Quantitative data were analyzed by using the statistical software SPSS (Version 21), and qualitative data were analyzed thematically in accordance with the objectives of the study.

RESULTS

The study found that about three-fifths of the respondents had undergone some forms of female genital mutilation during their life. An overwhelming majority believed that female genital mutilation practices were medically harmful, and a majority of them expressed their opinion against the medicalization of the practice of female genital mutilation. The study also observed a significant association between participants' age and their negative attitudes regarding the legalization of female genital mutilation.

CONCLUSION

Health care service providers' effort is critical to eliminating this harmful practice from the Somalian society. Strong policy commitment and a comprehensive health-promotion effort targeting the parents and community leaders are essential to avert the negative impact of female genital mutilation.

Effect of parental attitudes on the practice and medicalization of female genital mutilation: a secondary analysis of Egypt Health Issues Survey, 2015

Background

Despite the observed decrease in female genital mutilation (FGM) prevalence, it is increasingly being medicalized. We examined the attitudes of both parents towards the FGM practice in Egypt, and highlighted the effect of fathers’ decision making and attitudes towards FGM and violence on FGM practice and medicalization.

Methods

This study is a secondary analysis of Egypt Health Issues Survey (EHIS), 2015. The 2015 EHIS involved a systematic random selection of a subsample of 614 Shiakhas/villages out of the 884 shiakhas/villages that had been chosen as Primary Sampling Units in the 2014 EDHS. Descriptive statistics of the study sample and parents’ attitudes was performed. Three indices were created describing; mothers’ and fathers’ attitudes towards FGM, decision making and rejecting violence against women. Bivariate and multivariable analyses were conducted to identify predictors of FGM practice and medicalization.

Results

A considerable proportion of EHIS girls; 16.4% were circumcised and 36% of girls were expected to be circumcised. More than two thirds of circumcised girls were circumcised by a physician; namely 67% and 13.5% by nurses. The majority of mothers (88.4%) and fathers (84.8%) believed that FGM practice should continue. They believed that FGM is a religious obligation (72.3% of mothers and 73% of fathers). Parents believed that husbands prefer a circumcised wife (81.1% and 82.5% of mothers and fathers respectively). Being in the poorest wealth quintile (OR = 4.2, p < 0.001) and living in rural Upper Egypt (OR = 4.55, p < 0.001) were the predictors of FGM practice, while medicalization was more likely among the rich and educated parents. Parents’ attitudes supporting FGM was significantly associated with its practice (OR = 1.97, p < 0.001, for mothers and OR = 1.27, p < 0.001, for fathers). Rejecting violence against women was associated with less likelihood of practicing FGM (OR = 0.89, p < 0.05) and more likelihood of its medicalization (OR = 1.25, p < 0.01).

Conclusion

More attention should be paid to enforce the laws against FGM practice by health care providers. Raising the community awareness on girls’ human rights and elimination of FGM practice which is a severe form of violence against women and gender inequality in sexual rights should be prioritized with targeting men in FGM programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01834-7.

"You must cut that long and stinking thing": uncovering the lived experiences of uncircumcised pokot women in North-Eastern Uganda

BACKGROUND

Female circumcision remains a dominant practice among the Pokot of North-Eastern Uganda. This paper explores the lived experiences of uncircumcised Pokot women, as they continue to live in a community, where the practice is cherished.

METHODS

This qualitative study adopted an ethnographic research design. The study was based on thirty [30] serial interviews with 15 uncircumcised women in the Pokot local language between August and October 2021. Five [5] Key Informant Interviews were also conducted with key informants from Amudat District. A Focus Group Discussion with women, irrespective of their circumcision status, was organized as an entry point to identify the initial uncircumcised woman. Uncircumcised women were recruited using respondent-driven sampling while key informants were purposively selected. Data were analyzed thematically. Participants were allocated codes to ensure anonymity.

RESULTS

Participants expressed understanding of female circumcision, and the procedure although they were not circumcised. Denial of participation in community and cultural functions, rejection by elders and relatives, difficulties in getting marriage partners, denial of conjugal rights and basic needs, refusal to give names to their children, and home desertion were the negative experiences reported by uncircumcised women. Sexual enjoyment during sexual intercourse, epitomized by the ease of reaching orgasms, fewer complications while giving birth as well as reduced risk of exposure to sexually transmitted diseases were mentioned by participants as their positive experiences.

