Understanding the association between parental attitudes and the practice of female genital mutilation among daughters

"All you Gain is Pain and Sorrow": Facilitators and Barriers to the Prevention of Female Genital Mutilation in High-income Countries

BACKGROUND

Female genital mutilation (FGM) is a harmful practice that has long-lasting negative impacts on the physical and psychological health of victims. Deemed a global concern, this practice persists in high-income countries (HIC) among certain migrant communities. Given the deleterious effects of the practice, we conducted an updated systematic review of the facilitators and barriers associated with the prevention of FGM in HIC.

METHOD

A systematic review of published qualitative studies of FGM in HIC was conducted from 2012 to 2022. The search resulted in 276 studies. Of these, the majority were from low- and middle-income countries (LMIC) and excluded. A total of 14 studies were deemed fit for inclusion and none were excluded during quality appraisal. Relevant data were extracted from the studies and thematically analyzed to identify prevalent themes.

RESULTS

A total of 12 themes were identified and the majority reflected barriers to the prevention of FGM including beliefs about female virtue, beliefs about social sanctions, and the preservation of culture, among others. Facilitators to the prevention of FGM were fewer and included memory and trauma from experiencing FGM, knowledge and awareness of the female anatomy, and legislative protection from FGM due to migration. A few themes, such as religious beliefs, acted as both facilitators and barriers.

CONCLUSION

Findings highlight the importance of shared cultural and social threads among FGM practicing communities in HIC. Interventions can use these findings to guide the development of sociocultural strategies centered on community-level prevention and reduction of FGM in HIC.

Prevalence and drivers of female genital mutilation/cutting in three coastal governorates in Yemen

BACKGROUND

Female genital mutilation/cutting (FGM/C), a violation of human rights, remains common in the coastal areas of Yemen.

OBJECTIVE

This study aimed to identify the prevalence of FGM/C and its risk factors among the youngest daughters in families in the Yemeni coastal areas, as well as the knowledge and attitudes of the local population towards FGM/C.

METHODS

A cross-sectional survey was conducted among 646 women and 345 men from six districts in three Yemeni coastal governorates between July and September 2020 using a structured questionnaire. Categorical data were described by proportion. The chi-square test was used to identify factors associated with FGM/C. All factors with a p-value of ≤ 0.05 were included in the multivariate analysis. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated in the multivariate logistic regression analysis.

RESULTS

The prevalence of FGM/C in Yemeni coastal areas was 89.0% (95% CI 84.0%-92.5%) among women and 79.8% (95% CI 73.5%-84.8%) among the youngest daughters in the surveyed families. Nearly two-thirds of women and half of the men recorded a poor knowledge level about the harms of FGM/C. Furthermore, almost two-thirds of both women and men would like to continue the practice of FGM/C. Among women, significant predictors of FGM/C among youngest daughters included advanced maternal age of ≥ 40 years (AOR 7.16, 95% CI 2.73-18.76), mother's desire to continue FGM/C (AOR 8.07, 95% CI 3.64-17.89), and living in a rural area (AOR 3.95, 95% CI 1.51-10.30). Daughters of mothers who did not undergo FGM/C were more protected from FGM/C than those whose mothers had undergone FGM/C (AOR 0.04, 95% CI 0.02-0.09). Among men, the father's desire to continue FGM/C (AOR 15.10, 95% CI 6.06-37.58) was significantly associated with FGM/C among the youngest daughters.

CONCLUSION

This study confirmed that FGM/C is still prevalent among communities in Yemeni coastal areas. Thus, community-based interventions with a focus on the rural population are vital to improving the awareness of various harms of FGM/C.

