Community Influences on Female Genital Mutilation/Cutting in Kenya: Norms, Opportunities, and Ethnic Diversity

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.

Female genital mutilation/cutting among girls aged 0-14: evidence from the 2018 Mali Demographic and Health Survey data

BACKGROUND

Female genital mutilation/cutting (FGM/C) is considered a social norm in many African societies, with varying prevalence among countries. Mali is one of the eight countries with very high prevalence of FGM/C in Africa. This study assessed the individual and contextual factors associated with female FGM/C among girls aged 0-14 years in Mali.

METHODS

We obtained data from the 2018 Mali Demographic and Health Survey. The prevalence of FGM/C in girls was presented using percentages while a multilevel binary logistic regression analysis was conducted to assess the predictors of FGM/C and the results were presented using adjusted odds ratios with associated 95% confidence intervals (CIs).

RESULTS

The results indicate that more than half (72.7%, 95% CI = 70.4-74.8) of women in Mali with daughters had at least one daughter who has gone through circumcision. The likelihood of circumcision of girls increased with age, with women aged 45-49 having the highest odds compared to those aged 15-19 (aOR = 17.68, CI = 7.91-31.79). A higher likelihood of FGM/C in daughters was observed among women who never read newspaper/magazine (aOR = 2.22, 95% CI = 1.27-3.89), compared to those who read newspaper/magazine at least once a week. Compared to women who are not circumcised, those who had been circumcised were more likely to have their daughters circumcised (aOR = 53.98, 95% CI = 24.91-117.00).

CONCLUSION

The study revealed the age of mothers, frequency of reading newspaper/magazine, and circumcision status of mothers, as factors associated with circumcision of girls aged 0-14 in Mali. It is, therefore, imperative for existing interventions and new ones to focus on these factors in order to reduce FGM/C in Mali. This will help Mali to contribute to the global efforts of eliminating all harmful practices, such as child, early and forced marriage and female genital mutilation by 2030.

Ethical and Forensic Issues in the Medico-Legal and Psychological Assessment of Women Asylum Seekers

Asylum-seeking migrants represent a vulnerable segment of the population, and among them, women constitute an even more vulnerable group. Most of these women and girls have been exposed to threats, coercion, and violence of many kinds, including rape, forced prostitution, harassment, sexual slavery, forced marriage and pregnancy, female genital mutilation/excision, and/or other violations of their rights (e.g., deprivation of education, prohibition to work, etc.). The perpetrators of the violence from which they flee are often their own families, partners, and even institutional figures who should be in charge of their protection (such as police officers). In the process for the acceptance/rejection of an asylum application, the forensic and psychological certification can make the difference between successful and unsuccessful applications, as it can support the credibility of the asylum seeker through an assessment of the degree of compatibility between the story told and the diagnostic and forensic evidence. This is why constant and renewed reflection on the ethical, forensic, and methodological issues surrounding medico-legal and psychological certification is essential. This article aims to propose some reflections on these issues, starting from the experience of the inward healthcare service dedicated to Migrant Victims of Maltreatment, Torture, and Female Genital Mutilation operating since 2018 at the Institute of Forensic Medicine of the University Hospital of Palermo.

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.

Consortium for violence prevention research, leadership training, and implementation for excellence (CONVERGE): a protocol to train science leaders in gender-based-violence and violence-against-children research for impact

Background

Gender-based violence (GBV) and violence against children (VAC) are two prevalent and highly interconnected global health challenges, yet data and research capacities to study these forms of violence and to generate evidence-based policies and programs remain limited. To address critical shortages in research capacity in Vietnam and to establish a model for other Low- and Middle-Income Countries (LMICs), we are establishing CONVERGE-the Consortium for Violence Prevention Research, Implementation, and Leadership Training for Excellence.

