The Makkatte’ Tradition in The Bugis Muslim Community

Roughly 100 000 immigrants in the Nordic countries originate from areas in Africa where the tradition of FGC is still well known. A majority of this immigrant group consists of Somali women and men (approximately 25 000 in Sweden 16 000 in Denmark 8000 in Norway and 7000 in Finland less than 10 in Iceland; national statistics figures). FGC in the Nordic countries became an issue in the 1980s. The civil war in Somalia caused many Somalis to leave their country in the early 1990s. The arrival of large groups of Somali families forced the Nordic societies to take a stand on the health issue of FGC. Traditionally Somali girls are infibulated which involves excision of the clitoris labia minora and stitching of the vaginal opening. Health providers and social professionals in the Nordic countries are therefore obliged to know how to handle this issue. The primary motives for FGC in Somalia are that the practice is experienced as a religious duty and a prerequisite of marriage. Based on clinical experience the most common reaction to FGC in a Western country is one of disgust and rejection. However in countries where FGC is practiced it is looked upon as the "normal" state sometimes expressed in line with the following citations: "being smooth in the genital area without flaps is a beauty ideal" "if the labia minora are not cut they will continue to grow" "the clitoris and the labia minora have to be concealed in order to reduce sexual desire to reduce the risk of promiscuity promote fertility and make childbirth easier or the girl will not become a woman" "circumcision will ensure that the woman is a virgin as she gets married." These examples of motives do not necessarily coexist in the same ethnic groups. Thus FGC has deep and complex social and cultural roots that we cannot ignore when discussing how to best deal with FGC as a health issue in the Nordic countries. (excerpt)

There are many factors contributing to the existence of female genital mutilation (FGM). FGM has a long list of recorded complications, which include physical, obstetric, sexual, psychological and death. We assessed the knowledge, attitudes and perceptions of FGM practice among Egyptian medical students. An online questionnaire was distributed. One thousand one hundred and forty-one participants completed questionnaires. 71.2% were aware of FGM complications especially among females. Two-thirds reported illegality. 7.8% were in favour of FGM conduct with a higher male preference. Religious and traditional factors were the principle contributing factors to the practice. Three quarters of female students did not agree that FGM increased the chance of marriage. Almost one-fifth of female students reported having been subject to FGM, with a high level of dissatisfaction. It was shown that Egyptian medical students lacked knowledge about FGM with no structured training, so every effort should be done to end this inhumane practice. Impact Statement What is already known on this subject? The conduct of female genital mutilation (FGM) in Egypt is motivated by a variety of factors, including social notions, cultural beliefs and theological misunderstanding. FGM has a long list of recorded complications, which might include physical, obstetric, sexual, psychological and even death. What do the results of this study add? This study provides policy makers and community managers with the evidence needed to advocate for the addition of FGM education to be introduced across the board in medical school curriculums. What are the implications of these findings for clinical practice and/or further research? Possible elimination of the practice and further research on how to eradicate the roots behind it.

To determine (i) the prevalence and type of female genital cutting (FGC) in a rural multi-ethnic village in Tanzania, (ii) its associated demographic factors, (iii) its possible associations with HIV, sexually transmitted infections (STIs) and infertility and (iv) to assess the consistency between self-reported and clinically observed FGC. The study was part of a larger community-based, cross-sectional survey with an eligible female population of 1993. All were human immunodeficiency virus (HIV)-tested and asked whether they were circumcised (n = 1678; 84.2%). Participants aged 15-44 years were interviewed (n = 636; 79.7%), and 399 (50.0%) were gynaecologically examined to screen for STIs and determine the FGC status. At a mean age of 9.6 years, 45.2% reported being circumcised. In the age-group 15-44 years, 65.5% reported being cut, while FGC was observed in 72.5% and categorized as clitoridectomy or excision. The strongest predictors of FGC were ethnicity and religion, i.e. being a Protestant or a Muslim. FGC was not associated with HIV infection, other STIs or infertility. A positive, non-significant association between FGC and bacterial vaginosis was found with a crude odds ratio of 4.6. There was a significant decline of FGC over the last generation. An inconsistency between self-reported and clinically determined FGC status was observed in more than one-fifth of the women. The data indicate that both women and clinicians might incorrectly report women's circumcision status. This reveals methodological problems in determining women's circumcision status in populations practising the most common type of FGC. The positive association between FGC and bacterial vaginosis warrants further investigation.

