Changing practices and shifting meanings of female genital cutting among the Maasai of Arusha and Manyara regions of Tanzania

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.

Abandoning female genital mutilation/cutting (FGMC) is an emerging but costly parental investment strategy in rural Ethiopia

Female genital mutilation or cutting (FGMC) has profound consequences for an estimated 200 million women world-wide, yet affected communities often resist efforts to end the practice. Marriage market dynamics have been proposed as key to this resistance, because where FGMC is normative, parents are motivated to cut their daughters to improve their marriage prospects. Some economists have also argued that financial gain, through bride wealth payments, incentivises parents to cut daughter's at time of marriage. Bride wealth, however, does not necessarily equal net economic return, confounding efforts to test this assumption. Here we use detailed data on the financial value of all exchanges at marriage from Ethiopian Arsi Oromo agropastoralists to assess their association with FGMC. We also explore the idea that parents must replace FGMC with other forms of investment (e.g., education) when cutting practices are rejected. Multivariate multilevel Bayesian models were run using data from the first marriages of 358 women to assess the association between FGMC status and education and marriage-related outcomes: bride wealth payments, dowry costs, and age at marriage. Being cut is associated with lower dowry costs and earlier age at marriage but does not predict bride wealth paid by the groom's family. School attendance is associated with higher bride wealth, particularly for women with four or more years of education, and with later age at marriage. These findings indicate that bride wealth payments do not maintain FGMC among the Arsi Oromo. While we find a relative economic loss for parents from FGMC abandonment through higher value dowry gifts, this may be traded-off against the health benefits to uncut daughters. These findings point to the emergence of new norms, whereby Arsi Oromo parents reject cutting for their daughters and prefer their daughters-in-law to be educated.

What interventions are effective to prevent or respond to female genital mutilation? A review of existing evidence from 2008-2020

As the final decade of acceleration towards zero new cases of Female Genital Mutilation (FGM, SDG Target 5.3) by 2030 has begun, increasing the rigour, relevance, and utility of research for programming, policy development and resource allocation is critical. This study aimed to synthesize and assess the quality and strength of existing evidence on interventions designed to prevent or respond to FGM between 2008 and 2020.The study drew on a Rapid Evidence Assessment of the available literature on FGM interventions. The quality of studies was assessed using the 'How to Note: Assessing the Strength of Evidence' guidelines published by the Foreign, Commonwealth and Development Office (FCDO) and strength of evidence using a modified Gray scale developed by the What Works Association. Of the 7698 records retrieved, 115 studies met the inclusion criteria. Of the 115 studies, 106 were of high and moderate quality and were included in the final analysis. This review shows that at the system level, legislation-related interventions must be multifaceted to be effective. Whilst all levels would benefit from more research, for the service level especially more research is needed into how the health system can effectively prevent and respond to FGM. Community-level interventions are effective for changing attitudes towards FGM, but more must be done to innovate with these interventions so that they move beyond affecting attitudes alone to creating behaviour change. At the individual level, formal education is effective in reducing FGM prevalence among girls. However, the returns of formal education in ending FGM may take many years to be realized. Interventions targeting intermediate outcomes, such as improvement in knowledge and change in attitudes and beliefs towards FGM, are equally needed at the individual level.

Persistence of female genital mutilation/cutting in two Kenyan communities: What can we learn from change that falls short of abandonment?

Literature on dynamics of change in female genital mutilation/cutting (FGM/C) portray two common but conflicting views. On one side, FGM/C is seen as static and deeply entrenched, with parents lacking agency to interpret culture, evaluate options and adopt changes. An alternative perspective focuses on the fluidity of social norms, influencing whether and how FGM/C is practised. This study asks: in counties where FGM/C persists at high rates, Kisii and Narok, are there changes in the way that FGM/C is performed? and what drives these changes? In-depth interviews and focus group discussions were conducted to illuminate these questions. Data showed five ways that FGM/C practices have changed: (1) reduction in severity of cutting, (2) medicalised cutting, (3) performing FGM/C at younger ages, (4) cutting in secret, and (5) occasionally, abandonment of FGM/C. Messaging on health risks of FGM/C and fear of criminal punishment have motivated less severe cutting and medicalisation. Legislation has also driven the practice underground. Programmes aimed at ending FGM/C should create a critical dialogue on changes in norms with the intent of reducing stigmatisation of uncut girls and their families, and the ways cutting practices are shifting, thereby building on change that is already underway.

