Female Genital Cutting: a Community Based Approach to Behaviourchange

Cite: Memon, A., Female Genital Cutting: A community based approach to behaviour change. Working Paper October 2014

Female Genital Cutting: A community based approach to behaviourchange.

Amina Memon

The goal of this review is to consider some contemporary literature on what is commonly referred to as Female Genital Mutilation/ Cutting (FGM/C) with the goal of looking at the discourse, attitudes and beliefs around this practice, its prevalence in the UK today and the approaches to effecting change. The importance of cultural awareness and understanding together with the involvement of community participants and champions will be highlighted. Drawing upon the work of Hernlund & Shell-Duncan, (2007) it will be argued that theoretical models of behavioral change will aid our understanding of why and how interventions cause change.

This review was written to coincide with the publication of a community based intervention to raise awareness about FGM in the Somali community in the London Borough of Tower Hamlets: ‘ Hear our Voices’ -Women’s Health and Family Services (henceforth referred to as the WHFS, 2014 report)

FGM/C estimates in the UK

The latest statistics on the prevalence of FGM/C come from reports of household interview surveys in countries in which FGM/C is practised (City University, 2014) and the recent home affairs select committee report (see Table 1). Multiple factors derived from the census analysis were used to estimate the relevant numbers(City University, 2014). Since 2008 women with FGM have made up 1.5 per cent of women delivering in England and Wales, over half come from the horn of Africa. Recent estimates indicate that as many as 30 million girls are at risk of being cut over the next decade if current trends persist (UNICEF, 2013). It is therefore timely in light of theWHFS, 2014 reportthat we consider a bottom-up or community-based approach to effecting changes in attitudes and practices relating to FGM in the UK.

Table 1: FGM estimates

It is estimated that 125 million women and girls worldwide have undergone FGM.
It is estimated that 3 million girls are subjected to FGM every year
It is estimated that 170,000 women and girls are living with FGM in the UK
It is estimated that 65,000 girls aged 13 and under are at risk of FGM in the UK
Over 200 FGM-related cases investigated by the police nationally in the last five years
It has taken 29 years since the criminalisation of FGM for the first prosecutions to be brought

Source: Home Affairs Select Committee Report 2014-15

Terminology and the media

There has been much debate internationally about terminology in discussing this subject. Female circumcision, the term common in the 1970s, was replaced by the phrase female genital mutilation as a more accurate reflection of the severity of the practice and as a means of ‘condemnatory advocacy’ (Denison, 2014). However during the 1980s and 1990s a body of literature emerged that viewed the term FGM as problematic in a number of ways: to describe someone as ‘mutilated’ is degrading and prejudices debates about women’s autonomy (see also the WHFS, 2014 report).Gunning (1992) notes the arrogant perceptions which typify western criticisms of other cultural practices- “creating polarization between us women who make choices and are part of the modern world and them victims of an oppressive culture”. Moreover, Jones (2000) talks about an ancient cultural right that blights the lives of many women. This negative framing may prohibit rather than encourage women to come forward as supported by the WHFS (2014) report.

Thus women may find the term ‘mutilation’ offensive particularly when used by the media and by healthcare staff. Popular media explanations of genital cutting are often simplistic, and give a single underlying explanation, despite the literature documenting wide variations in practice (Gruenbaum 2005). The assumption isthat culture and cultural values are homogeneous and unchanging. They also ignore the values of the different groups (males, females, younger, older, community leaders, and ordinary people). Moreover, campaigns to eradicate FGM have ignored diversity and treated it as a single procedure, usually more extreme infibulation - “ a lumping together of diverse forms of practice into genital mutilation” (Walley, 1997). Moreover, the term ‘mutilation’ may alienate members of practising communities and may account for why women who seek reversal operations may not end up attending their appointments to have this procedure undertaken (see WHFS 2014 report). In recognition of these arguments, some commentators adopted what they saw as the more neutral language of female genital surgeries or cutting. Accordingly, this article uses the term female genital mutilation/cutting or FGM/C throughout. (See World Health Organization 2008: 3 and Annex 1 for further discussion.)

Why is FGM/C practiced?

Drawing upon recent literature reviews and peer reviewed publications on FGM/C (Berg & Dension, 2013; Brady & Files, 2007; Gele et al. 2013; Imoh, 2013; Reig Alcaraz et al. 2014; Vloeberghs et al. 2012) I have listed below the disparate and prevailing beliefs that may account for why FGM/C continues to be practised, as well as reasons why individuals and communities may support the discontinuation of FGM/C.