CONCLUSION

Uncircumcised Pokot women continue to experience unbearable challenges since female circumcision is perceived as the only rite of passage to womanhood. This calls for intensified awareness of the population on the challenges associated with female circumcision refusal while demonstrating the positive experiences mentioned by uncircumcised women, that can be exploited as the beacon of hope.

Does local resistance impact the transnational normative environment? The case of female genital mutilation (FGM)

More than 200 million girls and women today are estimated to have gone through female genital mutilation (FGM). In this study, I make a novel contribution to the global literature on FGM by examining domestic resistance to the anti-FGM norm in the context of norm diffusion processes. I provide a novel theoretical perspective to the study of FGM by introducing a compromise-building approach. According to this approach, strong local resistance to a transnational norm that obligates the removal of harmful traditional practices might motivate some transnational norm advocates to support a compromise solution to minimize harm, leading to normative contestation in the transnational domain. This approach is illustrated by the rise of advocacy for medicalized and minor forms of FGM as a harm reduction strategy as a result of the continuation of traditional forms of FGM. The compromise-building approach also brings a new theoretical perspective to the literature on norm diffusion.

Effects of antenatal care visits and health facility delivery on women's choice to circumcise their daughters in sub-Saharan Africa: evidence from demographic and health surveys

BACKGROUND

This study examines the association between maternal healthcare service utilisation and circumcision of daughters in sub-Saharan Africa (SSA).

METHODS

This study is based on a cross-sectional study design that draws on analysis of pooled data from current demographic and health surveys conducted between 2010 and 2019 in 12 countries in SSA. Both bivariate and multivariable binary logistic regression models were employed.

RESULTS

Mothers who had four or more antenatal care visits were less likely to circumcise their daughters compared with those who had zero to three visits. Mothers who delivered at a health facility were less likely to circumcise their daughters than those who delivered at home. With the covariates, circumcision of daughters increased with increasing maternal age but decreased with increasing wealth quintile and level of education. Girls born to married women and women who had been circumcised were more likely to be circumcised.

CONCLUSIONS

This study established an association between maternal healthcare service utilisation and circumcision of girls from birth to age 14 y in SSA. The findings highlight the need to strengthen policies that promote maternal healthcare service utilisation (antenatal care and health facility delivery) by integrating female genital mutilation (FGM) information and education in countries studied.

New research on the global prevalence of female genital mutilation/cutting: Research, clinical, and policy implications

In this perspective, Kerrie Stevenson and Brenda Kelly discuss new research on the prevalence of female genital mutilation/cutting alongside clinical and policy implications.

What makes a woman? Understanding the reasons for and circumstances of female genital mutilation/cutting in Indonesia, Ethiopia and Kenya

This study presents the reasons for, and circumstances of, female genital mutilation/cutting (FGM/C) in Indonesia, Ethiopia and Kenya. Data were collected in 2016 and 2017 by means of a household survey conducted with young people (15-24 years) and through focus group discussions, in-depth interviews and key informant interviews with youth and community stakeholders. The study findings confirm previously documented reasons for FGM/C, noting that these reasons are interconnected, and are rooted in gender norms. These reasons drive the alterations of bodies to produce a 'cultured' body in the form of the 'pure body' among Sundanese and Sasak peoples in Indonesia, the 'tame' body among the Amhara people in Ethiopia and the 'adult body' among the Maasai people in Kenya. While health workers and parents are important decision-makers in each setting, young Maasai women are, at times, able to exercise their agency to decide whether to undergo FGM/C, owing to their older age at circumcision. Changing legal and social contexts in each setting have brought about changes in the practice of FGM/C such as increased medicalisation of the procedure in Indonesia. The clear links between the different drivers of FGM/C in each setting demonstrate the need for context-specific strategies and interventions to create long-lasting change.

