Female Genital Cutting Female Genital Cutting Welcome to the programmatic area on female genital cutting (FGC) within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. FGC is one of the subareas found in the women’s health part of the sexual and reproductive health (RH) section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications. FGC, also known as female circumcision or female genital mutilation, refers to traditional practices that intentionally alter or injure female genital organs for non-medical reasons (World Health Organization, 2010). FGC is deeply rooted in many African societies but is also practiced in some Asian societies. Worldwide, an estimated 200 million women and girls may have been subjected to FGC (Elgot, 2016). Even daughters of immigrants from countries where FGC is practiced, and living in western countries such as Australia, Canada, and the United States and in Western Europe, have been excised or cut. The indicators in this database are intended for program managers desiring to monitor the scale and impact of FGC within their health program portfolio. Show Full Text Female genital cutting (FGC) or female circumcision refers to traditional practices that intentionally alter or injure female genital organs for non-medical reasons (WHO, 2010). Another term for this practice is female genital mutilation, which emphasizes the permanent physical damage done to the female genitalia (Yoder, Camara, and Soumaoro, 1999). Female circumcision is deeply rooted in many African societies but have also been reported to exist in some Asian countries. An estimated 140 million women and girls may have been subjected to this practice across the world, predominantly from 28 African countries (UNFPA, 2008). Even daughters of immigrants from countries where FGC is practiced, and living in western countries such as Australia, Canada, and the United States and in Western Europe, have been excised or cut. More a secular than a religious phenomenon, FGC is found in both Muslim and Christian societies. Although a number of countries have banned female circumcision, the degree of enforcement varies from one country to another. WHO (2010) has classified four types of female circumcision: Type I – Clitoridectomy: partial or total removal of the clitoris and, in very rare cases, only the prepuce (the folded skin surrounding the clitoris). Type II – Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type III – Infibulation: narrowing of the vaginal opening through the creation of a covering seal, which is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris. Type IV – Other: all other harmful procedures to the female genitalia for non-medical purposes (e.g. pricking, piercing, incising, scraping and cauterizing the genital area, enlarging the vagina, or introducing corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing). FGC of any type has been recognized as a harmful practice and a violation of women and girls’ human rights. In terms of the Millennium Development Goals (MGD), it is increasingly clear that, when perceived as a manifestation of gender inequalities, progress towards abandonment of FGC will contribute to the empowerment of women (MDG 3); improvement of maternal health (MDG 5) and reduction in child mortality (MDG 4). The practice has no health benefits and is harmful in many ways. Short term complications include: severe pain, shock, hemorrhage, tetanus or sepsis, urine retention, open sores in the genital area, and injury to nearby genital tissue. Long-term consequences include: recurrent bladder and urinary tract infections, painful or blocked menses, irregular bleeding and vaginal discharge, cysts, keloid scars (hardening of the scars), anxiety and/or depression, HIV transmission, infertility, need for later surgeries, and increased infant and maternal deaths (WHO, 2010). A WHO six-country study confirmed that women who had undergone FGC, compared with those who had not, ran a significantly greater risk of requiring a Caesarean section, an episiotomy and an extended stay in hospital, and also of suffering from post partum hemorrhage (WHO, 2006). Moreover, the infants of mothers who had undergone extensive forms of FGC were at an increased risk of dying in childbirth compared with infants of mothers without FGC. The more extensive the genital mutilation/cutting, the higher the risk of obstetric complications. The motivations behind FGC are complex. Feminist groups have attributed the perpetuation of the practice to African traditions of male dominance and of the patriarchal system. Those who support FGC believe that it purifies the girl (by reducing her sexual desire), favorably socializes her through the instruction and training she receives during her seclusion, and ensures fidelity. One widely held view in some countries is that men prefer to marry circumcised women and will pay more in brides‘ wealth for them, although this is by no means consistent over countries. Caldwell, Orubuloye, and Caldwell (2000) cite respect for tradition and social conformity: “the central issues are fears of making their daughters seem outside the expectations of society and possibly unmarriageable, and making themselves also the objects of deep suspicion.“ Two aspects of FGC absent from portrayals of this practice in the Western media are (1) that women play a key role in sustaining the practice, and (2) that, in some societies, the girls “decide“ whether to undergo FGC (Akweongo et al., 2001; Yoder, Camara, and Soumaoro, 1999; Caldwell, Orubuloye, and Caldwell, 2000). Traditionally, older women (including mothers, co-wives, and heads of compounds) sustain the practice by exerting enormous pressure on young girls to undergo the procedure. Social ostracism and mockery rather than physical coercion are often used to ensure that the girl gets circumcised. Several studies to date indicate that although the practice remains deeply rooted, the seeds of change are evident among more educated, urbanized populations. In a focus group study in Northern Ghana, the predominant view still favored FGC. However, a minority believed that the negative messages once directed to the uncircumcised are now more typically