Methods

Based on a needs assessment with partners in Vietnam, CONVERGE will provide a comprehensive research training program supporting 15 long-term, postdoctoral trainees with multi-disciplinary research training in GBV and VAC. We also will offer in-country trainings and short-courses to 40 short-term mid-career academic trainees and 60 short-term practitioner/stakeholder trainees over 5  years to build productive GBV and VAC academic, scientific, and practitioner networks. The CONVERGE training program has four components: (1) 14 h of virtual/in-person annual mentorship training to prepare research mentors and to create a pipeline of future mentors in Vietnam; (2) a one-month intensive research training for long-term postdoctoral fellows at Emory University; (3) a structured 17-month, in-country mentored research project for long-term trainees that results in a peer-reviewed manuscript and a subsequent grant submission; and, (4) week-long in-country intensive translational trainings on implementation science, advanced topics in leadership, and advanced topics in science dissemination. Opportunities for on-going virtual training and professional networking will be provided for CONVERGE trainees and mentors in Vietnam with other trainees and mentors of D43s focused on injury/violence prevention, D43s housed at Emory, and D43s with other institutions in Southeast Asia. To assess the reach, implementation, fidelity, and effectiveness of these four components, we will implement a rigorous, mixed-methods, multi-level evaluation strategy using process and outcome measures. Findings from the evaluation will be used to refine program components for future trainee and mentor cohorts and to assess long-term program impact.

Discussion

Led by Emory University in the US and Hanoi Medical University in Vietnam, CONVERGE represents leading institutions and experts from around the world, with a goal of providing mentorship opportunities for early-career scientists with an interest in violence prevention.

Understanding the consequences of Female Genital Mutilation: a phenomenological study in sub-Saharan women living in Spain

BACKGROUND

Female Genital Mutilation (FGM), which is culturally accepted in some African communities, has serious consequences on the physical, psychological, urogynecological, obstetrical and sexual health of girls and women. It is therefore important to understand women's experiences of the consequences of FGM.

OBJECTIVE

to understand the experiences of the consequences of female genital mutilation in sub-Saharan female survivors living in Spain.

DESIGN

a qualitative study based on Merleau-Ponty's hermeneutic phenomenology.

PARTICIPANTS AND SETTING

13 sub-Saharan female survivors of female genital mutilation participated. The study was carried out in two south-eastern Spanish provinces where many jobs in the agricultural and service industry are done by African immigrants originating from ethnic groups in which FGM is still prevalent.

FINDINGS

In-depth interviews were carried out for data collection. ATLAS.ti was used for inductive analysis, from which two main themes were developed that represent the experiences of the consequences of FGM: (a) The impact of FGM: Hijacked sexual health and (b) The difficult process of genital reconstruction: overcoming the aftereffects and regaining integrity.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The mutilated women experienced serious consequences in their sexual, psychological and obstetrical health. Genital reconstruction was a difficult decision but contributed to regaining their sexual health and identity. The professionals involved play an important role in the care provided for the associated consequences of FGM, in identifying risk groups and in providing advice that allows the women to regain their sexual and reproductive health.

Ending the Social Normalization of Violence against Children in Canada: A Framework, Rationale, and Appeal to Canadian Faith Leaders

Corporal punishment remains the most common form of violence against children in Canada. Along with being legally permitted, it is made socially acceptable through cultural and social norms often disguised as discipline. Paraphrases of Judeo-Christian sacred texts such as "spare the rod; spoil the child" have been widely used to justify corporal punishment, and to create norms around the idea that it is a god-given responsibility of parents to inflict corporal punishment on their children "for their own good." Corporal punishment is then not only an acceptable part of raising children but can be a godly duty. Though Canada is a secular country, this social norm provides a moral hegemony under which violence becomes the status quo and has proven very difficult to change. In this commentary, we outline the ways that Christian religion has contributed to social norms around corporal punishment. We then argue that religious leaders have an opportunity-and moral responsibility-to contribute to change. We conclude with insights from social norms theory and offer evidence-based recommendations for ways forward that could help shift attitudes around corporal punishment in order to decrease its prevalence and harm. While each of these issues has been written about extensively in isolation, this commentary offers an analysis of these matters together under one umbrella. By making this relationship between Christianity and the social norms that propagate corporal punishment more visible, we draw attention to the role leaders in Christian churches could play in disrupting the social acceptance of violence against our youngest Canadian citizens. We provide a practical and evidence-based framework, rationale, and appeal to Canadian faith leaders to use their influence to add momentum to a critical health, rights-and religion-issue in Canada.