Management of Female Genital Mutilation/Cutting-Related Obstetric Complications: A Training Evaluation

Although female genital mutilation/cutting (FGM/C) is a prevalent practice in Liberia, healthcare workers lack the capacity to provide adequate care for FGM/C survivors. Therefore, Liberian nurses, physician assistants, midwives and trained traditional midwives were trained in sexual, obstetric and psychosocial care for FGM/C survivors in 2019. Through questionnaires, we assessed knowledge acquisition, trainee attitudes towards FGM/C care and acceptability to implement WHO-endorsed recommendations. The questionnaires were analyzed using descriptive statistics for quantitative data and an inductive approach for qualitative data. A total of 99 female and 34 male trainees participated. Most trainees perceived FGM/C as harmful to women’s health, as a violation of women’s rights and showed a willingness to change their clinical practice. While 82.8% (n = 74/90) perceived their role in advocating against FGM/C, 10.0% (n = 9/90) felt that they should train traditional circumcisers to practice FGM/C safely. The pre-training FGM/C knowledge test demonstrated higher scores among physician assistants (13.86 ± 3.02 points) than among nurses (12.11 ± 3.12 points) and midwives (11.75 ± 2.27 points). After the training, the mean test score increased by 1.69 points, from 12.18 (±2.91) points to 13.87 (±2.65) points. The trainings successfully increased theoretical knowledge of FGM/C-caused health effects and healthcare workers’ demonstrated willingness to implement evidence-based guidelines when providing care to FMG/C survivors.

Reconstructive surgery after Female Genital Mutilation: a multidisciplinary approach

BACKGROUND AND AIM

Female Genital Mutilations (FMGs) are all interventions involving partial or total removal of external female genital apparatus, perpetrated not for therapeutic purposes. This review aims to describe a multidisciplinary approach to clinical management of women with FGM, requiring reconstructive surgery and therapeutic deinfibulation. Furthermore, these traditional procedures are harmful to women's physical integrity, being able to result in severe psychological damage with strong inhibitions in sexual and emotive life.

METHODS

Clinical management followed internal protocol implemented at the obstetric Pathology of IRCCS Burlo Garofolo of Trieste, in the framework of the regional project "Female genital mutilation and women immigrants: a draft integrated training and support person," supported by Regione Friuli Venezia Giulia, Italy. We have enrolled in our protocol 15 women that came in our Hospital spontaneously. Here, we present a case of a 38-year-old woman, who had undergone ritual FGM type III with a deep groove scar. She had suffered pain and limitations to sexual intercourses.

RESULTS

We performed a reconstructive surgery of the mutilated genital tissue and a therapeutic deinfibulation. The deep groove scar was successfully removed with a multidisciplinary approach. We achieved careful evaluation, both clinical and psychological, of the patient, before surgery.

CONCLUSIONS

Reconstructive surgery for women who suffer sexual consequences from FGM is feasible. It restores women's natural genital anatomy, allowing to improve female sexuality.

The relationship between women’s individual empowerment and the support to female genital cutting continuation: a study on 7 African countries

Female genital mutilation/cutting (FGM/C) is still present in many African countries, as well as a few others. The United Nations has targeted women’s empowerment in terms of both women’s health and gender equality as one of its Sustainable Development Goals. In this paper, we aimed to study the possible link between women’s empowerment and support for the continuation of FGM/C. We used DHS data from seven African countries and considered both the empowerment and FGM/C modules. We selected empowerment variables based on Kabeer’s conceptual framework and used multilevel logistic models to evaluate the putative role of empowerment in support for discontinuing the practice. The multilevel models highlighted the protective effect of education. Other variables, including justification of intimate partner violence (IPV) and having experienced FGM/C, were associated with FGM/C support. The relationship between decision-making and FGM/C support appears complex, while the unmet need for contraception and job conditions do not seem to play a role. Our findings confirm that some aspects of women’s empowerment (education and rejection of IPV) may enhance the discontinuation of FGM/C. However, the relationship between empowerment and support for continuation of FGM/C is complex and should not be treated as self-evident. Thus, using DHS data, we empirically support the UN’s proposal for discontinuing FGM/C through sustaining women’s empowerment.

Female Genital Cutting: An Evidence-based Review for the OBGYN of Long-term Sequelae and Management Options

Female genital cutting (FGC) is a persisting global practice that increases patients' risk for experiencing long-term health sequelae. Existing meta-analysis evidence strongly supports an association between FGC and the development of long-term dyspareunia, urinary tract infections, and sexual dysfunction as well as increased risk obstetrically of prolonged labor, cesarean section, perineal lacerations, and episiotomy. Surgical defibulation is recommended in patients with type III FGC to decrease obstetric and gynecologic morbidity. Existing evidence does not seem to definitively support clitoral reconstructive surgery. More research is needed to study conservative treatment and management approaches to long-term sequelae of FGC.

