A Tradition in Transition: Factors Perpetuating and Hindering the Continuance of Female Genital Mutilation/Cutting (FGM/C) Summarized in a Systematic Review
- DOI:
- 10.1080/07399332.2012.721417
pages 837-859
- Received: 16 Aug 2011
- Accepted: 24 Jul 2012
- Accepted author version posted online: 04 Sep 2012
Published online: 14 Mar 2013
Article Views: 2014
Copyright @copy; Rigmor C. Berg and Eva Denison
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Abstract
Understanding
the forces underpinning female genital mutilation/ cutting (FGM/C) is a
necessary first step to prevent the continuation of a practice that is
associated with health complications and human rights violations. To
this end, a systematic review of 21 studies was conducted. Based on this
review, the authors reveal six key factors that underpin FGM/C:
cultural tradition, sexual morals, marriageability, religion, health
benefits, and male sexual enjoyment. There were four key factors
perceived to hinder FGM/C: health consequences, it is not a religious
requirement, it is illegal, and the host society discourse rejects
FGM/C. The results show that FGM/C appears to be a tradition in
transition.
Related articles
View all related articlesAbstract
Understanding
the forces underpinning female genital mutilation/ cutting (FGM/C) is a
necessary first step to prevent the continuation of a practice that is
associated with health complications and human rights violations. To
this end, a systematic review of 21 studies was conducted. Based on this
review, the authors reveal six key factors that underpin FGM/C:
cultural tradition, sexual morals, marriageability, religion, health
benefits, and male sexual enjoyment. There were four key factors
perceived to hinder FGM/C: health consequences, it is not a religious
requirement, it is illegal, and the host society discourse rejects
FGM/C. The results show that FGM/C appears to be a tradition in
transition.
The World Health Organization (WHO, 2008)
classification describes four types of female genital
mutilation/cutting (FGM/C): clitoridectomy, excision, infibulations, and
other. Despite considerable variation in extent of genital tissue
removed, instruments used, age at which it is performed, and terminology
of the practice, common to all forms of FGM/C is that it involves “the
partial or total removal of the female external genitalia or other
injury to the female genital organs for cultural or other
non-therapeutic reasons” (WHO, 1997).
It is widely recognized that the practice violates a series of human
rights principles—including the Universal Declaration of Human Rights,
the Convention on the Elimination of all Forms of Discrimination Against
Women, the Convention on the Rights of the Child (WHO, 2008)—and
causes permanent, often detrimental, changes in the external female
genitalia, such as chronic pain, infections, and difficulty in passing
urine and feces (see, e.g., WHO, 2000, 2008; WHO Study Group on Female Genital Mutilation and Obstetric Outcome, 2006).
FGM/C
is primarily practiced among various ethnic groups in more than 28
countries in Africa. Recent national figures show that nine out of 10
women and girls in Djibouti, Egypt, Guinea, Mali, Northern Sudan, Sierra
Leone, and Somalia undergo the procedure (Yoder & Khan, 2008). The practice is also found in some countries in the Middle East and Asia (UNICEF, 2005a; WHO, 2006),
however, and, although limited data exist, among immigrant communities
in a number of Western countries, such as Australia, Canada, France,
Norway, Sweden, Switzerland, and the United States (WHO Study Group on
Female Genital Mutilation and Obstetric Outcome, 2006).
It is further believed that the majority of girls living in Western
countries who are subjected to FGM/C do not undergo the procedure in
these countries. Instead, they are sent to their country of origin,
usually in Africa, in order to undergo the practice (Elgaali, Strevens,
& Mårdh, 2005; Kaplan-Marcusan, Torán-Monserrat, Moreno-Navarro, Fàbregas, Muñoz-Ortiz, 2009; Poldermans, 2006).
For example, in a study of FGM/C among immigrants from northern Africa
with current residency in Scandinavia, 73 out of 220 women interviewed
reported being genitally cut during a return visit to their home
country. Additionally, 15 of the women explained that they had their
daughter clitoridectomized while living in Scandinavia (Elgaali et al., 2005). Similar data confirming that FGM/C takes place in Western countries have been reported by others (Chalmers & Hashi, 2002; Litorp, Franck, & Almroth, 2008; Morison, Dirir, Elmi, Warsame, & Dirir, 2004; Thierfelder, Tanner, & Bodiang, 2005).
As
Western governments have become more aware of FGM/C among some
immigrant communities, legislation has been implemented as the main
intervention tool (European Parliament, 2004; Leye et al., 2007).