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.

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.

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.

Ethnic diversity and mortality in northwest Burkina Faso: An analysis of the Nouna health and demographic surveillance system from 2000 to 2012

Ethnic diversity has been a topic of contention across the globe, contrasted with economic development, social security, and political stability. The link between health and ethnic diversity is not yet well established especially in low-middle- income countries. Our study aims to explore the association between ethnic diversity and all-cause mortality in rural areas of Burkina Faso. We used data from the Nouna Health & Demographic Surveillance System (HDSS) collected between 2000 and 2012. To derive Standardized Mortality Ratios (SMR), the observed number of deaths was compared to the expected deaths based on the entire HDSS taking into account sex, age, rainy season, calendar year, and village. SMR were calculated for ethnic and religious diversity on a village level (using the Simpson Index), sub-region, wealth, and distance to Healthcare Facilities (HCF). Furthermore, we modeled SMR with a multilevel random intercept Poisson regression considering individual ethnic and religious groups in addition to the above-mentioned village-level information. Village wealth (poorest fifth: SMR 1.07; 95% CI: 1.02-1.13, richest fifth: SMR 0.85; 95% CI: 0.82-0.88), distance to HCF (within the village: SMR 0.88; 95% CI: 0.85-0.91, further than 5km: SMR 1.13; 95% CI: 1.10-1.16), and sub-region showed significant associations with overall mortality. Villages belonging to the third with the highest ethnic diversity had lowered SMR (0.86; 95% CI: 0.84-0.89) compared to the entire HDSS, while those belonging to the lowest diversity third yielded elevated SMR (1.13; 95% CI: 1.09-1.17). The multilevel model confirmed the association. Our study showed that historically established ethnic diversity in rural areas of Burkina Faso was associated with lower all-cause mortality. Generally, the literature suffers from a lack of standardization in defining ethnic diversity, along with measuring it. More research is needed to understand this relation and to establish it in different settings.

The Perception of African Immigrant Women Living in Spain Regarding the Persistence of FGM

Approximately 200 million women and girls have undergone female genital mutilation (FGM) worldwide. Migration has spread the practice of FGM around the world, thus making it a global public health issue. The objective of this descriptive qualitative study was to explore the perceptions of Sub-Saharan immigrant women in Spain in relation to the causes of the persistence of FGM. In-depth interviews were carried out with 13 female FGM survivors of African origin, followed by inductive data analysis using ATLAS.ti software. Two main themes emerged from the analysis: (1) A family ritual symbolic of purification and (2) a system of false beliefs and deception in favour of FGM. The FGM survivors living in Europe are aware that FGM is a practice that violates human rights yet persists due to a system of false beliefs rooted in family traditions and deception that hides the reality of FGM from young girls or forces them to undergo the practice. The ritualistic nature of FGM and the threat of social exclusion faced by women who have not had it performed on them contributes to its persistence nowadays.

Learning through social interaction: Kenyan women against female genital cutting in Kenya

Female Genital Cutting (FGC) is a human rights issue that involves the partial or total removal of the external female genitalia for non-medical reasons. Drawing on in-depth interview data collected in 2017 with 20 women from three FGC-practising ethnic groups in Kenya, I argue that informal learning through social interaction plays a critical role in the ability of Kenyan women to oppose and work against FGC in their communities. In addition to knowledge gained through formal education such as schooling and anti-FGC campaigns, women learned about FGC and ways to resist the practice through social interaction with family members, role models and peers from non-FGC practising communities. These interactions have framed challenging FGC as a worthy behaviour to pursue. They also helped women reframe 'success.' While a hallmark of being a successful woman has traditionally been tied to FGC, through these interactions, women learned that they can achieve a respected status as a woman without undergoing FGC. Finally, they provided support for women to stay resilient in resisting FGC. Overall, informal learning is important for understanding how some Kenyan women resist FGC.

