PRB

(February 2007) Despite the decades-long worldwide campaign against female genital cutting, more than 3 million girls a year still undergo this harmful traditional practice. But speakers at a symposium in Washington this month said they hoped that recently published social science and health research could have a major impact in persuading communities to abandon the custom.

There are increasing numbers of good studies about which kinds of programs have promise in persuading communities to abandon cutting. At the same time, recent medical research provides new evidence that females who are cut are more likely to have complicated births and stillbirths.

The Feb. 6 symposium, attended by dozens of researchers, advocates and government officials, was sponsored by the U.S. Agency for International Development and organized by the Population Reference Bureau. It was held on the fourth International Day of Zero Tolerance for Female Genital Cutting, a day first proclaimed by the first lady of Nigeria on behalf of all the African first ladies.

Banned Worldwide, Cutting Still Is Widely Practiced

Female genital cutting, also known as female genital mutilation or female circumcision, has been banned in many countries over the last decade as a violation of human rights. It persists as a local custom in at least 26 developing countries, and many people believe, mistakenly, that it not only is a religious requirement, but that it makes a girl clean and sexually modest. More than 130 million women have been cut, mainly in Africa. The practice ranges from a nick on the clitoris to surgical removal of the entire outer genital area, which is then stitched up. Some girls have bled to death, and others suffer long-term medical and psychological complications.

Genital cutting has become less common in many countries, according to surveys, but remains almost universal in others, including Egypt, whose government pledged in 1994 to abolish it.

The rise in immigration to the United States and other developed nations from places where cutting is practiced has raised fears that it could become more common in destination countries. Last year, an Ethiopian immigrant to the United States was sentenced to prison in Georgia for cutting his infant daughter. “We’ve got to figure out a way to address it in our backyard, not just far away,” Kent Hill, assistant administrator of USAID’s Bureau for Global Health, told the symposium.

Research Points to Common Factors in Promising Programs

One lesson that researchers have drawn is that although world opinion condemns cutting as a violation of human rights, framing it that way may not be the most effective local tool. Campaigns that focus only on the harm of cutting to a girl’s health may present other risks, in part because that message may contribute to “medicalizing” the procedure—that is, encourage parents to have their daughters cut by medical professionals rather than traditional practitioners.

One new development is that some groups are enlisting help from religious leaders in trying to persuade communities to abandon the practice of female circumcision. Two speakers from Kenya—Maryam Sheikh Abdi, a program officer with the Population Council, and Ibrahim Asmani, an advocate and Islamic scholar—talked about how to counter arguments that being cut is a requirement to be a good Muslim woman. But obstacles include the low priority given women’s issues in some communities and the lack of scholarly consensus, they said.

The most effective programs, researchers agree, are community-based, account for differing local customs, and use respected local leaders to get the message across. “Change is not possible from the outside,” said John Townsend of the Population Council, who summed up the day’s presentations. “It requires an internal process.”

The most commonly cited success story is a program developed by the nonprofit group Tostan (a word that means “breakthrough” in the Wolof language) that began in Senegal and expanded to six other African countries. The group’s “community empowerment program” does not talk about cutting in isolation, but also provides lessons on other topics such as problem-solving, hygiene, and human rights.

Nafissatou Diop, a program associate with the Population Council, also cited the success of a tough law in Burkina Faso that incorporates free phone calls for reporting violations, extensive public-service advertising on radio and television, and the involvement of 13 government ministries. Diop, who is based in Senegal, said one common factor in both Burkina Faso and Senegal was use of comprehensive, well-structured holistic intervention, coupled with decentralized, locally controlled programs.

Researchers Encounter Some False Answers

Another program, operated by the Navrongo Health Research Center in northern Ghana, included the topic of cutting in a series of lessons about reproductive health and cultural expectations of women. The program, known for its scientifically rigorous evaluation, also included training in livelihood and life skills, from crafts production to bookkeeping. Its evaluation found that the education program alone, or education combined with livelihood and life skills, was more effective than skills training alone, but program officials believe skills training may be an “entry point” to encourage girls to join.

Reshma Naik, principal investigator in the Navrongo evaluation, said evaluators learned that some girls who had been cut told researchers they had not been. It may be that girls are worried about being arrested for violating the law, she said, or perhaps they were trying to tell interviewers what they wanted to hear. Evaluators must find other ways to ask the question, she said, and be cautious in reporting data.

Medical Consequences Are More Severe Than Previously Documented

It has long been known that cutting harms the health of girls. But a World Health Organization study published last year inThe Lancet concluded that it also affects childbirth, providing the first evidence of obstetric complications linked to female genital cutting.

The study, based on a sample of more than 28,000 women in six African countries, found that mothers with more extreme forms of cutting were more likely to have complications. Cutting also was associated with 10-20 additional stillbirths per 1,000 live births.

Hill, of USAID, described the study’s conclusions as “landmark findings.”

Yet, according to Hermione Lovel, a British health official who was a member of the WHO study group, medical students know little about the practice of female genital cutting, including its potential complications. It is not included in medical school training, she said, but should be.

Summing Up: The Needs of Women and Girls Must Be Central

A key lesson from the symposium, said Townsend in his wrap-up presentation, is that no technique will work by itself in reducing this long-time custom. Human rights, laws, religious scholars, cultural leaders and the media all have a role. Ethical issues, such as the propriety of interviewing girls under 10, must be considered. And he said organizations should focus more sharply on promising programs—and turn away from what is known to fail, such as simply retraining traditional practitioners to do other work.

But at the center of the campaign, he said, must be the needs of women and girls. Do not stigmatize those who have been cut, he said; rather, support the example of “positive deviance” set by those who challenge cultural norms and resist being cut.

“The larger issue of women’s equality,” he said, “is critical to anything we do.”

D’Vera Cohn is a senior editor at the Population Reference Bureau.