expressed as negative attitudes toward the practice (Akweongo et al., 2001). In one area of Guinea, women did not seem to want to abandon the practice, but they are ready to adopt a less severe form of FGC (Yoder, Camara, and Soumaoro, 1999). In most countries where FGC is practiced, local groups (often NGOs) bolstered by international supporters have developed programs to combat FGC. Four intervention strategies used to reduce the practice of FGC include: raising awareness selecting some members of the community to serve as change agents (facilitators) in their communities including individuals who have resisted FGC (positive deviants) integrating anti-FGC messages into development activities strengthening advocacy (Abdel-Tawab and Hegazi, 2000). To date, governments and NGOs have tried different approaches for eradicating FGC. In the 1980s and 1990s, advocacy groups exposed the practice in selected countries through the mass media, in the hopes that the international community would exert pressure on local governments to ban the practice. Indeed, FGC is now illegal in numerous African countries. However, these countries may or may not enforce the laws. A second wave of initiatives, beginning in the 1990s, has attempted to eliminate FGC by helping communities to understand the factors that sustain FGC and to explore alternative strategies for ushering girls into womanhood. These initiatives seek to conserve the positive cultural values associated with the traditional ceremonies, while eliminating the physical and psychological trauma of FGC (Nazzar et al., 2001; LSC, 1998a; LSC, 1998b). Methodological Challenges of Evaluating Programs to Eradicate FGC • As people become increasingly aware that these practices are illegal and socially unacceptable, response bias will increase. As programs to prevent these practices reach an increasing number of people, those who may previously have reported the practice will become increasingly reluctant to do so. One approach to combating this problem is to obtain information from more than one source (e.g., the young woman, her parents, and other community members). The incidence of underreporting may relate to age of the respondent, especially if younger women are more aware of the anti-FGC initiatives and/or are more motivated to appear “modern.“ Thus, comparison of percentage circumcised by different age cohorts may be subject to this bias. • Members of the key population may leave home, creating a problem of “censoring” in the data. In the case of FGC research, a key population of interest is young women. However, young adults often leave their rural settings to pursue economic activities in larger cities. In areas with high levels of migration toward urban areas, studies in rural areas may have a considerable “lost to observation“ rate for adolescent women (Nazzar et al., 2001). Results will be biased if those who migrate are less likely to be circumcised than those who stay are (i.e., selectivity). • Women may not be able to accurately report if they are circumcised or not. Self-reported data are always subject to bias, especially in relation to a medical procedure such as the type of circumcision performed. Some FGC researchers have questioned whether women know whether they are circumcised; even their husbands may not know for sure. This question arose in connection with the 1995 DHS in Egypt, a country with high prevalence of FGC (97 percent as of 1995). A special clinic-based study compared the clients‘ responses (self-report) to physical evidence obtained at the time of a pelvic exam performed by specially trained gynecologists. The 1,339 women included in the study of clients at the clinic for family planning or gynecological problems were not representative of the national population, but provided a useful basis for this assessment. In 94 percent of the cases, the woman‘s self report coincided with the physical evidence of the amount of tissue excised during circumcision. In 5 percent of the cases, the women reported circumcision when in fact the gynecologists found no physical evidence of it. And one percent of women reported that they were not circumcised, when in fact they were (El-Zanaty et al., 1996). These findings from this one study suggest that women are able to reliably report the type of procedure performed. However, these findings conflict with anecdotal evidence that some women may not even know if they are circumcised, let alone the type of circumcision performed. Moreover, as promotional/informational programs on FGC become more frequent and FGC becomes less socially acceptable or —modern,“ then the reliability of self-report may diminish. ____________ References: Akweongo, P., S. Appiah-Yeboah, J.F. Phillips, E. Jackson, and E. Sakeah. 2001. “It’s a Woman’s Thing: Gender Roles Sustaining the Practice of Female Genital Mutilation among the Kassena-Nankana of Northern Ghana.” Navrongo Health Research Centre, Ministry of Health, Box 114, Navrongo, Upper East Region, Ghana. Abdel-Tawab, N. and S. Hegazi. 2000. “Critical Analysis of Interventions against FGC in Egypt.” Washington, DC: The Population Council, FRONTIERS. Caldwell, J.C., I.O. Orubuloye, and P. Caldwell. 2000. “Female Genital Mutilation: Conditions of Decline.” Population Research and Policy Review 19: 233-54. El-Zanaty, F., E.M. Hussein, G.A. Shawky, A.A. Way, and S. Kishor. 1996. Egypt Demographic and Health Survey 1995. Cairo, Egypt: National Population Council and Calverton, MD: Macro International Inc. Nazzar, A., L.L. Reason, P.B. Adongo, and J.F. Phillips. 2001. “A Community-informed Experiment in Preventing Female Genital Cutting among the Kassena-Nankana of Northern Ghana.” Navrongo Health Research Centre, Ministry of Health, Box 114, Navrongo, Upper East Region, Ghana. (Unpublished) UNFPA. Global Consultation on Female Genital Mutilation/Cutting. Techncial Report. 2008. WHO. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. 2006. WHO. Female genital mutilation. Fact sheet No241. February 2010. Yoder, S., P.O. Camara, and B. Soumaoro. 1999. Female Genital Cutting and Coming of Age in Guinea. Calverton, MD: MACRO International Inc. and Conakry, Guinea: Universite de Conakry.