Sweden was the first country to introduce a specific law prohibiting
FGM/C in Europe, the 1982 Act Prohibiting Female Genital Mutilation
(Leye & Sabbe, 2009). Now, there are laws prohibiting FGM/C in most Western countries (UNICEF, 2005a; WHO Study Group on Female Genital Mutilation and Obstetric Outcome, 2006).
In Europe, about 45 criminal court cases on grounds of suspected FGM/C
have been tried, and almost as many convictions obtained (Leye &
Sabbe, 2009).
Although responses to preventing the practice of FGM/C in Western
countries primarily consist of prosecution, some countries—such as
Austria, the Netherlands, and the United Kingdom—give priority to
prevention strategies, including awareness raising and empowerment of
women (Poldermans, 2006).
To
achieve success in preventing the continuation of FGM/C, it is
necessary to understand the forces underpinning the practice, such that
information, messages, and activities can be tailored to their audiences
accordingly. Programs can aim to modify or remove factors perpetuating
the practice and use or build upon existing factors that are seen to
hinder the continuation of the practice. To this end, a systematic
review identifying factors perpetuating and hindering FGM/C was
conducted. This article is based on and an update of a report (Berg,
Denison & Fretheim, 2010)
and results are presented regarding factors perpetuating and hindering
FGM/C, as expressed by members of communities practicing FGM/C residing
in a Western country. Research on the perspectives of exile communities
is particularly useful, because it is often the case that in the
diaspora, members of communities where FGM/C is practiced more readily
reflect upon, question, and challenge their home cultural models and
values (Johansen, 2006).
Thus, they may be uniquely able to identify the beliefs, values, and
codes of conduct that influence the practice of FGM/C. Johansen (2006)
writes: “Research in an exile community can help cast new light on
cultural processes that were less accessible in the home context,
because in exile they are voiced and debated to a higher extent” (p.
275).
METHODOLOGY
A
literature search was performed up to March 2011 in 13 international
databases: African Index Medicus, Anthropology Plus, British Nursing
Index and Archive, The Cochrane Library, EMBASE, EPOC, MEDLINE, PILOTS,
POPLINE, PsycINFO, Social Services Abstracts, Sociological Abstracts,
and WHOLIS. It was supplemented with searches of the databases of six
international organizations that are engaged in projects regarding
FGM/C, the reference lists of relevant reviews and included studies, and
communication with experts involved in FGM/C-related work.
Study
designs eligible for inclusion were cross-sectional quantitative
studies, qualitative studies, and mixed-methods studies. The population
considered in scope was members of communities practicing FGM/C residing
in a Western country, defined as a country with a culture of European
origin (Huntington, 1996).
The outcome of interest was the practice of FGM/C; specifically, the
studies had to describe participants’ perspectives and understandings of
the factors perpetuating or hindering the continuation of FGM/C. All
publication years and languages were acceptable and when considered
likely to meet the inclusion criteria, studies were translated to
English. Unpublished reports and brief and preliminary reports were
considered for inclusion on the same basis as published articles.
The
processes of literature screening, assessment of methodological
quality, and data extraction were first done independently by two
reviewers. A final decision was agreed upon after discussing whether
there was a discrepancy between the two reviewers. For all processes,
differences in opinion were few and were resolved through rereading the
publications and consensus. In selecting literature, the reviewers read
all titles, abstracts, or both resulting from the search process and
obtained full text copies of studies considered relevant. Next, they
read the full texts and determined whether they met all inclusion
criteria. Predesigned inclusion forms were used for each screening
level.
To assess the quality of included
studies, the checklist for cross-sectional quantitative studies (NOKC)
and the Critical Appraisal Skills Programme (CASP) appraisal tool for
qualitative research (www.sph.nhs.uk/what-we-do/public-health-workforce/resources/critical-appraisals-skills-programme)
were used. For mixed-methods studies, both the qualitative component
and the quantitative component of the study were subjected to quality
appraisal, using the aforementioned tools.
Data
from the full texts were extracted using a predesigned data recording
form. Extracted data pertained to study and participant characteristics
and descriptive data of factors perpetuating and hindering FGM/C. For
the qualitative research papers, study findings were defined to be all
of the text considered results or findings in the publications, whether
interpretations made by the authors or statements by the participants
(Sandelowski & Barrows, 2003; Thomas & Harden, 2008).