Factors favoring the continuation of FGM/C

Social pressure (see social norms approach)

Preservation of women’s virginity

Aesthetics

Male preference and increased sexual pleasure for men

To preserve a women’s dignity and honour and avoid shame on entire family

Pre-requisite for marriage

Cultural conformity: Tradition and Religion (although it is not dictated by any religion)

Hygiene and assumed health benefits

Lack of knowledge about the practice of health care professionals

Discrimination, marginalisation, lack of trust

Poor communication

Lack of respect for women’s privacy

Language difficulties

Factors favoring the discontinuation of FGM/C

Knowledge of the dangers

Media publicity

Discussions with family members, community, friends, religious institutions

Health concerns and consequences: problems during pregnancy and childbirth

Negative personal experience including loss of sexual pleasure

Impact on mental health

The husband is against it

Law of the country of residence*

*Where FGM/C is punishable by law, new attitudes towards the eradication of FGM/C are adopted in the women’s place of residence. Dustin (2004) argues that in the UK efforts to reduce FGM/C have focused on punitive legislation without sufficiently empowering women in the communities concerned to engage in debate to change attitudes and create alternative ways of affirming their cultural identity.

World Health Organization (WHO) classification of female genital mutilation:

The WHO defines FGM/C types as I: partial excision; II: total excision; III: infibulation; IV: pricking, piercing, cauterisation; scraping or cutting the vagina and the introduction of corrosives or herbs[1]. Somalia has the highest global prevalence of FGM/C and the majority of girls in Somali community are subjected to the most severe form, i.e. infibulations (Gele, Bo & Sundby, 2013). It is this group that are most likely to be traumatised as will be detailed later in this review (Vloeberghs et al. 2012). About 98% of Somali women aged between 15 to 49 have experienced FGM/C according to the UNICEF database which draws on nationally representative surveys and was last updated in July 2014.

The traditional practice[2]

Traditional practitioners without surgical training perform FGM/C with razors, glass, or knives in unsterile conditions. No anaesthetic is used, and relatives hold the girl down. Twigs or rock salt are inserted afterwards to maintain a small opening for urine and menses. The area may be covered with soil or bark before the girl is sewn with thorns or gut, and has her legs bound for three weeks (Momoh 2005). As the environment is unsterile, there is a high risk of tetanus and sepsis. The girl may suffer urinary retention or a haematoma. Other complications include haemorrhage, severe pain, local/systemic infection, shock, and death (Shell-Duncan and Hernlund 2001). The actual number of girls dying from FGM/C is unknown, as many deaths go unreported but anecdotal evidence suggests that over 10% die at the time of the procedure, with the bodies often being disposed of in neighbouring villages until they are taken by animals (Wilson 2008). Longer-term, the stitched area may be so scarred that there is insufficient opening for menses, causing abdominal swelling.

The impact of FGM/C on mental health

It is beyond the scope of this literature review to discuss the wide ranging and long lasting effects of FGM/C on health and well-being. I have therefore narrowed down this review to considering just one body of evidence that points to the adverse effects on women’s mental health. This review is necessarily selective but illustrates that consequences go beyond the physical and social.

The literature on the effects of FGM/Con mental health is sparse but indicates that any of the FGM/C procedures can increase health problems such as anxiety, depression and phobia (see for example, Elnashar & Abdelhady’s (2007) study of newly married women in Egypt). Here I give an example of a recent study that illustrates the importance of involving community members in data gathering and documents the impact of FGM/C on mental well-being.

Vloeberghs et al (2012) examined the psychosexual consequences of FGM in the Netherlands. They adopted a mixed methods approach of questionnaires and in-depth interviews of 66 women who had migrated from Somalia, Sudan, Eritrea, Ethiopia and Sierra Leone. One sixth suffered from PTSD and a third had symptoms related to depression and anxiety.

The Vloeberghs et al (2012) study is based on a culturally-validated structured questionnaire, and in-depth interviews with circumcised migrant women from different countries.To gain women’s trust,members of the community were actively involved in the process of data collection and in the interpretation and analysis of data. Representatives of communities were consulted on the preferred terminology, phrasing of questions and acceptability of research methodology.

The interviewers met to see how questions should be formulated, how answers should be noted and how special situations were dealt with (such as refusal to answer/did not understand). The authors analysed the data using grounded theory and triangulation to understand the mental, social and relational consequences of FGM/C in a migration context (see Hammersly and Atkinson, 1983). All respondents were asked about the type of FGM/C they had experienced, at what age it was performed, and how they see it now they are living in the Netherlands.