Reconsidering the role of patriarchy in upholding female genital modifications: analysis of contemporary and pre-industrial societies

According to the World Health Organization (WHO), customary female genital modification practices common in parts of Africa, South and Southeast Asia, and the Middle East are inherently patriarchal: they reflect deep-rooted inequality between the sexes characterized by male dominance and constitute an extreme form of discrimination against women. However, scholars have noted that while many societies have genital modification rites only for boys, with no equivalent rite for girls, the inverse does not hold. Rather, almost all societies that practice ritual female genital modification also practice ritual male genital modification, often for comparable reasons on children of similar ages, with the female rites led by women and the male rites led by men. In contrast, then, to the situation for boys in various cultures, girls are not singled out for genital modification on account of their sex or gender; nor do the social meanings of the female rites necessarily reflect a lower status. In some cases, the women's rite serves to promote female within-sex bonding and network building-as the men's rite typically does for males-thereby counterbalancing gendered asymmetries in political power and weakening male dominance in certain spheres. In such cases, and to that extent, the female rites can be described as counter-patriarchal. Selective efforts to discourage female genital modifications may thus inadvertently undermine women-centered communal networks while leaving male bonding rites intact. Scholars and activists should not rely on misleading generalizations from the WHO about the relationship between genital cutting and the social positioning of women as compared to men. To illustrate the complexity of this relationship, we compare patterns of practice across contemporary societies while also highlighting anthropological data regarding pre-industrial societies. Regarding the latter, we find no association between the presence of a female initiation rite and a key aspect of patriarchy as it is classically understood, namely, social endorsement of a gendered double-standard regarding premarital sexual activity. We situate this finding within the broader literature and discuss potential implications.

Plurality of beliefs about female genital mutilation amidst decades of intervention programming in Narok and Kisii Counties, Kenya

Female genital mutilation derails efforts to achieve gender equality and the empowerment of girls and women. In Kenya, national estimates show a steady decline in prevalence, although there is considerable variation at the sub-national level. There is a need to better understand female genital mutilation-related norms and meanings and whether there have been changes in these given long-term and diverse efforts to promote abandonment. Focusing on Narok and Kisii counties, we conducted a cross-sectional qualitative study to identify social norms surrounding the practice of female genital mutilation, as well as consensus or contestation with respect to these norms. Ten focus group discussions were held with men and women aged 18 years and older from the Maasai and Abagusii communities that have traditionally practised female genital mutilation. Study findings showed that norms associated with female genital mutilation such as sexuality and marriageability were actively contested by community members. This change may provide a useful starting point for programmes that seek to create dialogue and critical reflection on female genital mutilation to accelerate its abandonment.

Beyond will: the empowerment conditions needed to abandon female genital mutilation in Conakry (Guinea), a focused ethnography

Background

Female genital mutilation (FGM) can give rise to immediate and long-term health problems for girls/women. Numerous studies have identified the sociocultural determinants of this tradition, but so far, in a national context where FGM is highly practiced, virtually none have focused on people refusing to have their daughters cut. We therefore aimed to understand the sociocultural dynamics underlying the non-practice of FGM in Guinea, a country which has one of the most prevalent rates of this practice in the world. This research explored the demographic and sociocultural profiles of Guineans who do not practice FGM, as well as their non-practice experience in a context of high FGM prevalence and social pressure.

Methods

We used a “focused ethnography” methodology and conducted semi-structured individual interviews with 30 women and men from different generations (young adults, parents, grandparents) living in Conakry, Guinea.

