"Taming tradition": medicalized female genital practices in western Kenya

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.

Mothers' perceptions of the medicalisation of female genital cutting among the Kisii population in Kenya

While within the Kisii community in Kenya the prevalence of female genital cutting (FGC) is decreasing, the practice is increasingly being performed by health professionals. This study aims to analyse these changes by identifying mothers' motives to opt for medicalised FGC, and how this choice possibly relates to other changes in the practice. We conducted face-to-face semi-structured in-depth interviews with mothers who had daughters around the age of cutting (8-14 years old) in Kisii county, Kenya. Transcripts of the interviews were coded and analysed thematically, applying researcher triangulation. According to mothers' accounts, the main driver behind the choice to medicalise was the belief that medicalising FGC reduces health risks. There were suggestions that medicalised FGC may be becoming the new community norm or the only option. The shift to medicalisation was examined in relation to other changes in the practice of FGC signalling how medicalisation may provide a way to increase the practice's secrecy and decrease its visibility.

"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.

'Birds of the same feathers fly together': midwives' experiences with pregnant women and FGM/C complications - a grounded theory study in Liberia

Background

In Liberia, approximately 70% of the women of the North-Central and North-Western regions could have undergone female genital mutilation/cutting (FGM/C) in their childhood during a traditional ceremony marking their entrance into Sande, a secret female society. Little is known about FGM/C from Liberian women’s perspective. This study aimed to understand the health implications of FGM/C as perceived by qualified female midwives.

Methods

This qualitative study was conducted in 2017 in Monrovia, Liberia’s capital. Twenty midwives were approached. Of these, seventeen consented to participate in in-depth interviews. A thematic guide was used to gain insights about their knowledge on FGM/C and their experiences attending women victims of FGM/C. A feminist interpretation of constructivist grounded theory guided data generation and analysis.

Results

The midwives participants described how clitoridectomy was the most common FGM/C type done to the girls during the Sande initiation ceremonies. Sexual impairment and intrapartum vulvo-perineal laceration with subsequent hemorrhage were described as frequent FGM/C-attributable complications that some midwives could be unable to address due to lack of knowledge and skills. The majority of midwives would advocate for the abandonment of FGM/C, and for the preservation of the traditional instructions that the girls in FGM/C-practicing regions receive when joining Sande. The midwives described how migration to urban areas, and improved access to information and communication technologies might be fuelling abandonment of FGM/C.

Conclusion

Liberian midwives need tailored training to provide psychosexual counseling, and to attend the obstetric needs of pregnant women that have undergone FGM/C. In spite of FGM/C being seemingly in the decline, surveillance at clinic-level is warranted to prevent its medicalization. Any clinic- or community-based training, research, prevention and awareness intervention targeting FGM/C-practicing populations should be designed in collaboration with Sande members, and acknowledging that the Liberian population may place a high value in Sande’s traditional values.

Medicalized Female Genital Mutilation/Cutting: Contentious Practices and Persistent Debates

Purpose of Review

Female genital cutting/mutilation (FGM/C) performed by health care professionals (medicalization) and reduced severity of cutting have been advanced as strategies for minimizing health risks, sparking acrimonious ongoing debates. This study summarizes key debates and critically assesses supporting evidence.

Recent Findings

While medicalization is concentrated in Africa, health professionals worldwide have faced requests to perform FGM/C. Whether medicalization is hindering the decline of FGM/C is unclear. Factors motivating medicalization include, but are not limited to, safety concerns. Involvement of health professionals in advocacy to end FGM/C can address both the supply and demand side of medicalization, but raises ethical concerns regarding dual loyalty. Ongoing debates need to address competing rights claims.

Summary

Polarizing debates have brought little resolution. We call for a focus on common goals of protecting the health and welfare of girls living in communities where FGM/C is upheld and encourage more informed and open dialog.

