How to deal with female circumcision as a health issue in the Nordic countries

Female genital mutilation is a human rights issue of concern to all women and men.

Female genital cutting (FGC) remains highly prevalent in Ethiopia, in spite of a slowly decreasing trend over the last decade. In an effort to inform and strengthen FGC interventions in Ethiopia, this study aimed to assess FGC prevalence in cross-administrative border* districts and to explore barriers to ending FGC. A mixed methods, cross-sectional study was employed in three districts in the Afar and Amhara regions in Ethiopia. A sample of 408 women with female children under the age of 15 were included in the study. Additionally, 21 key informant interviews and three focus group discussions were held with local government officials and community stakeholders. The study found that the prevalence of FGC among mothers interviewed was 98%. Seventy-four percent of the female children of participants had undergone FGC. Of the youngest (last born) female children, 64.7% had experienced FGC. The participation of respondents in cross-administrative FGC practices ranged from 4% to 17%. Quantitative analysis found that knowledge and attitude towards FGC, level of literacy, place of residence, and religious denomination were associated with FGC practice. The study also found that the lack of participatory involvement of local women in programs that aim to end FGC and the lack of suitable legal penalties for those who practice FGC exacerbate the problem. A significant proportion of participants support the continuation of FGC practices in their communities. This finding indicates that FGC practice is likely to persist unless new approaches to intervention are implemented. It is recommended that a comprehensive response that couples community empowerment with strong enforcement of legislation is administered in order to effectively end FGC in Ethiopia by 2025, in alignment with the national plan against Harmful Traditional Practices. * Cross-administrative border means a border between two regional states in Ethiopia. In this document, it refers to the movement of people between Amhara and Afar regional states.