Exploring Perceptions of Female Genital Mutilation/Cutting Abandonment (FGM/C) in Kenyan Health Care Professionals

Female genital mutilation/cutting (FGM/C) remains a global problem. We aimed to explore Kenyan health care professionals' (HCPs) perceptions of FGM/C abandonment and, in particular, those focused on those serving Maasai communities who continue to practice FGM/C. Using a grounded theory Straussian approach, 18 interviews were conducted with HCPs in Kajiado County, Kenya, to understand perceptions of FGM/C as a cultural practice, identify barriers and facilitators to abandonment, and explore attitudes to medicalization (FGM/C conducted by HCPs) and alternatives of FGM/C. Within a substantive theory, one core category ("FGM/C persists but can be abandoned") comprised two subcategories: "exploring the influencers of persistence" and the "roadmap to abandonment." HCPs believed collaborative multilateral efforts were necessary to support successful abandonment and that "enlightening" the community needed to focus on changing the perception of FGM/C as a social norm alongside a health risk educational approach. Future effective intervention is needed to support the abandonment of FGM/C in Kenya.

Assessing the reliability and validity of attitudes and confidence scales for the care of women and girls affected by female genital mutilation/cutting

Background

Approximately 545,000 women and girls in the USA have undergone Female Genital Mutilation/ Cutting (FGM/C) or have mothers from a country where FGM/C is practiced. Women and girls living with FGM/C in the USA may experience stigma and bias due to their FGM/C, immigration, racial, and language status. Health care provider attitudes toward FGM/C and confidence for related clinical care may affect the quality of care, yet there are no validated instruments to measure these constructs.

Methods

We developed the instruments via review of the FGM/C literature, the development of scale items, expert review, and pre-testing. We validated the instruments using a convenience sample of providers in Arizona and Maryland. We used exploratory factor analysis (EFA) to confirm factor structures, and compared scores between known groups to assess validity.

Results

The EFA revealed a two-factor solution for attitudes, including subscales for Negative Attitudes and Empathetic Attitudes toward FGM/C and those who practice with Cronbach’s alphas of 0.814 and 0.628 respectively. The EFA for confidence revealed a two-factor solution including Confidence in Clinical FGM/C Care and Confidence in Critical Communication Skills for FGM/C Care with Cronbach’s alphas of 0.857 and 0.694 respectively.

Conclusions

Health care provider attitudes and confidence toward FGM/C care may affect quality of care and health outcomes for women and girls. Our study describes the rigorous psychometric analysis to create reliable and valid instruments to assess health care provider attitudes and confidence for the care of women and girls who have experienced FGM/C.

Trial registration

ClinicalTrials.gov, NCT03249649. Registered on 15 August 2017. Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11455-8.

Cohort analysis of the state of female genital cutting in Nigeria: prevalence, daughter circumcision and attitude towards its discontinuation

BACKGROUND

Female genital cutting (FGC) inflicts life-long injuries on women and their female children. It constitutes a violation of women's fundamental human rights and threats to bodily integrity. Though decreasing, the practice is high and widespread in Nigeria despite efforts towards its eradication. This study was conducted to perform cohort analysis of the state of FGC between the years 2009 and 2018 in Nigeria.

RESULTS

The study found that that FGC has reduced over the years from 56.3% among the 1959-1963 birth cohort to 25.5% among 1994-1998 cohorts but a rise in FGC between 1994-1998 cohorts and 1999-2003 cohorts (28.4%). The percentage of respondents who circumcised their daughters reduced from 40.1% among the oldest birth cohort to 3.6% among the younger cohort. Birth-cohort, religion, education, residence, region, and ethnicity were associated with FGC. Factors associated with the daughter's circumcision were birth-cohort, religion, residence, region, ethnicity, wealth, marital status, FGC status of the respondent, and FGC required by religion. Similar factors were found for discontinuation intention.

CONCLUSIONS

The practice of FGC is still high but decreasing among younger birth-cohorts in Nigeria. There is no significant change in the perception of the discontinuation of FGC. More awareness about the adverse effects of FGC, particularly among women with poor education in Nigeria will greatly reduce this cultural menace's timely eradication.