The Psychosocial Impacts of Intimate Partner Violence against Women in LMIC Contexts: Toward a Holistic Approach

Work on the mental health impacts of intimate partner violence in low-and middle-income countries has focused primarily on clinical disorders such as post-traumatic stress disorder, depression, and substance abuse. This paper analyzes how non-clinical, psychosocial impacts from everyday stressors, particularly economic hardships and concern over one's children, cause extensive suffering and damage women survivors' well-being, influencing the development and expression of clinical disorders. Using a social ecological framework, the paper analyzes how psychosocial impacts arise at multiple levels, including societal levels where social norms often devalue women and privilege men, and how the stressor accumulation increases the harm caused by intimate partner violence (IPV) against women (IPVAW). Drawing on survivors' narratives and studies from diverse low and middle income country (LMIC) settings, including armed conflict and natural disaster settings, the paper underscores the importance of understanding both clinical impacts and the non-clinical, psychosocial impacts, which interact with and complement one another. Recognizing the interplay also between IPVAW and other forms of violence against girls and women, the paper calls for a more comprehensive approach to understanding and addressing the impacts of IPVAW. Recognizing the enormous variety within and across countries that are considered to be LMIC settings, the paper cautions against universalized approaches to understanding the effects of IPVAW and helping to support survivors.

Cultural Beliefs, Perceptions, and Experiences on Female Genital Mutilation Among Women and Men: A Qualitative Analysis

The practice of female genital mutilation (FGM) is a deeply-rooted tradition that affects predominantly regions of Africa and Asia. Because of migration flows, FGM is an issue of increasing concern worldwide. FGM is now carried out in Europe, North America, Australia and New Zealand, and more specifically among immigrant communities from countries where it is common. This study aims to assess the experience, knowledge, attitudes, and beliefs related to FGM of migrant women and men from FGM-affected countries residing in Spain and the United Kingdom. A phenomenological qualitative approach was used. Participants (n=23) were recruited by using the snowball sampling technique until data saturation was reached. Data were collected through 18 open-ended interviews and a focus group. Of the 23 participants, 20 women had undergone FGM. The following five themes were generated from interviews: (a) FGM practice development, (b) knowledge about the practice, (c) reasons for performing FGM, (d) attitudes toward continuing or abandoning the practice, and (e) criminalization of FGM. The study here presented identifies a lack of information, memory, and knowledge about the practice of FGM and typology among women with FGM. The justification of the practice seems to be based on a multifactorial model, where sociocultural and economic factors, sexual factors, hygienic-esthetic factors, and religious-spiritual factors take on a greater role in the analysis of the interviews carried out. The participants practically unanimously agree to advocate the abandonment and eradication of this harmful traditional practice. The knowledge displayed in this study may provide a basis for improving awareness and healthcare in such collectives, aiming the eradication of this harmful traditional practice.

Changing attitudes towards female genital mutilation. From conflicts of loyalty to reconciliation with self and the community: The role of emotion regulation

The practice of female genital mutilation (FGM) is a social norm embedded in the patriarchal system and is resistant to change due to its roots in the tradition of the practising communities. Despite this difficulty in change, some women succeed in changing their attitudes towards the practice. In trying to understand what makes these women change their attitudes, we identified in a previous study, the critical life events at which change occurs (turning point). These turning points were described with emotions and conflicting feelings based on which we hypothesised that emotion regulation and the resolution of conflicts of loyalty might be possible mechanisms that explain the change of attitudes by the women. In this article, we sought to investigate how the mechanisms interact and how they were at play to explain the change. We, therefore, triangulated our previous data, fifteen women interviewed twice, with the published life stories and public testimonies of 10 women with FGM, and interviews of six experts chosen for their complementary fields of expertise to discuss the emerging concepts and theory, generated by our study. The data were analysed using framework analysis and an element of the grounded theory approach (constant comparison). As a result of our theorisation process, we propose a model of change in five stages (Emotion suppression, The awakening, The clash, Re-appropriation of self, and Reconciliation). This describes the process of a woman’s journey from compliance with FGM and community norms to non-compliance. Our study reveals how the women whose stories were analysed, moved from being full members of their community at the cost of suppressing their emotions and denying their selves, to becoming their whole selves while symbolically remaining members of their communities through the forgiveness of their mothers.