Editor's Choice

We commend Berg and Underland for taking on the momentous task of systematically reviewing and summarizing available data on the association between female genital mutilation (FGM) and obstetric outcomes [1, 2]. FGM is an important health and human rights issue and reliable evidence on its effects on health is critical for advocacy to encourage its abandonment. Despite the obvious hard work and adherence to a prespecified protocol, there are two major problems with this systematic review that undermine the validity of the conclusions reached. The first problem is that the review did not distinguish between studies of fundamentally differing designs and combined their results to reach summary estimates. The studies included in the Berg and Underland review were from a wide variety of countries and all were observational [1]. Three of the studies included in the review ascertained FGM status prior to the occurrence of delivery and followed the study participants for their outcomes at delivery [3–5]. The rest of the studies ascertained FGM status and obstetric outcomes at the same time, often retrospectively. However, all studies were classified as cross-sectional and their results were combined. The authors claim that there is a lack of cohort study data (i.e., prospective data) on FGM, hence difficulties coming to conclusions about causality, despite the existence of the three studies with prospectively ascertained FGM and follow-up for outcomes, including the UNDP/UNFPA/World Bank/World Health Organization Special Programme on Research Development and Research Training in Human Reproduction (WHO/HRP) study outlined below [3]. The evidence contained in the higher quality studies is effectively obscured by the lower quality data from the more numerous cross-sectional studies. The second is that crude results were used to calculate summary estimates of the relationship of FGM to obstetric outcomes, even when appropriately adjusted results were available. The obstetric outcomes examined in the review include prolonged labor, obstetric tears/lacerations, Caesarean section, episiotomy, instrumental delivery, obstetric/postpartum haemorrhage, and difficult labor/dystocia. The operational definitions of several of these endpoints differ across countries and between hospitals within countries, as do the frequencies of the endpoints related to interventions during delivery, since these depend on prevailing, often hospital-specific obstetric practices. The prevalence of the different types of FGM varies widely within and between countries. The occurrence of these exposures and outcomes are also likely to vary according to participant factors such as age and parity. Therefore, a range of confounding factors are likely to be important in assessing the relationship of FGM to obstetric outcome in the data used for this systemic review and meta-analysis. However, the authors used RevMan v5.2.4 [6], which is a program largely designed to deal with randomized controlled trials, to calculate summary risk ratios (RR) from crude numbers and hence did not account for potential confounding factors and did not use adjusted estimates of risk, even when these were published. To illustrate the pitfalls of using this inappropriate methodology for meta-analysis of observational data, we used data from the study conducted by WHO/HRP on obstetric outcomes in women exposed to FGM [3], which is among the studies included in the review by Berg and Underland [1, 2]. We compared the adjusted relative risk (RR) estimates from the WHO/HRP study in the original study publication in the Lancet with the RR estimates for the WHO/HRP study calculated by Berg and Underland from crude data, pooling all types of FGMs into one “exposed” group (see Table 1). The WHO/HRP study was conducted in 28 hospitals in 6 countries in Africa and ascertained the type of FGM by clinical examination in individual women prior to delivery, along with data on a range of potential confounding factors. The means of identifying and measuring potential confounding factors is explained in the original publication of the WHO/HRP study [3]. The four crude estimates calculated by Berg and Underland differ substantively from the original adjusted WHO/HRP results, and for two of them, namely, perineal tears and Caesarean section, the crude results suggest, erroneously, that FGM protects against the examined obstetric outcome, directly contrary to the adjusted relative risk estimates in the original Lancet publication [3] (see Table 1). The use of crude numbers to estimate these relative risks from multicentre observational studies is incorrect and produces misleading results. Table 1 Relative risk (RR) estimates (95% confidence limits) for health outcomes in a data set on obstetric outcome of delivery by FGM status and method of analysis. Adjusted RRs from WHO/HRP 2006 and unadjusted RRs from Berg and Underland 2013. Berg and Underland refer to a dose-response relationship as an important factor in determining a causal relationship but fail to consider it when deliberating on the issue of causality between FGM and poor obstetric outcome. In the WHO/HRP study, there was a dose-response relationship between the severity of the FGM (from FGM type l through type lll) and the magnitude of the relative risk estimate for virtually all examined obstetric outcomes (Caesarean section, postpartum haemorrhage, extended maternal hospital stay, resuscitation of infant, inpatient perinatal death, fresh stillbirth, episiotomy, and vaginal tear), except for risk of an infant with low birth weight (LBW), macerated stillbirth, and Apgar score < 4. This pattern of dose-response was similar among parous and nulliparous women. Based on the findings of their meta-analysis and review, Berg and Underland conclude that “the quality of the evidence for all outcomes as being too low to warrant conclusions about a causal relationship between FGM/C and obstetric complications” and that “inconsistencies in results and estimate imprecision” contribute to this conclusion [1]. By using erroneous statistical methods for meta-analysis and inappropriately combining the results of disparate study designs, it is not surprising that the authors arrived at this bland conclusion, which does not do justice to the available evidence. The evidence indicates that the risk of many adverse obstetric outcomes is increased in women who have had FGM, compared to those who have not had it, and that this relationship is likely to be causal.

Female genital cutting: distinguishing the rights from the health agenda.