Experiences of Girls Who Underwent Female Genital Mutilation/Cutting

Objective To describe the experiences of girls who have undergone FGM/C, so that efforts toward ending this practice can be scaled up using evidence-based interventions. Method: A qualitative descriptive design with in-depth interviews conducted with 16 genitally mutilated girls, aged between 12 and 19 years. Results: Four themes and 10 sub-themes were identified. The themes were: it is the right thing to do; the cold circumcision morning; life after FGM/C; FGM/C is ongoing. They experienced fear, uncertainty, pain, and helplessness due to the practice. Conclusion: The FGM/C experiences of these girls could serve as evidence to scale up efforts toward ending FGM/C.

Changes in the prevalence and trends of female genital mutilation in Iraqi Kurdistan Region between 2011 and 2018

Background

Female genital mutilation (FGM) is commonly practiced in Iraqi Kurdistan Region, where there are extensive efforts to combat the practice over the last decade. This study aimed to determine the trends and changes in the FGM prevalence in Iraq between 2011 and 2018 and assess their associated factors.

Methods

Secondary data analysis of the Iraq Multiple Indicator Cluster Survey 2011 and 2018 was carried out to calculate the prevalence and the relative changes in the prevalence of FGM for 2011 and 2018 by governorate. The change in the prevalence was compared with the changes in other exposure variables such as age, education level, wealth, and area of residence over the same period.

Results

The prevalence of FGM in 2018 was high in Erbil and Suleimaniya governorates (50.1% and 45.1%). The prevalence of FGM decreased remarkably from 2011 to 2018 in all governorates of the Iraqi Kurdistan Region. The decrease in the prevalence was statistically significant in Erbil and Suleimaniya. FGM prevalence declined remarkably in all age, education level, residence area groups, and most economic level groups. Such decline was associated with a significant increase in the education level, wealth, and urban residence. The decline was highest in the younger age groups, with a relative change of − 43.0% among 20–24 years and − 39.2% among 15–19 years. The decline was also highest in those with secondary and higher education (relative change = −32%). The decline was higher in rural areas than in urban areas (relative change = −35.3% and − 27.4%, respectively). The decline was higher among the poorest and second wealth quintile (relative change = −38.8% and − 27.2%, respectively).

Conclusion

The trend of FGM in Iraqi Kurdistan Region declined remarkably and significantly from 2011 to 2018. Further decline is predicted because of having lower rates and a higher decline in the younger age groups. However, the rates remained high in Erbil and Suleimaniya governorates that need further intensifying the preventive measures. The education level of women plays a primary role in decreasing the prevalence and should be considered in future efforts to ban the practice.

"A lot of them have scary tears during childbirth…" experiences of healthcare workers who care for genitally mutilated females

Despite concerted efforts to curb Female Genital Mutilation/Cutting (FGM/C), it is still a contributor to the high morbidity and mortality rates among females in Africa. According to available literature, the experiences of healthcare workers who care for the genitally mutilated females in Nigeria have not been described, hindering efforts towards ending this procedure through evidence-based, community-led interventions. This qualitative study described the experiences of healthcare workers caring for the genitally mutilated females in South-Eastern Nigeria. In-depth interviews conducted with 17 participants resulted in two themes and five sub-themes. The participants faced major challenges in caring for these females as the complications of FGM/C resulted in situations requiring advanced skills for which they were ill-prepared. Irrespective of this complex situation, the participants believed FGM/C was an age-old cultural practice; some even supported its continuation. The solution to this problem is not simple. However, educational programmes involving all cadres of healthcare workers could assist with eradicating this practice. Also, enforcing the anti-FGMC law could enhance the eradication of this procedure.

Do educated women in Sierra Leone support discontinuation of female genital mutilation/cutting? Evidence from the 2013 Demographic and Health Survey

INTRODUCTION

Female genital mutilation/cutting (FGM/C) comprises all procedures that involve the total or partial elimination of the external genitalia or any injury to the female genital organ for non-medical purposes. More than 200 million females have undergone the procedure globally, with a prevalence of 89.6% in Sierra Leone. Education is acknowledged as a fundamental strategy to end FGM/C. This study aims to assess women's educational attainment and how this impacts their views on whether FGM/C should be discontinued in Sierra Leone.