There were some interesting results by the type of procedure the women had undergone. Women who were infibulated and who clearly remembered the event, and women who had education concerning the circumcision, reported more Post-Traumatic Stress Disorder (PTSD) symptoms as well as more anxiety and depression.Women who were older at the time and with whom circumcision was discussed also reported more PTSD symptoms. The interesting finding here is that both the severity of the procedure and age at which it occurred appears to be related to the effects of mental health. Nevertheless all the women reported some adverse effects of stress such as recurrent bad memories and nightmares at all times (see Utz-Billing & Kentenich, 2008 for a similar finding).

One counter-intuitive finding from the Vloeberghs et al (2012) study is that support- seeking was associated with moremental health complaints. So those who sought support experienced more anxiety and depression than those who did not seek it. Obviously the relationship is complex here, because it may simply mean those who were suffering from more anxiety and depression were more likely and willing to seek help. A number of respondents indicated that they had not received support from people important to them (partners, mothers in law) and a number said they felt lonely and a spectacle when they sought the help of service providers in the Netherlands. The authors developed a taxonomy based on how women are adapting with different rates of success. They classified women into three types based on their questionnaire measures:

The Adapted: These women were overcoming FGM/C but continue to be troubled by problems of a physical/sexual nature although they can overcome them. They talk about what bothers them and some are in contact with family but can make decisions independently. For Muslim women, the opinion of the umma or the community is important and comfort can be found in prayer and religion.

The Disempowered: These women feel angry and defeated. They bear their grief and do not see any way out- they do not talk about what was done to them, they feel ashamed, alone and disempowered. They avoid sexual contact and are emotionally inhibited. They have a poor relationship with their husbands and feel they would not approach a service provider for help on their own accord.

TheTraumatised have been infibulated and suffered a lot of pain and sadness. They are divorced/and or in a bad relationship with their husband, they have recurrent memories, sleep problems, chronic stress, they feel misunderstood by their immediate environment and health providers. The women may isolate themselves and experience a high incidence of anxiety/depression.

This study is important not only in showing the mental health consequences of FGM /C but in illustrating how important it is not to stereotype or place women in a single category. Instead, we need to look at circumcised women as individuals who may have differing emotional and social needs, and tailor support structures and interventions accordingly.

A community focused approach

While FGM/C appears to be a violent practice, it is not motivated by violence. Seen from the eyes of the community, it is a rite of passage and of great importance in defining the roles and boundaries of womanhood (Gruenbaum 2001). Evidence from 300 in-depth interviews, 28 focused group discussions and survey data from 1220 women from Senegal and Gambia suggests that FGM/C is indirectly related to marriage via preserving virginity (Shell-Duncan et al. 2011).The authors argue that being circumcised serves as a signal to other circumcised women that a girl has been trained to accept the authority of her circumcised elders and is worthy of inclusion in their social network. In an earlier study, Hernlund and Shell-Duncan(2007) studied Senegalese communities near the northern Gambian border using a mixed method approach including in-depth interviews and focus-group discussions. The researchers were men and women fromGambian families that practiced FGM/C and these field workers immersed themselves in the study communities, carried out participant observation, and wrote field journals and community descriptions. They found that it is the proximate persons or people that are close to individuals (family members, friends and other trusted sources) who shape opinions and intentions around the practice of FGM/C. Shell-Duncan et al (2011) maintain that interventions aimed at eliminating FGM/C should target inter-generational social networks and include both men and women in their discussions. This offers direct support for the conclusions from community-based studies such as that recently completed by WHFS (2014).

The important point is that change must be coordinated among interconnected members of social networks and this favours an approach that draws upon cultural values in the community and works with members of that community to understand the barriers to behaviour change. In order to better understand how this could work, we need to have a look at the importance of developing cultural awareness and how this fits with social psychological models that can be used in developing interventions.

FGM/C is a belief set in which its value as a cultural tradition takes precedence over any health concerns. As indicated earlier there are social mechanisms in place to encourage it (meeting of family approval, increased marriage prospects). Therefore a good place to start is to with the cultural values.To quote Gruenbaum (2005), “Cultural values can be anchors that reinforce tradition but they can also be the source of ideas for rethinking and challenging cultural practices.” According to Braddy & Files (2007), to foster a more trusting relationship with patients, health care providers must have an accurate understanding of the cultural background surrounding the practice as well as a working knowledge of the different types of practices.

Models of Behaviour Change and Interventions to address FGM/C

Theoretical models of behavioral change are needed to understand why and how interventions cause change (Askew, 2005; Gele et al., 2013). While awareness of FGM is growing, the issue of behavior change remains poorly understood (Hernlund & Shell-Duncan, 2007). “The decision about whether, when or how to perform FGM/C results in a constant process of negotiation about how to position oneself in the light of shifting social relationships, contexts and experiences.” (Hernlund & Shell-Duncan, 2007).