All findings—in the form of sentences, phrases, or text units dealing
with factors perpetuating and hindering FGM/C—were copied verbatim onto
the data extraction form.
In recognition
that the analysis method needs to be appropriate to the aim of the
evidence synthesis, the systematic review utilized an integrative
evidence approach (Figure 1).
The approach was largely based on published examples and guidelines
from the Evidence for Policy and Practice Information and Co-ordinating
Centre (EPPI Centre; see, e.g., Harden et al., 2004; Shepherd et al., 2006).
Briefly, data from cross-sectional survey studies were combined with
data from studies that examined participants’ perspectives of factors
perpetuating and hindering FGM/C. The synthesis was aggregative
(Dixon-Woods et al., 2006)
and focused on summarizing data by pooling conceptually similar data
from the quantitative studies and the qualitative “views” studies.
First, a synthesis within study types was performed and then a synthesis
between study types. Throughout the analysis, the quantitative results
were used as the analytic point of departure (shown through
capitalization in Figure 1),
such that the qualitative results were subsumed under the quantitative
results and were used to extend the results from the quantitative
analysis.
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With
respect to the quantitative analysis, the results from each study were
categorized according to whether the factors were perpetuating
(continuance) or hindering (discontinuance) factors of FGM/C. The
reviewers then calculated the frequencies of these factors in order to
create a ranked list of factors. In the next step, similar factors
perpetuating and hindering FGM/C were grouped, to facilitate the
integration of quantitative factors and thematic categories from the
qualitative evidence. The grouping was based on commonality of meaning.
The
analysis of qualitative evidence was thematic; that is, the reviewers
identified prominent or recurring themes in the literature and
summarized the findings of the different studies under thematic headings
(Dixon-Woods, Agarwal, Jones, Young, & Sutton, 2005).
They organized and assigned descriptive codes to the raw data from each
study (Level 1 findings). Next, findings were grouped into thematic
categories, based on commonality of meaning as well as frequency and
strength of participants’ cognitions about FGM/C, thereby developing
broader concepts that captured similar themes from different papers
(Level 2 findings). Given that the quantitative evidence served as the
analytic point of departure, the reviewers worked by using both a priori
codes developed from the included quantitative studies to seek out
evidence from the qualitative findings, as well as allowing themes to
emerge from the qualitative data. In the last qualitative analysis step,
categories were combined to create synthesized themes (Level 3
findings). This involved reflecting on the thematic categories as a
whole and looking for similarities and differences among the categories.
The analyses were first conducted individually, and then the reviewers,
through discussion and reflection, agreed on a set of categories and
analytic themes.
In the last analysis step,
once both the quantitative and qualitative sets of data were analyzed,
they were integrated. The integration involved creating a matrix in
which the list of quantitative factors and thematic categories were
juxtaposed. The juxtaposition of findings allowed examination of factors
and themes that had been investigated, and factors and thematic
categories for which there were more credible evidence due to
convergence and corroboration. The analytic themes from the last
qualitative synthesis were used as a thematic guide. The accumulation of
the analyses and the conclusions were summed in a conceptual model that
linked the factors and concepts together and delineated the underlying
forces perpetuating and halting the practice. Further details about the
methods and findings are described in Berg and colleagues (2010).
RESULTS
The searches resulted in 6,732 individual records (Figure 2). Two records could not be obtained in full text (Black Women's Health and Family Support Group, 1994; Sy, 1993) and one study is forthcoming (Kaplan-Marcusan et al., 2010).
The reviewers read 117 full texts and included 21 studies, 15 of which
were qualitative investigations, five were quantitative cross-sectional
studies, and one was a mixed-methods study (Table 1). There were two
dissertations (Gali, 1997; Khaja, 2004), three studies were reports submitted to funding agencies (Mwangi-Powell, 1999, 2001; Norman, Hemmings, Hussein, & Otoo-Oyortey, 2009),
and the remaining studies were published in peer-reviewed journals.
Application of the checklists showed that nine of the studies had low
methodological quality, six moderate, and five high methodological
quality. The qualitative and quantitative components of the
mixed-methods study were assessed separately, and these were judged as
high and moderate, respectively. All quantitative studies lacked
documentation about whether the measures were reliable and valid, and
most of them failed to explain whether the sample was representative of
the population. Concerning the qualitative studies, several of them
failed adequately to describe consideration of the relationship between
the researcher and participants, ethical issues, and rigor of data
analysis.
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In
total, the studies included 1,741 participants (Morris [1996] did not
report the number of participants in the study), of which 78% were women
(Table 1).