METHODS

We used data from the 2013 Sierra Leone Demographic and Health Survey. A total of 15,228 women were included in the study. We carried out a descriptive analysis, followed by Binary Logistic Regression analyses. We presented the results of the Binary Logistic Regression as Crude Odds Ratios (COR) and Adjusted Odds Ratios (AOR) with 95% confidence intervals (CIs).

RESULTS

Most of the women with formal education (65.5%) and 15.6% of those without formal education indicated that FGM/C should be discontinued. Similarly, 35% of those aged 15-19 indicated that FGM/C should be discontinued. Women with a higher education level had a higher likelihood of reporting that FGM/C should be discontinued [AOR 4.02; CI 3.00-5.41]. Christian women [AOR 1.72; CI 1.44-2.04], those who reported that FGM/C is not required by religion [AOR 8.68; CI 7.29-10.34], wealthier women [AOR 1.37; CI 1.03-1.83] and those residing in the western part of Sierra Leone [AOR 1.61; CI 1.16-2.23] were more likely to state that FGM/C should be discontinued. In contrast, women in union [AOR 0.75; CI 0.62-0.91], circumcised women [AOR 0.41; CI 0.33-0.52], residents of the northern region [AOR 0.63; CI 0.46-0.85] and women aged 45-49 [AOR 0.66; CI 0.48-0.89] were less likely to report that FGM/C should be discontinued in Sierra Leone.

CONCLUSION

This study supports the argument that education is crucial to end FGM/C. Age, religion and religious support for FGM/C, marital status, wealth status, region, place of residence, mothers' experience of FGM/C and having a daughter at home are key influences on the discontinuation of FGM/C in Sierra Leone. The study demonstrates the need to pay critical attention to uneducated women, older women and women who have been circumcised to help Sierra Leone end FGM/C and increase its prospects of achieving Sustainable Development Goals (SDG) three and five.

Leadership among Women Working to Eradicate Female Genital Mutilation: The Impact of Environmental Change in Transcultural Moments

The study of cultural moments can identify the level of acceptance of female genital mutilation and the visibility of the involved health problems in a globalized world.

AIMS

To describe the transcultural process through which immigrant women who have experienced female genital mutilation become leaders against this practice.

METHOD

Descriptive research with cross-cultural principles and a qualitative approach. A semi-structured interview was the chosen technique for data collection. A total of 18 women participated in the preliminary observation and analysis unit, and only 8 women (38.8%) were ideologically against female genital mutilation (FGM).

INCLUSION CRITERIA

The selected women had undergone FGM and were fully prepared to discuss it.

RESULTS

Staying in a different country and the associated social relations reduce cultural pressure and promote critical thinking. Cultural moments reflect the different situations that affect the perception and practice of female genital mutilation. Health problems associated with female genital mutilation (sexual, reproductive, and psychological) become visible at transcultural moments.

CONCLUSIONS

Environmental country change affects the cultural pressure that sustains this practice in individual minds, institutions, structures, and bodies. These changes produce transcultural moments. The practice of female genital mutilation constitutes a significant segment of gender-based violence.

Determinants of disagreement with female genital mutilation/cutting of future daughters and awareness of the ban among Egyptian university students

Background

Egypt is one of three countries where half of female genital mutilation/cutting (FGM/C) victims live, despite its ban. To inform policy on the awareness of this ban and the impact of other interventions, this study sought to assess FGM/C-related knowledge, perceptions, and determinants of disagreement with FGM/C and circumcision of future daughters among university students.

Methods

A cross-sectional study was conducted using a self-administered questionnaire in a random sample of 502 male and female students in Menoufia University between September and December 2017. Bivariate and multivariable logistic regression analyses were performed.

Results

Students were 21.0 ± 1.6 years old; 270 (54.0%) were males, 291 (58.0%) were non-medical students, and 292 (58.2%) were rural residents. 204 (46.7%) students were not aware of the ban and their main source of information about FGM/C was educational curricula or health education sessions (162, 37.0%). Only 95 (19.0%) students had good knowledge about FGM/C. 217 (43.3%) students were neutral towards discontinuing FGM/C. 280 (56.2%) students disagreed with FGM/C. 296 (59.3%) students disagreed with circumcision of their future daughters; independent determinants of this outcome were awareness of the ban (ORa = 1.9) and disagreement with: FGM/C preserves females’ virginity (ORa = 5.0), has religious basis (ORa = 3.8), makes females happier in marriage (ORa = 3.5), enhances females’ hygiene (ORa = 2.1).