Child abuse and neglect Culture and religion Female genital mutilation is a cultural practice carried out predominantly in countries of southern Africa. The World Health Organization (WHO) (1997) defines female genital mutilation as: ‘all procedures involving the partial or total removal or other injury to the female genital organs whether for cultural or other nontherapeutic purposes’ (Rawlings-Anderson and Cameron 2000). An estimated 130 million women and girls worldwide have undergone some form of female genital mutilation (Hobbs 1999, WHO 1997, cited in Rawlings-Anderson and Cameron 2000). There are three classifications of female genital mutilation: 1. ‘Sunna’ circumcision: this is the removal of the hood or prepuce of the clitoris. 2. ‘Excision’: this is the removal of either part or all of the clitoris and the labia minora. The resulting wound may be stitched together using catgut or thorns. The vaginal opening is not covered by this procedure. 3. ‘Infibulation’: this is the most radical of the three types and is the removal of the entire clitoris and labia minora. Additionally incisions are made in the labia majora to create raw edges, which are then stitched using catgut or thorns, or the legs are bound to together to hold the wound in place while healing occurs. The result is a firm band of tissue covering the usual urethra and vaginal openings, but leaving a small opening for the passage of urine and menstrual blood (RawlingsAnderson and Cameron 2000). There have been numerous anecdotal research studies revealing how female genital mutilation is performed. Usually when the girl is between the age of four and eight years old (Amnesty International 1997), either the grandmother or the mother decides that the operation will be done. The child, however, will generally have little or no idea of what is going to happen to her. The operation takes place in the home, or at a special ceremonial place. The girl is stripped naked and made to sit on a stool or on the floor. Held down by female relatives, a traditional birth attendant, lay person, or the local village practitioner, starts the cutting, using a knife, razor blade, scissors or sometimes even a piece of glass. The girl is given no anaesthesia or antiseptic during the procedure which can last up to 15 minutes (Wright 1996). Sometimes the relatives are invited to place their fingers into the hole created to check that enough tissue has been removed (Hosken 1989). As a woman living in the UK, learning about the details of these procedures filled me with horror and anger, as well as disbelief that anyone could do this to a child. Indeed, it is hard to believe that women who have been circumcised themselves can want the same to be done to their daughters. To understand why this happens it is important to view this practice as a small part of a whole belief system. For women living in these countries female genital mutilation is an initiation rite that all girls must go through to enable them to become an accepted member of adult society, and to allow them to marry. For these girls (the average age of marriage is between 12 and 16 years), marriage and producing children is their societal role. Also, it is through marriage that women can ensure their financial security. The most common reasons given for female genital mutilation are tradition and religion; other reasons are Female genital mutilation: cultural practice or child abuse?

In the Gambia, three out of four women of reproductive age have undergone Female Genital Cutting (FGC). Many studies and policy advocates suggest that for such a practice that is deeply rooted in culture, a more holistic approach focusing on educating the population will have sustainable impact. This research examined whether educational level of women has an association with their attitude towards the practice of FGC. Data from the 2013 Gambia Demographic Health Survey (GDHS) were analyzed. The sample included 6217 households: 10,233 females aged between 15 to 49 years and 3831 males between 15-59 years. This study focused only on women participants. The outcome variable was the attitude of women toward the practice of FGC. In multivariate regression model, women who were circumcised are found to have 80 times higher odds of supporting FGC [Odds Ratio = 80 (95% CI 50.93-124.4)] compared to uncircumcised women. Women with primary and secondary level education have lower odds of supporting FGC [OR = 0.73 (95% CI 0.915-0.007)) and those with higher education had the lowest odds [OR = 0.28 (95% CI 0.147-0.543)) of supporting FGC relative to women with no education at all. Education and awareness programs targeting women who are married and older, those with less education and those who are already circumcised can help change attitudes towards the practice of FGC.

Factors associated with female genital cutting in Yemen and its policy implications

Efua Dorkenoo

Insights from outside BJOG

To conduct a cross-national comparative study of the prevalence and correlates of female genital cutting (FGC) practices and beliefs in western Africa. Data from women who responded to the Multiple Indicator Cluster Surveys between 2005 and 2007 were used to estimate the frequencies of ever having been circumcised, having had a daughter circumcised, and believing that FGC practices should continue. Weighted logistic regression using data for each country was performed to determine the independent correlates of each outcome. The prevalence of FGC was high overall but varied substantially across countries in western Africa. In Sierra Leone, Gambia, Burkina Faso and Mauritania, the prevalence of FGC was 94%, 79%, 74% and 72%, respectively, whereas in Ghana, Niger and Togo prevalence was less than 6%. Older age and being Muslim were generally associated with increased odds of FGC, and higher education was associated with lower odds of FGC. The association between FGC and wealth varied considerably. Burkina Faso was the only country in our study that experienced a dramatic reduction in FGC prevalence from women (74%) to their daughters (25%); only 14.2% of the women surveyed in that country said that they believe the practice should continue. The prevalence of FGC in western Africa remains high overall but varies substantially across countries. Given the broad range of experiences, successful strategies from countries where FGC is declining may provide useful examples for high-prevalence countries seeking to reduce their own FGC practices.