Factors associated with female genital mutilation among women of reproductive age and girls aged 0-14 in Chad: a mixed-effects multilevel analysis of the 2014-2015 Chad demographic and health survey data

BACKGROUND

Chad is one of the African countries with high prevalence of female genital mutilation (FGM). The aim of this study was to examine the factors associated with FGM among women aged 15-49 and girls aged 0-14 in Chad.

METHODS

Data for the study were obtained from the 2014-2015 Chad Demographic and Health Survey. FGM among women aged 15-49 and girls aged 0-14 were the outcome variables. The prevalence of FGM among women and girls were presented using percentages while a mixed-effects multilevel multivariable logistic regression analysis was carried out to assess the factors associated with FGM. The results were presented using adjusted odds ratio with associated 95% confidence intervals.

RESULTS

The results indicate that more than half (50.2%) of the women and 12.9% of girls in Chad had been circumcised. Among women aged 15-49, level of education, employment status, ethnicity, religion, wealth quintile and community literacy level were significant predictors of FGM. Age, partner's level of education, marital status, employment status, ethnicity, religion and mother's FGM status were associated with FGM among girls aged 0-14.

CONCLUSION

This study has identified several individual and contextual factors as predictors of FGM among women and girls in Chad. The findings imply the need to adopt strategies aimed at addressing these factors in order to help eliminate the practice of FGM. Government and non-governmental organisations in Chad need to implement policies that enhance media advocacy and community dialogue to help deal with FGM in the country.

The medicalisation of female genital cutting: Harm reduction or social norm?

Today, female genital cutting is increasingly practised by trained healthcare providers. While opposition to medicalised female genital cutting (FGC) is strong, little is known about the underlying motivation for this medicalisation trend in practising communities. We formulated three hypotheses based on medicalisation theories. The medicalisation of FGC: (i) is stratified and functions as a status symbol, (ii) functions as a harm-reduction strategy to conform to social norms while reducing health risks and (iii) functions as a social norm itself. Conducting multilevel multinomial regressions using the 2005, 2008 and 2014 waves of the Egyptian Demographic Health Survey, we examined the relationship between the mother's social position, the normative context in which she lives and her decision to medicalise her daughter's cut, compared to the choice of a traditional or no cut. We found that an individual woman's social position, as well as the FGC prevalence and percentage of medicalisation at the governorate level, was associated with a mother's choice to medicalise her daughter's cut. Further research on factors involved in decision-making on the medicalisation of FGC is recommended, as an in-depth understanding of why the decision is made to medicalise the FGC procedure is relevant to both the scientific field and the broader policy debate.

Negotiating Female Genital Cutting in a Transnational Context

In this article, we explore migrant Somali and Sudanese women's reflections and decision-making regarding female genital cutting in a transnational context wherein women are compelled to maneuver between contradictory social norms. These include traditional norms, which consider the practice to be associated with socially acceptable sexuality and reproduction, and international norms, which consider the practice to be a violation of sexual and reproductive rights. Our analysis builds on data from in-depth interviews with 23 women of Somali and Sudanese origin residing in Norway. Informed by three central theories of change, we categorize women along a continuum of readiness to change ranging from rebellious women eagerly pursuing the abandonment of female genital cutting and adopting international norms regarding the practice, to women supporting the practice and its traditional meanings. Ambivalent contemplators were placed in the middle of the continuum. Women's positioning was further interlinked with social networks and perceived decision-making power.

Trends and Determinants of Female Genital Mutilation in Ethiopia: Multilevel Analysis of 2000, 2005 and 2016 Ethiopian Demographic and Health Surveys

Background

Female genital mutilation (FGM) is a harmful practice that causes health-related problems in the life of the affected women and girls. Though FGM is declared as a human right violation, studies revealed it is being practiced throughout Ethiopia. Therefore, this study was conducted to assess the prevalence, trends, and predictors of FGM among reproductive-aged (1549 years) women in Ethiopia.