Female genital mutilation is the removal of a woman's external genitalia in whole or in part for a non-obvious medical reason. Female genital mutilation causes short- and long-term complications like bleeding, pain, infection and exposes girls to sexually transmitted diseases. The determinants of female genital mutilation among children under the age of five have received less attention. As a result, the purpose of this study was to determine the factors that influence female genital mutilation in children under the age of five. A community-based unmatched case control study design was used. The study participants were chosen using computer-generated simple random sampling technique. With a ratio of 1:4 between cases and controls, 323 participants were recruited. Data were collected using an interviewer-administered questionnaire. The association between each independent variable and the dependent variable was determined using binary logistic regression. In a multivariable analysis, variables were considered statistically significant if they had a P-value of less than 0.05 at a 95% confidence interval. In this study, mothers' circumcision status (AOR = 4.6; 95% CI: 2.29-9.25), mothers who had an unfavorable attitude (AOR = 4.15; 95% CI: 1.96-8.82), households in the poorest wealth quintile (AOR = 3.65; 95% CI: 1.2-11.54), mothers who had inadequate knowledge (AOR = 3.31; 95% CI: 1.51-7.25) and antenatal care visit of mothers (AOR = 2.46; 95% CI: 1.03-5.83) were found to be determinant factors of female genital mutilation. Mothers' circumcision status, mother's attitude, wealth quintile, knowledge of mothers, and number of antenatal care visits were factors associated with female genital mutilation. Regular awareness-building on the impacts of the practice and special attention to the mother's attitude are important to eliminate female genital mutilation.

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.

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Female genital mutilation is a public health problem resulting in multiple health complications. In Ethiopia, female circumcision is widely practiced, with women taking center stage in the perpetuation of the practice. Using the Theory of Planned Behavior for variable selection, the following study assessed the association between maternal attitude towards female circumcision and daughter's circumcision status. From the 2016 Ethiopian Demographic and Health Survey, we analyzed a subsample of 6948 women. The outcome variable assessed daughter's circumcision status; the main independent variable assessed participant's opinion towards female circumcision. We conducted univariate, bivariate, and multiple logistic regression analyses. In the bivariate analysis, none of the variables, except for religion, showed any association with daughter's circumcision status. In the multivariable regression model, several variables showed a significant association with daughter's circumcision status. Older, rural, and circumcised women were more likely to have at least one daughter circumcised, but wanting female circumcision to stop, being a Muslim, and having at least a secondary education were negatively associated with daughter's circumcision status. Our findings suggest that eliminating female circumcision may require changing maternal attitudes towards the practice by targeting rural, circumcised, and older women with no formal education.

This study evaluates the prevalence, complications, and attitudes concerning the practice of female circumcision among the women of Eritrea. Four hundred thirty-six Eritrean women from rural and urban environments were questioned about their perceptions and beliefs concerning female circumcision. Eighty-eight percent of those interviewed had undergone some form of female circumcision. Those who favored the continuation of the practice were more likely to be rural dwellers with little formal education, and they did so primarily out of tradition or cultural conformity. The direct and indirect consequences of this practice to the health of women and infants are considerable and as complex as the social, religious, and traditional factors that have led to its preservation.

Female circumcision is a practice based on tradition carried out by most people in Indonesia. Historically, female circumcision existed long before the presence of Islam since the days of ancient Egypt which inherited the traditions of the wives of the Prophet Ibrahim> hi> m As., They believed it to be part of the ritual of purification of the soul. This tradition then spread to various regions in Africa, the Middle East, Latin America and Asia such as India, Malaysia and Indonesia. Medical science observes that female circumcision does not provide benefits to women, but instead causes damage to the tissues of female organs which threatens reproductive fertility and decreases the level of aggression of women. On that basis, the Minister of Health of the Republic of Indonesia has issued a regulation prohibiting female circumcision and is only allowed to do so symbolically. The rule was later revoked because of reaping protests from elements of the muslin community who considered it a command of the Shari'a. This paper analyzes female circumcision in the perspective of history, medical and Islamic law in order to find the truth on the assumption that female circumcision is part of the command of Shari'a. The results of this study state that female circumcision is not at all included in the commandments of the Shari'a, but as a tradition passed down through the lives of Muslim communities.

Female genital mutilation (FGM) is still a prevalent practice in Egypt. Healthcare workers (HCWs) are often involved in performing the FGM procedure. Understanding FGM-related attitudes can help prevent this harmful practice. To assess knowledge and attitudes of medical students about FGM. A cross-sectional study recruiting 560 medical students using a structured self-administered questionnaire for data collection. Females represented 59.5% and those of urban residence represented 54.5%. FGM was accepted by 30% of males compared to 22.2% of females with a significant odds ratio of 1.497 (95% CI = 1.020-2.197). Participants from rural areas (OR = 1.809, 95% CI: 1.232-2.658) and those whose fathers (OR = 2.509, CI = 1.685-3.738) and mothers (OR = 2.422, 95% CI = 1.643-3.571) lacked university education showed significantly higher acceptance of FGM. Medical students cited religion (89.1%) and female chastity (84.5%) as the main reasons for supporting FGM. They rejected the practice primarily due to the risk of serious complications (67.7%) and the belief that it is a harmful social custom (63.4%). A total of 88% of participants reported knowing the long-term consequences of FGM, including psychological trauma (63.2%), reduced sexual pleasure (38.8%), and marital problems (23.2%). Among participants, 48.2% reported that FGM violates the law, 20.9% believed religion supports it, and 15.4% supported its continuation. Medical students showed a considerable acceptance of FGM, which was affected by gender, residence, and parental education. Participants had good knowledge about its negative consequences, but they still had a positive attitude towards it. Key messages Egypt has one of the highest global prevalence rates of FGM despite its criminalization in 2008. A significant proportion of cases are performed by healthcare professionals. This study explores the underlying cultural, religious, and social factors that shape the perceptions of future physicians, whose views may directly impact the continuation or prevention of FGM. Results will support targeted awareness campaigns for young healthcare professionals.