Understanding the motivations of health-care providers in performing female genital mutilation: an integrative review of the literature

Background

Female genital mutilation (FGM) is a traditional harmful practice that can cause severe physical and psychological damages to girls and women. Increasingly, trained health-care providers carry out the practice at the request of families. It is important to understand the motivations of providers in order to reduce the medicalization of FGM. This integrative review identifies, appraises and summarizes qualitative and quantitative literature exploring the factors that are associated with the medicalization of FGM and/or re-infibulation.

Methods

Literature searches were conducted in PubMed, CINAHL and grey literature databases. Hand searches of identified studies were also examined. The “CASP Qualitative Research Checklist” and the “STROBE Statement” were used to assess the methodological quality of the qualitative and quantitative studies respectively. A total of 354 articles were reviewed for inclusion.

Results

Fourteen (14) studies, conducted in countries where FGM is largely practiced as well as in countries hosting migrants from these regions, were included. The main findings about the motivations of health-care providers to practice FGM were: (1) the belief that performing FGM would be less harmful for girls or women than the procedure being performed by a traditional practitioner (the so-called “harm reduction” perspective); (2) the belief that the practice was justified for cultural reasons; (3) the financial gains of performing the procedure; (4) responding to requests of the community or feeling pressured by the community to perform FGM. The main reasons given by health-care providers for not performing FGM were that they (1) are concerned about the risks that FGM can cause for girls’ and women’s health; (2) are preoccupied by the legal sanctions that might result from performing FGM; and (3) consider FGM to be a “bad practice”.

Conclusion

The findings of this review can inform public health program planners, policy makers and researchers to adapt or create strategies to end medicalization of FGM in countries with high prevalence of this practice, as well as in countries hosting immigrants from these regions. Given the methodological limitations in the included studies, it is clear that more robust in-depth qualitative studies are needed, in order to better tackle the complexity of this phenomenon and contribute to eradicating FGM throughout the world.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-017-0306-5) contains supplementary material, which is available to authorized users.

Injured bodies, damaged lives: experiences and narratives of Kenyan women with obstetric fistula and Female Genital Mutilation/Cutting

BACKGROUND

It is well acknowledged that Female Genital Mutilation/Cutting (FGM/C/C) leads to medical, psychological and sociocultural sequels. Over 200 million cases of FGM/C exist globally, and in Kenya alone, a total of 12,418,000 (28%) of women have undergone FGM/C, making the practice not only a significant national, but also a global health catastrophe. FGM/C is rooted in patriarchal and traditional cultures as a communal experience signifying a transition from girlhood to womanhood. The conversations surrounding FGM/C have been complicated by the involvement of women themselves in perpetuating the practice.

METHODS

A qualitative inquiry employing face-to-face, one-on-one, in-depth semi-structured interviews was used in a study that included 30 women living with obstetric fistulas in Kenya. Using the Social Network Framework and a feminist analysis we present stories of Kenyan women who had developed obstetric fistulas following prolonged and obstructed childbirth.

RESULTS

Of the 30 participants, three women reported that health care workers informed them that FGM/C was one of the contributing factors to their prolonged and obstructed childbirth. They reported serious obstetric complications including: the development of obstetric fistulas, lowered libido, poor quality of life and maternal and child health outcomes, including death. Fistula and subsequent loss of bodily functionalities such as uncontrollable leakage of body wastes, was reported by the women to result in rejection by spouses, families, friends and communities. Rejection further led to depression, loss of work, increased sense of apathy, lowered self-esteem and image, as well as loss of identity and communal sociocultural cohesion.

CONCLUSION

FGM/C is practised in traditional, patriarchal communities across Africa. Although the practice aims to bind community members and to celebrate a rite of passage; it may lead to harmful health and social consequences. Some women with fistula report their fistula was caused by FGM/C. Concerted efforts which embrace feminist understandings of society, as well as multi-sectoral, multidisciplinary and community development approaches need to be employed to address FGM/C, and to possibly reduce cases of obstetric fistulas in Kenya and beyond. Both government and non-government organisations need to be involved in making legislative, gender sensitive policies that protect women from FGM/C. In addition, the policy makers need to be in the front line to improve the lives of women who endured the consequences of FGM/C.