Methods

Trends of FGM among reproductive-age women were estimated using the three Ethiopian Demographic and Health Survey (EDHS): 2000 (n=15,367), 2005 (n=14,070) and 2016 (n=7248) data. Multilevel logistic regression analysis was conducted to identify both individual- and community-level factors of FGM using the latest (2016) EDHS. To adjust potential confounders, the analysis was conducted considering sample weighting, clustering, and stratifications using STATA-14 software.

Results

The prevalence of FGM among women of reproductive age in Ethiopia decreased from 79.91% in 2000 to 70.37% in 2016. Similarly, FGM among daughters of circumcised mothers decreased from 56.16% in 2000 to 16.76% in 2016. Being Muslim (adjusted odds ratio [AOR] 5.48; 95% confidence interval [CI]: 4.23, 7.09), attending higher education (AOR 0.40; 95% CI: 0.29, 0.54), 45–49 years old (AOR 5.06; 95% CI: 3.38, 7.57), marriage at ≥ 18 years (AOR 0.80; 95% CI: 0.66, 0.96), not working (AOR 1.20; 95% CI: 1.02, 1.41), married (AOR 1.41; 95% CI: 1.12, 1.77) and residing in peripheral region (AOR 3.0.4; 95% CI: 1.96, 4.70) were determinants of FGM.

Conclusion

Though the reduction of FGM among women of reproductive age in Ethiopia was minimal, it was encouraging among daughters of circumcised women over the last 16 years. Education, religion, age, age at marriage, occupation, marital status, and geographical regions were determinants of FGM. Combined and integrated interventions based on the identified factors are recommended to abandon FGM in Ethiopia.

Female genital mutilation/cutting in Sierra Leone: are educated women intending to circumcise their daughters?

Background

Female genital mutilation/cutting (FGM/C) has been recognized as a gross violation of human rights of girls and women. This is well established in numerous international legal instruments. It forms part of the initiation ceremony that confers womanhood in Sierra Leone. Girls and women who are subjected to this practice are considered to be ready for marriage by their parents and communities and are rewarded with celebrations, gifts, and public recognition. Following this, we examined the relationship between education and women’s FGM/C intention for their daughters in Sierra Leone.

Methods

We used cross-sectional data from the women’s file of the 2013 Sierra Leone Demographic and Health Survey (SLDHS) to explore the influence of education on FGM/C intention among women in the reproductive age (15–49). A sample of 6543 women were included in the study. Our analysis involved descriptive computation of education and FGM/C intention. This was followed by a two-level multilevel analysis. Fixed effect results were reported as Odds Ratios and Adjusted Odds Ratios with their respective credible intervals (CrIs) whilst results of the random effects were presented as variance partition coefficients and median odds ratios.

Results

Our findings showed that women who had no formal education were more likely to intend to circumcise their daughters [aOR = 4.3, CrI = 2.4–8.0]. Among the covariates, women aged 20–24 [aOR = 2.3, CrI = 1.5–3.4] were more likely to intend to circumcise their daughters compared to women between 45 and 49 years old. Poorest women were more likely to report intention of circumcising their daughters in the future compared with the richest [aOR = 2.1, CrI = 1.3–3.2]. We noted that, 63.3% of FGM/C intention in Sierra Leone is attributable to contextual factors.

Conclusion

FGM/C intention is more common among women with no education, younger women as well as women in the lowest wealth category. We recommend segmented female-child educational and pro-poor policies that target uneducated women in Sierra Leone. The study further suggests that interventions to end FGM/C need to focus on broader contextual and social norms in Sierra Leone.

Social norm coordination and readiness to change female genital cutting: Evidence from Senegambia

Background

Female genital cutting (FGC), which poses risks to the health of girls, has proved remarkably persistent in many communities in Africa, despite decades of efforts to discourage it. The social coordination norm model of FGC attributes this persistence to high social costs for uncut women, such as exclusion from marriage markets or social support networks.