Results

We found that participants 1) do not disclose their non-practicing status in the same way, and 2) have different experiences with social pressure. A typology was created to describe participants as per their various profiles and experiences, which we named as: 1) the “activists”, 2) the “discrete”, 3) the “courageous”, 4) the “strategists”.

Discussion

Wanting to stop practicing FGM is not enough. The main empowering conditions allowing people to enact their decision not to have their daughters undergo FGM are: benefiting from social support (positive social capital), or being financially independent from the traditional solidarity network (sufficient economic capital). We therefore recommend finding ways to increase women’s/families’ empowerment to enact their decision not to practice FGM, mainly by: 1) providing them with new sources of social support, and 2) supporting them to gain more financial independence, including through schooling and improved access to better-paid employment.

Conclusions

This study was the first to explore the experience of people who do not practice FGM in a context of high FGM prevalence and social pressure. The results and recommendations of this research can inform strategies for FGM abandonment and therefore contribute to improving or developing intervention strategies that promote the health and well-being of girls and women.

Women with infertility complying with and resisting polygyny: an explorative qualitative study in urban Gambia

Background

In many low-and middle-income countries women with infertility are often in polygynous marriages. From a human and women’s rights perspective, the practice of polygyny is commonly understood as harmful. Studies indicate that polygyny aggravates negative life circumstances of women with infertility with respect to their health and social well-being. The purpose of this qualitative study is to explore how women with infertility experience polygyny and to understand their decision-making regarding these marriages.

Methods

An explorative qualitative study was conducted among women with infertility in the urban communities of the West Coast region of The Gambia using in-depth interviews (30). Data analysis involved an emergent and partially inductive thematic framework and was carried out using NVivo 11.

Results

With the exception of some women with infertility who described positive experiences within polygynous marriages, most women emphasised conflicts that exist within polygynous households and reported financial and emotional difficulties. Thematic analysis identified several strategies of women with infertility to cope with and resist polygynous marriages, including overcoming childlessness, addressing conflict, spending time outside the compound, looking for social support, kanyaleng kafoolu, living separately and initiating divorce. Moreover, the experiences and decision-making power of women with infertility when it comes to polygynous marriages was found to be closely related to their socio-demographic background.

Conclusion

This work highlights how women with infertility in polygynous marriages are in a precarious situation in urban Gambia. Women utilize a mix of compliance, coping and resistance strategies to navigate the challenges of polygynous marriages in a structurally constraining context.

Lessons learned from implementing alternative rites in the fight against female genital mutilation/cutting

Introduction

historically, programs aimed at making communities abolish female genital mutilation or cutting (FGM/C) consisted mainly of awareness campaigns on sexual reproductive health and rights and the enforcement of newly implemented laws. These types of programs or interventions appear to be only partially effective and sometimes yield unintended results, such as actually strengthening commitment to FGM/C or transforming it into a secret practice. A newer approach to change that is intended to account for the cultural meanings ascribed to FGM/C are alternative rites of passage (ARP). Amref Health Africa started adopting this approach in 2007. Since then, by a trial-and-error process lessons have been learned, that will be reflected upon in this paper.

Methods

desk research was conducted on organizational data regarding all Amref Health Africa's efforts to end FGM/C. Ninety-four in-depth formal interviews were held with members from Maasai and Samburu communities in Kenya targeted through maximum variation sampling. And participant observation of significative events as well as daily pastimes took place during school holiday season at the end of 2016. Furthermore extensive informal talks were held with project donors, activists, journalists, members of other non-governmental organizations, members of community services organizations, local government officials, high-ranking Dutch and US diplomats and senior members of the Anti-Female Genital Mutilation Board, which is part of the Kenyan Ministry of Public Service, Youth and Gender Affairs. On the basis of these data a framework on different positions on FGM/C was developed and published in early 2018. By reviewing the data again from a particular change management and public health perspective, by peer-debriefing within a multi-disciplinary research team and by explicating the lessons learned this paper adds to an overview that is of crucial importance to practitioners working to end FGM/C.