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 ...

To provide an overview of the current global status of female genital mutilation (FGM) or female circumcision practised in various countries. Major published series of peer reviewed journals writing about female genital mutilation (FGM) over the last two decades were reviewed using the index medicus and medline search. A few earlier publications related to the FGM ritual as practised earlier were also reviewed including the various techniques and tools used, the "surgeons or perpetrators" of the FGM ritual and the myriad of medical and sexual complications resulting from the procedure. Global efforts to abolish the ritual and why such efforts including legislation has resulted in little or no success were also critically reviewed. FGM remains prevalent in many countries including African countries where over 136 million women have been 'circumcised' despite persistent and consistent efforts by various governments, WHO and other bodies to eradicate the ritual by the year 2000 AD. This is as a result of deep rooted cultures, traditions and religions. Although FGM should be abolished globally, it must involve gradual persuasion which should include sensitisation and adequate community-based educational and medical awareness campaign. Mere repression through legislation has not been successful, and women need to be provided with other avenues for their expression of social status approval and respectability other than through FGM.

A clash of ideas between Islamic teachings and local traditions regarding female circumcision. Bugis women still practice circumcision as a mandatory rite. This research aimed to reveal female circumcision, community understanding, and maslahah contextualization of female circumcision in the traditions of the Bugis tribe in South Sulawesi. This research was field research with a legal culture and benefits approach. Symbolic interactionism theory was used as an analytical tool. The data collection was carried out using observation, interviews, and documentation methods using field studies. The data obtained was then processed and analyzed through three stages, namely data reduction (data selection), data presentation, and conclusions. The research results found that the Bugis female circumcision rite consisted of three stages, namely the preparation, implementation, and post-implementation stages. Bugis female circumcision had a symbolic meaning such as a symbol of Islamic teachings, glory and high rank, prosperity, harmonious family life, purity, and safety in this world and the hereafter. The maslahah assessment of the practice of Bugis female circumcision rites in South Sulawesi and West Sulawesi was studied from 2 benchmarks, namely based on the impact caused and based on the level of damage caused. The practice of symbolic circumcision was permitted and even recommended because it had maslahah value and the symbolic values contained in this practice can be a dzarai (intermediary) in obtaining benefits.

Insights from outside BJOG

Female genital mutilation (FGM) is widely acknowledged globally as a violation of the fundamental human rights of girls and women. FGM is still widely practiced in Nigeria but at diminishing rates. Primary care physicians must educate and campaign to end this hazardous practice in Nigeria, especially in high-incidence areas. This study fills the knowledge gap by identifying FGM determinants to help policymakers reduce it. The study employed a retrospective cross-sectional design using data from the United Nations International Children's Emergency Fund for 2011, 2016-2017, and 2021. The sampling involved multistage cluster sampling. Data analysis utilized IBM-SPSS, presenting FGM prevalence across years and exploring associations with various factors. This study analyzed 63,365 Nigerian women across a decade (2011, 2016-2017, and 2021). FGM awareness fluctuated (35.1% in 2016-2017, 33.0% in 2011, and 31.9% in 2021), while FGM prevalence increased from 46.6% (2011) to 69.5% (2021). Education correlated with lower FGM prevalence. Geographic disparities were observed, with the Southwest having the highest (70.1%) and the Northeast having the lowest (34.5%) prevalence. Religion influenced FGM rates, with Christians (54.2%) and those with other/no religion (58.0%) showing higher rates than Muslims (52.6%). Urban women had a slightly lower prevalence (52.6%) than rural women (54.2%), and wealth quintiles displayed variations. Variability was also evident among states, ranging from 2.0% to 86.3%. Daughters' circumcision was influenced by maternal circumcision status, education, region, religion, and wealth quintile. Common FGM procedures involved removing genital flesh (63.7%) and nicking without removal (55.1%), often performed by nurses/midwives (63.7%). The study emphasized the urgent need for continuous awareness campaigns and education to combat FGM among Nigerian women. Education emerged as a critical factor in reducing FGM, highlighting the importance of investing in girls' education.