"On the Wings of Wishes" (Icchedana), Adolescent Girls in Bangladesh Taking Flight Using A Social Behavioral Change Communication Program to Address Child Marriage Related Social Norms: A Longitudinal Panel Study

This paper examines the relationship between exposure to a transmedia entertainment-education (EE) social and behavior change communication (SBCC) initiative with shifting child marriage-related social norms. Districts were selected purposively, whereas households were selected randomly. A total of 1102 households (n = 3905) with fathers, mothers, adolescent boys, and girls completed the baseline and endline survey. Logistic regression using panel data was conducted. There was a decline in the perceived prevalence of child marriage and dowry exchange within respondents' communities at endline. For injunctive norms, fathers reported significantly higher levels of disapproval for child marriage at endline. However, the reverse was true for mothers and adolescent girls. Almost all respondents had a significantly lower odds of identifying rewards/benefits and punishments/consequences associated with rejecting child marriage at endline. Most respondents with exposure to Icchedana were more likely to report the importance of injunctive norms or expectations of others on their behaviors, than those who were not exposed. Exposure to EE contributes to improved articulation of and shifts in social norms and engenders normative changes at the population level.

Women's Empowerment as It Relates to Attitudes Towards and Practice of Female Genital Mutilation/Cutting of Daughters: An Ecological Analysis of Demographic and Health Surveys From 12 African Countries

Background: Women's empowerment may play a role in shaping attitudes towards female genital mutilation/cutting (FGM/C) practices. We aimed to investigate how empowerment may affect women's intention to perpetuate FGM/C and the practice of FGM/C on their daughters in African countries. Materials and methods: We used data from Demographic and Health Surveys carried out from 2010 to 2018. The countries included in our study were Benin, Burkina Faso, Chad, Côte d´Ivoire, Ethiopia, Guinea, Kenya, Mali, Nigeria, Senegal, Tanzania, and Togo. This study included 77,191 women aged 15-49 years with at least one daughter between zero and 14 years of age. The proportion of women who reported having at least one daughter who had undergone FGM/C as well as the mother's opinion towards FGM/C continuation were stratified by empowerment levels in three different domains (decision-making, attitude to violence, and social independence) for each country. We also performed double stratification to investigate how the interaction between both indicators would affect daughter's FGM/C. Results: The prevalence of women who had at least one daughter who had undergone FGM/C was consistently higher among low empowered women. Tanzania, Benin, and Togo were exceptions for which no differences in having at least one daughter subjected to FGM/C was found for any of the three domains of women's empowerment. In most countries, the double stratification pointed to a lower proportion of daughters' FGM/C among women who reported being opposed to the continuation of FGM/C and had a high empowerment level while a higher proportion was observed among women who reported being in favor of the continuation of FGM/C and had a low empowerment level. This pattern was particularly evident for the social independence domain of empowerment. In a few countries, however, a higher empowerment level coupled to a favorable opinion towards FGM/C was related to a higher proportion of daughters' FGM/C. Conclusion: Women's empowerment and opinion towards FGM/C seems to be important factors related to the practice of FGM/C in daughters. Strategies to improve women's empowerment combined with shifts in the wider norms that support FGM/C may be important for achieving significant reductions in the practice.

Evaluating changes in the prevalence of female genital mutilation/cutting among 0-14 years old girls in Nigeria using data from multiple surveys: A novel Bayesian hierarchical spatio-temporal model