The age-old tradition of Female Genital Cutting (FGC), most commonly known as Female Genital Mutilation (FGM), is a coming-of-age ritual practiced in some countries in Africa, the Middle East, Asia, and Latin America. It is also practiced in the immigrant communities that migrate from these regions to Western countries. There are a multitude of physical and mental health issues associated with FGC, including chronic infections, infertility, anxiety and depression, complications during childbirth, and death. In 1985, the United Kingdom criminalized the practice of FGC in order to eliminate it. However, evidence suggests that criminalization has been ineffective and that immigrant communities continue to practice FGC without proper medical training and equipment. This paper proposes that replacing criminalization with harm reduction programs will allow policy makers to obtain accurate data on FGC in the UK in order to inform the development of future programs that will ultimately eradicate the practice.

was just seven years old when I was cut, says Leyla Hussein, a British woman of Somali origin. first thing I heard was my sister screaming. Then it was my turn. Four women held me down while they cut my clitoris. I felt every single The pain was so intense--I blacked out. Hussein's experience of female genital mutilation (FGM) is fairly typical. The ancient rite of passage in many African and some Middle Eastern countries in which part or all of the genitals are cut off with razors or knives--often without anaesthetic--is supposed to make girls clean and pure, and ready for marriage. The grim reality is that an estimated 125 million women and girls living today have undergone some form of FGM --many of them suffer severe emotional and physical consequences. FGM is classified into four forms ranging from partial or total removal of the clitoris, the outer or inner vaginal lips to narrowing the vaginal opening by partially sealing it up. In countries such as Djibouti, Egypt and Somalia more than 90% of girls undergo some form of FGM, some of them before they are old enough to walk. [ILLUSTRATION OMITTED] The fight to end FGM is now global, with international agencies such as the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) at the helm, and has strong support from governments, such as that of the United Kingdom and nongovernmental organizations (NGOs). But for women like Hussein, now a London-based psychotherapist and anti-FGM campaigner, progress has been too slow. A few countries have seen rates of FGM fall. In Kenya, these rates in women aged 15 to 49 years fell from 38% in 1998 to 26% in 2008; in the Central African Republic, rates fell from 43% in 1994 to 24% in 2010. Yet most other African countries have seen rates stay stable or fall only marginally. Unless decisive action is taken to stop the the United Nations Population Fund (UNFPA) projects that 86 million girls between 15 and 19 years will be subjected to FGM by 2030. FGM has no health benefits and often leaves women with lifelong physical and emotional trauma, there is a human rights justification to end the says Dr Joar Svanemyr, from the Department of Reproductive Health and Research at WHO, but he adds, we have solid research evidence to show that FGM has devastating health effects. These include painful menstrual periods and intercourse, urinary problems, and birth complications. According to Dr Nafissatou Diop, FGM expert at UNFPA, FGM leaves a damning legacy, as deaths among babies during and immediately after birth are higher for those born to mothers who have been cut. International pressure to end FGM has been mounting since 1997, when the WHO, UNICEF and UNFPA issued a joint statement calling on governments to ban the practice. This commitment was renewed in 2008 and, in 2012, the UN General Assembly passed a resolution to step up efforts towards the elimination of FGM. Since 2008, nearly 10 000 communities in 15 countries, representing about 8 million people, have renounced the practice, says Diop. While public declarations do not guarantee changes in actual behaviour, they have important symbolic value. A report on FGM released in July last year by UNICEF, entitled Female genital mutilation/cutting: a statistical overview and exploration of the dynamics of change, provides critical insight into the underlying cultural beliefs. It presents data showing that in many countries where FGM is practised most men and women think the practice should end. So what explains its continuity? According to United Kingdom-based campaigner Hussein, who has talked extensively to men and women from communities where the practice is maintained, some women say they agree to the practice to ensure they are marriageable while men think it is the women who want it. …

Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries

Eve Ensler's The Vagina Monologues and the accompanying global ‘anti-violence against women’ activist project by now has come to embody female liberation from violence all over the world. What has ...