Conclusions

Knowledge about FGM/C and its ban is low, even in this educated population. FGM/C is still misperceived as a religious percept. Maximizing the utilization of health education and curricula might help increase anti-FGM/C attitudes among university students with neutral perceptions and initiate the much-needed momentum for elimination.

Economic status, a salient motivator for medicalisation of FGM in sub-Saharan Africa: Myth or reality from 13 national demographic health surveys

Female Genital Mutilation or Cutting (FGM) and its medicalisation remain a challenge in sub-Sahara African (SSA). Early identification of at-risk women might help in instituting focused counselling against FGM medicalisation. We hypothesised that the risk of medicalised FGM by girls/women is associated with socioeconomic status (SES) their household belongs.

We used 2010–2019 Demographic and Health surveys data from 13 countries in SSA. We analysed information on 214,707 women (Level 1) nested within 7299 neighbourhoods (Level 2) from the 13 countries (Level 3). We fitted 5 multivariable binomial multilevel logistic regression models using the MLWin 3.03 module in Stata. The estimation algorithms adopted was the first order marginal quasi-likelihood linearisation using the iterative generalised least squares.

The odds of FGM medicalisation increased with the wealth status of the household of the woman, with 29%, 45%- and 75%-times higher odds in the middle, richer and richest household wealth quintiles, respectively than those from the poorest households (p < 0.05). The more educated a woman and the better a woman's community SES was, the higher her odds of reporting medicalisation of FGM. Rural community was associated with higher odds of medicalised FGM than urban settings.

Medicalised FGM is common among women from a high socioeconomic, educational background and rural settings of SSA. We recommend a culturally sensitive policy that will discourage perpetuation of FGM, particularly by healthcare providers. Future studies should focus on identifying drivers of FGM among the high social class families in the society in SSA.

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The first evidence to show an association between socio-economic and educational status, and report of a medicalised FGM.

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The role of individual, community and national related factors on medicalisation of FGM.

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Use of first order marginal quasi-likelihood linearisation model using iterative generalised least squares.

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Identification of drivers of FGM among high social class families in sub-Saharan Africa.

Transforming social norms to end FGM in the EU: an evaluation of the REPLACE Approach

Background

Despite numerous campaigns and interventions to end female genital mutilation (FGM), the practice persists across the world, including the European Union (EU). Previous interventions have focused mainly on awareness raising and legislation aimed at criminalizing the practice. Limited evidence exists on the effectiveness of interventions due in part to the lack of systematic evaluation of projects. This paper presents an evaluation of the REPLACE Approach, which is a new methodology for tackling FGM based on community-based behaviour change and intervention evaluation.

Methods

We developed, trialed and evaluated the REPLACE Approach through extensive engagement with eight FGM affected African diaspora communities in five EU countries. We employed qualitative and quantitative tools to obtain data to inform the development, implementation and evaluation of the Approach. These included community-based participatory action research, questionnaires and community readiness assessments. The research took place between 2010 and 2016.

Results

Findings suggested that the Approach has the capability for building the capacities of FGM affected communities to overturn social norms that perpetuate the practice. We observed that community-based action research is a useful methodology for collecting data in FGM intervention settings as it allows for effective community engagement to identify, educate and motivate influential community members to challenge the practice, as well as obtaining useful information on the beliefs and norms that shape the practice. We also found that community readiness assessments, pre and post intervention, were useful for tailoring interventions appropriately and for evaluating changes in attitudes and behaviour that may have resulted from the interventions.

Conclusion

This evaluation has demonstrated that the REPLACE Approach has the potential, over time, to bring about changes in norms and attitudes associated with FGM. Its strengths lay in the engagement with influential community members, in building the capacity and motivation of community members to undertake change, in recognising contextual differences in the barriers and enablers of FGM practice and in tailoring interventions to local community readiness to change, and then evaluating interventions to re-inform implementation. The next steps would therefore be to implement the Approach over a longer time frame to assess if it results in measurable change in behaviour.