Female Genital Mutilation Is a Violation of Reproductive Rights of Women: Implications for Health Workers

Female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia or other injury to the female genital organs for nonmedical reasons. This coercive practice is still prevalent in many parts of the world, in both developed and developing countries. However, FGM is more prevalent in African countries and some Asian countries. In this study, an attempt has been made to understand the prevalence and practice of FGM worldwide and its adverse effects on women's reproductive health. To fulfill the study objectives, the author collected evidence from various studies conducted by international agencies. Many studies found that FGM has no health benefits; is mostly carried out on girls before they reach the age of 15 years; can cause severe bleeding, infections, psychological illness, and infertility; and, most important, can have serious consequences during childbirth. The practice is mainly governed by the traditions and cultures of the communities without having any scientific or medical benefit. In conclusion, FGM is a practice that violates the human and reproductive rights of women.

Developmental Idealism and Cultural Models of the Family in Malawi

This paper examines the extent to which developmental idealism has been disseminated in Malawi. Developmental idealism is a set of beliefs and values about development and the relationships between development and family structures and behavior. Developmental idealism states that attributes of societies and families defined as modern are better than attributes defined as traditional, that modern societies help produce modern families, that modern families facilitate the achievement of modern societies, and that the future will bring family change in the direction of modernity. Previous research has demonstrated that knowledge of developmental idealism is widespread in many places around the world, but provides little systematic data about it in sub-Saharan Africa or how knowledge of it is associated with certain demographic characteristics in that region. In this paper, we address this issue by examining whether ordinary people in two settings in Malawi, a sub-Saharan African country, have received and understood messages that are intended to associate development with certain types of family forms and family behaviors. We then examine associations between demographic characteristics and developmental idealism to investigate possible mechanisms linking global discourse about development to the grassroots. We analyze data collected in face-to-face surveys from two samples of Malawian men in 2009 and 2010, one rural, the other in a low-to-medium income neighborhood of a city. Our analysis of these survey data shows considerable evidence that many developmental idealism beliefs have been spread in that country and that education has positive effects on beliefs in the association between development and family attributes. We also find higher levels of developmental idealism awareness in the urban sample than we do in the rural sample, but once dissimilarities in education and wealth between the two samples are controlled, awareness levels no longer differed between urban and rural respondents. We explore how these beliefs intersect with longstanding local values and beliefs in Malawi.

Female genital mutilation and efforts to achieve Millennium Development Goals 3, 4, and 5 in southeast Nigeria

OBJECTIVE

To determine the prevalence of female genital mutilation (FGM), the common forms of FGM, reasons for the practice, associated obstetric outcomes, and how these have affected efforts to achieve Millennium Development Goals (MDGs) 3, 4, and 5 in southeast Nigeria.

METHODS

A prospective descriptive study of parturients in southeast Nigeria was conducted from January to December 2012. All primigravid women attending delivery services at 2 health institutions during the study period were recruited, examined, and classified using the 2008 WHO classification for FGM.

RESULTS

The mean age of the 516 participants was 27.24±4.80 years and most (66.3%) had undergone FGM. Type II FGM was the most common form, accounting for 59.6% of cases. Most FGM procedures were performed in infancy (97.1%) and for cultural reasons (60.8%). Women who had undergone FGM had significantly higher risk for episiotomy, perineal tear, hemorrhage, cesarean delivery, neonatal resuscitation, fresh stillbirth/early neonatal death, and longer hospitalization, with higher risk ratios associated with higher degrees of FGM.

CONCLUSION

FGM is still a common practice in southeast Nigeria, where its association with adverse reproductive outcomes militates against efforts to achieve MDGs 3, 4, and 5.