The participants were mostly from northern Africa and the horn of
Africa, especially Eritrea, Ethiopia, Somalia, and Sudan. Currently, the
majority of the participants resided in either Scandinavia (N = 634) or Canada (N =
603), while the remaining reported residency in England, France, New
Zealand, or the United States. Duration of residency in the West varied,
but, across the 10 studies reporting duration of residency in Western
countries, it was about 10 years. Most participants appeared to have
been in their thirties or forties at the time of the study, and most
considered themselves Muslim. All but a few of the women had been
subjected to FGM/C, typically infibulation.
Factors Perpetuating and Halting FGM/C
Quantitative data.
Across the five quantitative studies, the range of similar reasons
perpetuating and hindering FGM/C were grouped. Grouped factors
perpetuating FGM/C follow: religion, tradition, marriageability, sexual
morals, health benefits, male preference, aesthetics, and social
pressure. Factors hindering FGM/C included the following: negative
health issues, negative personal experiences, illegal, there's no need
to do it, not religious requirement, it's not natural, and husband is
against it. There were no studies that investigated only men's
perspectives, but two studies specified views of men separately from
women's: Men expressed a preference for a circumcised wife, but some
said they did not view FGM/C as a religious requirement and some that
they did not think that uncircumcised women were promiscuous.
Qualitative data.
There were 15 qualitative studies and one mixed-methods study with a
qualitative component. No qualitative studies examined only men's
perspectives; thus men's views were incorporated with women's views.
From the thematic categories, a set of eight analytic themes was
produced that most parsimoniously and accurately captured the content
and meaning of all the findings. First, in almost all studies, FGM/C was
mentioned as a highly meaningful and valued cultural tradition. For
example, “This is our tradition, it's something we should do” a
participant in Johnsdotter (2009,
p. 129) said. In almost all studies, the participants described
enforcement of the norm through community mechanisms, explaining, “There
are several social pressures and everyone has a say with regards to
circumcising, especially from family and friends and the society as a
whole” (Norman et al., 2009,
p. 25). Nonetheless, due to exposure to Western thought models,
migration allowed the participants to question doxic cultural models,
including those of FGM/C, a reassessment that helped slow the
continuation of the practice: Participants in Berggren and colleagues’
study (2006)
explained, “Because of migration, they got rid of most of the female
peer pressure to continue all forms of FGC” (p. 55). The two closely
linked analytic themes of sexual morality and marriage were crucial as
facilitators of FGM/C. In almost all studies, participants reasoned that
FGM/C decreased women's sexual desires (“An uncut woman will run after
men and have sex with anyone,” said a participant in Johansen [2007, p.
248]), thus protecting virginity, which was in many communities seen as
prerequisite for marriage: “People perform FGC to reduce a girl's sexual
desire to preserve her virginity before marriage” (Berggren et al., 2006, p. 55).
Another analytic theme was religion. According to Khaja's findings (2004),
all but two of the life history interviewees cited religion as a main
reason for FGM/C, viewing it as a practice honoring their Muslim faith.
One participant said, “A girl who is not excised is considered as a bad
Muslim” (Allag, Abboud, Mansour, Zanardi, & Quéreux, 2001,
p. 2). Conversely, religion appeared also as a factor slowing the
continuation of FGM/C in that many saw it merely as a religious option,
or even in violation of Islam: “The most important reason for the women
involved in our study for being opposed to pharaonic circumcision is
that they are convinced that pharaonic circumcision is contrary to basic
Islamic principles,” Johnsdotter (2003, p. 99) concluded.
A
fifth analytic theme was hygiene. FGM/C was seen as ensuring the
hygiene of the genitals, which in their natural form were classified as
unclean. Asked what they thought to be the reasons behind the practice
of FGM/C, one woman replied: “Some say that the girl who is not
circumcised has a bad odour because she is not clean down there” (Norman
et al., 2009,
p. 23). A last analytic theme looking specifically at the continuance
factors was that some perceived womanhood to be accomplished or
activated through FGM/C: “As long as she hasn't been through it
[excision] she hasn't become a woman” (Vissandjée, Kantiébo, Levine,
& N’dejuru, 2003, p. 118).