Results

risk of exclusion, perceived loss of cultural identity, changing meanings ascribed to cultural practices, lack of precise knowledge about subjective (sexual) experience and negative stereotyping are reasons not to adhere to anti-FGM/C programs. Areas of concern are the role confusion with following-up on policing, perceived outsider interference and the intended prolonging of the transition phase into womanhood not being explicated and embedded with ARP. Aspects to enhance to lever change more effectively are education and school curriculum development, male involvement, new stylization of love relationships, monitoring and evaluation and inclusive aspects of religion.

Conclusion

changing a culturally embedded practice such as FGM/C is inherently complex. Because the cultural meanings ascribed to this practice are also evolving, any intervention that is effective at present might become superfluous in the future. A holy grail approach to change simply does not exist. Change needs to be levered in a variety of ways while working on the alignment of all these efforts by regular and thorough quantitative and qualitative assessments of effects and side-effects and reflections on lessons learned.

'I want what every other woman has': reasons for wanting clitoral reconstructive surgery after female genital cutting - a qualitative study from Sweden

Female genital cutting (FGC) involves the removal of women's external genitalia for non-therapeutic reasons. An estimated 38,000 women living in Sweden have undergone some form of the procedure. These women often belong to marginalised minorities of immigrant women from countries where FGC is widespread. Clitoral reconstructive surgery following FGC has recently been introduced in Sweden. This study investigates women's perceptions of FGC and clitoral reconstructive surgery with a particular focus on: (1) reasons for requesting reconstructive surgery, and (2) FGC-affected women's expectations of the surgery. Seventeen women referred for clitoral reconstructive surgery at the Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, Stockholm, participated in the study. Findings revealed five factors motivating women's request for clitoral reconstruction (CR): (1) symbolic restitution - undoing the harm of FGC; (2) repairing the visible stigma of FGC; (3) improving sex and intimacy through physical, aesthetic and symbolic recovery; (4) eliminating physical pain; (5) and CR as a personal project offering hope. These factors were highly interconnected, suggesting that the reasons for seeking surgery were often multiple and complex.

Understanding different positions on female genital cutting among Maasai and Samburu communities in Kenya: a cultural psychological perspective

This paper presents an analysis of different positions on female genital cutting, either legitimising the practice or challenging it. The framework it offers has been developed from cultural psychological theory and qualitative data collected in Maasai communities around Loitokitok and Magadi, Kajiado County, and Samburu communities around Wamba, Samburu County, in Kenya. Over the course of one month, 94 respondents were interviewed using maximum variation sampling. Triangulation took place by means of participant observation of significant events, such as alternative rites, participation in daily activities and informal talks while staying at traditional homesteads and kraals. The framework adds to understanding of why more contextual approaches and holistic interventions are required to bring an end to female genital cutting.

Living with mutilation: A qualitative study on the consequences of female genital mutilation in women's health and the healthcare system in Spain

INTRODUCTION

Female genital mutilation is a health and human rights issue which extends to western countries. It is estimated that there are some seventeen thousand women and girls living in Spain who have either been mutilated or are at risk of being so. Healthcare professionals face the challenge of providing adequate care in response to this emerging problem.

AIM

To discover the repercussions of female genital mutilation on the health of sub-Saharan women residing in Spain, as well as the healthcare received.

METHODS

A life-history qualitative research design was utilized. The study population included 14 genitally mutilated women residing in the Region of Murcia who had given birth in Spain and been attended to by the national public healthcare system.

RESULTS

Women suffer physical, psychological, obstetric and sexual health issues as a result of female genital mutilation and despite having a favourable perception of the healthcare received during the pregnancy and the delivery, the provision of health education, detection and treatment of female genital mutilation by healthcare professionals was seen to be lacking.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Healthcare policy must address insufficiencies in delivering adequate care to immigrant women who have been the victim of female genital mutilation by implementing the necessary resources and training for professionals to effectively meet the specific healthcare needs of this population and prevent this cruel practice from being perpetuated.