Objective/methods

To test the social coordination model of FGC decision-making in Senegambia, we examined variation in FGC across communities, attitudes toward FGC, and how attitudes affected readiness to change (abandon) FGC. We used an ethnographically-grounded survey to assess valuation of FGC and readiness to change FGC. We used factor analysis to identify constructs in valuation of FGC and logistic regression models to evaluate hypothesized predictors of cut status and readiness to change FGC drawn from the social coordination norm model.

Results

1220 women with at least one daughter completed the survey; FGC valuation and readiness to change were characterized in 820 of these women. Findings were generally consistent with the social coordination norm hypothesis: Both locality and ethnicity were associated with cut status, and the prevalence of cutting across communities clustered at high and low levels. Factor analysis identified two distinct concerns in valuation of FGC—social advantages and health costs—and these were distributed differently for cut and uncut women, reflecting distinct normative schema. Further, readiness to change FGC differed in predicted ways with valuation of FGC.

Conclusions

These findings support the social coordination norm model, and reveal distinct normative schema among cut and uncut women. Furthermore, our findings point to a dynamic reassessment of social benefits and health costs underlying FGC decision-making and readiness to change FGC. The reappraisal of social benefits may be an unrecognized opportunity for programs aiming to discourage FGC.

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Female genital cutting (FGC) in Senegambia fits the social coordination norm model.

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Decision-making around FGC is dynamic, and women vary in readiness to change FGC.

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Readiness to change FGC is influenced by both perceived health costs and social benefits.

Community gender systems and a daughter's risk of female genital mutilation/cutting: Multilevel findings from Egypt

We tested a feminist social-ecological model to understand community influences on daughters' experience of female genital mutilation/cutting (FGMC) in Egypt, where over 90% of women ages 15-49 are cut. FGMC has potential adverse effects on demographic and health outcomes and has been defined as a human-rights violation. However, an integrated multilevel-level framework is lacking. We theorized that a more favorable community-level gender system, including stronger gender norms opposing FGMC and expanded extra-familial opportunities for women in the village or neighborhood, would be associated with a daughter's lower risk of FGMC and would strengthen the negative association of a mother's opposition to FGMC with her daughter's risk of cutting. Using a national sample of 14,171 mother-daughter dyads from the 2014 Egypt Demographic and Health Survey, we estimated multilevel discrete-time hazard models to test these relationships. Community gender norms opposing FGMC had significant direct, negative associations with the hazard that a daughter was cut, but women's opportunities outside the family did not. Maternal opposition to FGMC was negatively associated with cutting a daughter, and these associations were stronger where community opposition to FGMC and opportunities for women were greater. Results provided good support for a gender-systems framework of the multilevel influences on FGMC. Integrated, multilevel interventions that address gender norms about FGMC and structural opportunities for women in the community, as well as beliefs about the practice among the mothers of at-risk daughters, may be needed for sustainable declines in the practice.

Community Influences on Female Genital Mutilation/Cutting: A Comparison of Four Francophone West African Countries

Despite long-term efforts to encourage abandonment of female genital mutilation/cutting (FGMC), the practice remains widespread globally. FGMC is situated in specific social and historical contexts, and both prevalence and rates of decline vary widely across practicing countries. However, cross-national comparative research on the determinants of FGMC is sparse. This paper adds to the limited body of rigorous, theoretically grounded quantitative studies of FGMC and takes a step toward advancing cross-national comparative research. We apply an integrated theoretical framework that brings together norms-based and gender-based explanations of community-level influences on FGMC. We test this framework in four francophone West African countries, drawing on comparable nationally representative data from the Demographic and Health Surveys in Burkina Faso (2010), Côte d'Ivoire (2011-2012), Guinea (2012), and Mali (2012-2013). Results show that community-level FGMC norms and community-level gendered opportunities are associated with girls' risk of FGMC, but that the direct and moderating associations vary qualitatively across countries. Our findings highlight the contribution of context-specific social and institutional processes to the decline or persistence of FGMC.