Factors
hindering the practice constituted two additional analytic themes, most
prominently negative consequences of FGM/C, particularly their loss of
sexual pleasure. The health consequences were wideranging, as explained
by one woman in Norman and colleagues (2009):
“Harmful effects and complications arise from circumcision, especially
the pharaonic type, which has a lot of complications—emotional,
physical, and health problems. A woman suffers those complications
throughout her life” (p. 24). And “Sexual intercourse was hard, painful,
especially the first few months” (Khaja, 2004, p. 113). “You know, circumcision affects your sexual life. I feel less. I feel I miss something” explained a third (Johansen, 2007,
p. 268). Some women who themselves had experienced complications
following FGM/C did not want to expose their daughters to such risks: “I
don't want my daughter to pass through all the pain and suffering that I
had” stated one woman in Lundberg and Gerezgiher (2008,
p. 221). The unlawful practice of FGM/C emerged as a last analytic
theme. It was clear in many of the studies that most exiled communities
respected Western countries’ laws against the practice. Researchers such
as Berggren and colleagues (2006)
found that “Almost all women explained how they perceived the Swedish
law as supporting them in their decision to protect their daughters from
FGC” (p. 55). Without forming consistent themes, a few additional
factors signaled beliefs perpetuating and countering FGM/C, including
the following beliefs: FGM/C enhances sexual pleasure (generally for
men), being cut is a sign of honor, and the clitoris is dangerous (kleitorid dangereux).
Integration of data.
In the last analysis step, quantitative and qualitative data
integration identified six key factors perpetuating and four key factors
hindering the practice of FGM/C. A conceptual model summarizes the
findings (Figure 3),
showing the most dominant factors, those with more and credible data
through convergence and corroboration (marked through capitalization),
perpetuating and hindering the continuation of FGM/C. The center
represents any member of a practicing community presently residing in a
Western country, exposed to myriad influences regarding FGM/C. Porous
lines signal that factors are related.
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Key
drivers perpetuating FGM/C are presented in the upper half of the
model, with the most influential factor, cultural tradition, most
proximal to the center because there were more data for this factor than
the other five key factors situated more distally. When asked why FGM/C
is performed, in almost all studies, the participants considered it a
meaningful cultural tradition, which functioned both as a form of social
control and identity for women, as well as a feature of the ideal girl.
It was deeply rooted in their social systems, and the compulsory nature
of the practice reflected in community mechanisms enforcing it.
Extensive collective enforcement of the tradition was strongly linked
with honor and avoidance of shame, not just for the girl but also the
mother and sometimes the extended family.
The
second key factor, sexual morals, reflected the common view that FGM/C
is a cornerstone of moral virtue. FGM/C, especially infibulation, was
believed to reduce sexual lust, which was seen as easily aroused and
difficult to control thus likely to lead the uncut woman to sexual
promiscuity. Together with FGM/C, premarital chastity and marital
fidelity were seen to function as proof of morality, granting the woman
social respect. Related, the factor marriageability was frequently found
in both the quantitative and qualitative data sets and converged to a
significant extent with sexual morals in that premarital virginity
served as a guarantee of moral standards. FGM/C in childhood or young
adulthood was considered a prerequisite for good marriage later in life.
Quantitative results showed that men strongly favored a future wife to
have FGM/C, and findings from qualitative data indicated that the
partiality concerned preference for a moral, faithful wife.
As
a fourth important factor influencing the continuation of FGM/C, the
practice was commonly expressed as a duty according to the religion of
Islam. Respondents from countries where FGM/C is traditionally performed
believed that FGM/C is sanctioned by Islamic religion. Individuals who
did not conform to the practice were considered to be acting against
their religion and the Qur’an.
Two
additional, less influential factors reported in the included studies
were health benefits and male sexual enjoyment. Health benefits referred
to cleanliness and hygiene. The perception that men preferred cut women
for their sexual enjoyment was mentioned both in some quantitative and
qualitative studies, perpetuating the view among women that men favored
women who had been subjected to FGM/C, specifically infibulation,
because they gained greater sexual pleasure from a tight vagina. This
idea was disputed by men quoted in the qualitative studies.
The
lower half of the model shows the four key factors identified as
hindering the practice of FGM/C. This model area offers a negated
reflection of the top area in that three factors perpetuating FGM/C are
similarly found to hinder FGM/C, thus demonstrating that FGM/C among
exiled communities is a tradition in transition. One factor hindering
FGM/C, health issues, was mentioned most prominently in the data sets.