Female genital mutilation/cutting (FGM/C) is considered a public health and human rights concern, mainly concentrated in Africa, and has been targeted for elimination under the sustainable development goals. Interventions aimed at ending the practice often rely on data from household surveys which employ complex designs leading to outcomes that are not totally independent, thus requiring advanced statistical techniques. Combining data from multiple surveys within robust statistical framework holds promise to provide more precise estimates due to increased sample size, and accurately identify ‘hotspots’ and allow for assessment of changes over time. In this study, rich datasets from six (6) successive waves of the Nigeria Demographic and Health Surveys and Multiple Indicator Cluster Surveys undertaken between 2003 and 2016/17, were combined and analyzed in order to better assess changes in the likelihood and prevalence of FGM/C among 0-14-year old girls in Nigeria. We used Bayesian hierarchical regression models which explicitly accounted for the inherent spatial and temporal autocorrelations within the data while simultaneously adjusting for variations due to different survey methods and the effects of linear and non-linear covariates. Parameters were estimated using Markov chain Mote Carlo techniques and model fit assessments were based on Deviance Information Criterion. Results show that prevalence of FGM/C among 0–14 years old girls in Nigeria varied over time and across geographical locations and peaked in 2008 with a shift from South to North. A girl was more likely to be cut if her mother was cut, supported FGM/C continuation, or had no higher education. The effects of mother’s age, wealth and type of residence (urban-rural) were no longer significant in 2016. These results reflect the gains of interventions over the years, but also echo the belief that FGM/C is a social norm thus requiring tailored all-inclusive interventions for the total abandonment of FGM/C in Nigeria.

Sexual violence and unmet need for contraception among married and cohabiting women in sub-Saharan Africa: Evidence from demographic and health surveys

INTRODUCTION

Contraception plays a significant role in fertility regulation and determines the reproductive health rights of women. Studies in other parts of the world have found that sexual violence has negative effects on unmet need for contraception. There has not been any study on the association between these two phenomena in sub-Saharan Africa using current nationally-representative survey data. We investigated the association between sexual violence and unmet need for contraception among married and cohabiting women in sub-Saharan Africa.

MATERIALS AND METHODS

This study was based on secondary datasets from 26 sub-Saharan African countries' Demographic and Health Surveys conducted between 2010 and 2018. A sample of 101,968 women in sexual unions (married and cohabiting) with complete information on sexual violence and all the variables of interest were included in the analyses. Both bivariate and multilevel logistic regression analyses were carried out to examine the association between sexual violence and unmet need for contraception. Other individual and contextual level socio-economic and demographic variables were considered as covariates. Crude odds ratios [cOR] and adjusted odds ratios [aOR] with their corresponding 95% confidence intervals [CI], signifying precision, were presented. Level of statistical significance was declared at p<0.05.

RESULTS

The overall prevalence of sexual violence and unmet need for contraception in the 26 sub-Saharan African countries were 8.7% and 28.7% respectively. Experience of sexual violence within the last 12 months resulted in 10% increase in unmet need for contraception [OR = 1.10, CI = 1.03-1.14] and 5% increase in unmet need for contraception after controlling for individual and contextual level factors [aOR = 1.05, CI = 1.01-1.11]. With the individual level factors, women with 4 or more births [aOR = 4.85, CI = 4.41-5.33], those cohabiting [aOR = 1.43, CI = 1.37-1.47], those in female headed households [aOR = 1.22, CI = 1.18-1.27] and those who watched television at least once a week [aOR = 1.12, CI = 1.07-1.16] had higher odds of unmet need for family planning. However, those aged 30-34 [aOR = 0.56, CI = 0.52-0.61], those with secondary/higher level of education [AOR = 0.80, CI = 0.77-0.84], those who read newspaper less than once a week [aOR = 0.75, CI = 0.71-0.79] and those who listened to radio at least once a week [aOR = 0.94, CI = 0.90-0.97] had lower odds of unmet need for contraception. In terms of the contextual factors, women in rural areas [aOR = 0.87, CI = 0.84-0.91] and those in the richest wealth quintile households [aOR = 0.80, CI = 0.75-0.85] had lower odds of unmet need for contraception.

CONCLUSION

Our study has shown an association between sexual violence and unmet need for contraception in sub-Saharan Africa. Experiencing sexual violence increases the likelihood of unmet need for contraception in sub-Saharan Africa. It is also worthy to note that having four or more children, cohabiting with a male partner, and living in female-headed households are some of the key variables associated with unmet need for contraception in sub-Saharan Africa. Our study recommends that, successful contraceptive initiatives should focus on reducing sexual violence, while taking into consideration other significant factors that increase unmet need for contraception. Meanwhile, in doing this, contextual factors ought to be prioritised.