Building social currency with foreskin cuts: a coping mechanism of Papua New Guinea health workers and the implications for new programmes

BACKGROUND

Recent research as part of a multi-disciplinary investigation on the acceptability and impact of male circumcision for HIV prevention in Papua New Guinea (PNG) has shown that health workers (HWs) undertake unauthorized forms of penile cutting practices in public health facilities or in community settings, at times within a traditional context. Participation in these activities shares common features with coping mechanisms, strategies used by HWs to alleviate the burden of unsatisfactory living and working conditions. Coping mechanisms, however, are typically described as motivated by economic advantage, but in PNG evidence exists that the behaviours of HWs are also influenced by opportunities for social capital.

METHODS

Twenty-five in-depth interviews (IDIs) were completed with a variety of HWs from 2009 until 2011 and were triangulated with findings from 45 focus group discussions and 82 IDIs completed with community members as part of a wider qualitative study. Thematic analysis examined HW participation in unauthorized penile cutting services.

RESULTS

The emergence of unauthorized practices as a coping mechanism in PNG is compelled by mutual obligations and social capital arising from community recognition and satisfaction of moral, professional and cultural obligations. Using the example of unauthorized penile cutting practices amongst HWs in PNG, the research shows that although economic gains are not explicitly derived, evidence exists that they meet other community and socio cultural responsibilities forming a social currency within local traditional economies.

CONCLUSIONS

Coping mechanisms create an opportunity to extend the boundaries of a health system at the discretion of the HW. Fragile health systems create opportunities for coping mechanisms to become institutionalized, pre-empting appropriate policy development or regulation in the introduction of new programmes. In order to ensure the success of new programmes, the existence of such practices and their potential implications must be addressed within programme design, and in implementation and regulation.

The impact of health education on attitudes towards female genital mutilation (FGM) in a rural Nigerian community

OBJECTIVES

To determine the level of practice of female genital mutilation (FGM) and the impact of a health education intervention in Shao community.

MATERIALS AND METHODS

Intervention study using a multistage sampling technique. The instrument was a pre-tested, structured questionnaire. The survey was supplemented by an in-depth interview of the traditional excisors.

RESULTS

Most respondents (88.0%) cited traditional excisors as operators of the procedure, while 7.8% mentioned health workers. Factors found to be statistically significantly associated with the practice of FGM are age, gender and educational status of respondents (p<0.05). The age at which FGM is usually performed was put at under one year old by 60.3% of respondents. All respondents cited type II FGM as the type practised in the community. Most (88.0%) of the female respondents were excised. A greater proportion of men than women did not want the practice of FGM stopped in the pre-intervention stage; however, there was a statistically significant decrease in the proportion of males who did not want the practice of FGM stopped in the post-intervention stage. Also, there was a statistically significant increase in the proportion of respondents who had no intention to excise future female children in the post-intervention stage (p<0.05). Legislation, female literacy and empowerment, educating men and provision of alternative vocation for excisors were means suggested by respondents for stopping the practice.

CONCLUSION AND RECOMMENDATIONS

The health education intervention had a positive impact on the attitude of respondents towards FGM. However, for sustainable behavioural changes that will lead to elimination of FGM practice, we recommend placing FGM elimination efforts within a comprehensive development strategy and the larger context of reproductive health and gender education in Nigeria.

Genital mutilation of girls

Female genital mutilation is a traditional practice affecting girls when their genitals are cut for social, cultural or other non-medical reasons. It is estimated that 3 million girls undergo the procedure every year, mainly in areas in Africa and Asia where it is traditionally practised, but owing to migration patterns, girls living in other parts of the world are also at risk. This article describes the practice of female genital mutilation in a changing world and outlines some aspects in relation to female genital mutilation in girls and women that health staff, teachers, social workers and others should pay attention to. Knowledge regarding complications is important for healthcare, but when complications have been used as arguments against the practice this has had limited effect. Information regarding health risks has to be integrated into culturally sensitive approaches based on human rights and improving the situation for girls and women in order to reach a point where genital mutilation of girls will be generally abandoned.