The participants were conscious of the harmful consequences following
FGM/C, mentioning pain and women's reduced sexual responsiveness in
particular. There was also strong convergence between quantitative and
qualitative findings concerning the second and third factors hindering
FGM/C. First, most participants knew the illegal status of FGM/C in
their Western host countries. The law was not just a deterrent but for
many was also a support in their decision to abandon FGM/C. Second, many
participants stated that FGM/C was not an Islamic duty and put this
forth as an important reason why they would not follow the tradition.
The last key factor tempering FGM/C also influenced the first three
factors: Migration presented individuals in exile exposure to other
cultural models, models that opposed FGM/C, thereby allowing sharper
scrutiny of the practice.
DISCUSSION
Using
results from this systematic review, the authors show that FGM/C is
deeply rooted culturally and held in place by reciprocal expectations
within practicing communities’ social systems. In the included studies,
exiled members of practicing communities consistently argued that FGM/C
was an essential cultural traditional and so must continue. Kleinman (1980)
has described culture as an integrated pattern of human knowledge,
beliefs, and behaviors as well as a set of shared values and practices
that characterize a group. From this description it follows that, as
Gali (1997)
explains, FGM/C is embedded in many cultural systems through multiple
ties to historical tradition, tribal affiliation, social status,
marriageability, and religion. Most of these ties were perceptible in
the datasets and will be discussed below. A related way of understanding
FGM/C's continuance at the meso level through culture is by noting how
it is culture congruent: According to Leininger (1997),
the actions and decision for FGM/C are highly meaningful and preserve
the valued lifeways of people in the community, whether in the home
community or a Western host community. Or, as related to, for example,
the Somalis, among whom the practice is near universal (Yoder &
Khan, 2008), the practice has come to occupy an important place in the psyche of the society (Nkrumah, 1999).
The results are also largely congruent with the WHO's “mental map” of
why the practice continues. The WHO concluded that members of practicing
communities held culturally ingrained beliefs about FGM/C, which formed
a “mental map” and largely included psychosexual and social reasons,
religion, society, and hygiene and aesthetics (WHO, 1999).
It seems the reasons for FGM/C as viewed by individuals living in home
communities are largely the same as those expressed by communities in
Western exile. The results suggest that factors perpetuating FGM/C form a
belief set, in which its value as a cultural tradition takes
precedence. It is performed out of cultural conformity and, over time,
the practice has developed social significance, signaling people's sense
of identity and respectability as an ideal member of the community.
Today,
including in the context of life in exile, FGM/C continues to be valued
with strong support, socially and culturally. In fact, the results of
exile communities’ reasons as expressed in the 1990s and 2000s show that
a great deal of pressure is enforced within the communities. Accepting
its place as a social organizing principle in practicing communities,
the socially constructed normalizing mechanisms perceived by exile
members are not wholly unexpected. Gilette-Frenoy (1992)
writes that pressure to submit to the practice themselves or subject
their daughters to it came from extended family members living in the
West and those still residing in their countries of origin. On the one
hand, findings showed that girls who undergo FGM/C, and their family,
are met with social approval, notably respectability and honor (Khaja, 2004; Vissandjée et al., 2003).
On the other hand, in response to failure to conform to FGM/C, social
mechanisms included insulting an uncut girl's mother, teasing uncut
girls, denying them social acceptance, and, most significantly,
rejecting them as marriage partners (e.g., Ahlberg, Krantz, Lindmark,
& Warsame, 2004; Berggren et al., 2006; Gali, 1997; Gilette-Frenoy, 1992; Khaja, 2004; Morison et al., 2004; Vissandjée et al., 2003).
These findings show the role of FGM/C as a tool in social control.
Refusing FGM/C would not only introduce the psychological problem of
being different, but it also would shrink women's marriage prospects in
their community. It is important to note that in most societies
practicing FGM/C, being a wife and mother is of utmost value
(Johnsdotter, 2002; Lightfoot-Klein, 1989; Nkrumah, 1999).
Relatedly,
the results showed that the perpetuating factor of marriageability was
significantly linked with the ideology of sexual morals. Many exile
community members considered premarital virginity as a guarantee of
moral standards, the fundamental assurance of marriageability. In the
included studies and in other reports (e.g., Abor, 2006; Ebong, 1997),
a belief that a woman's sexuality is wanton and therefore must be
controlled through FGM/C was expressed. FGM/C is in this respect a means
to control the sexuality of women analogous to the iron chastity belts
allegedly used in medieval Europe. From a physiological perspective,
implications of FGM/C on sexual desire and satisfaction have been
substantiated (Berg & Denison, 2012),
but the procedure does not ensure virginity, including among
infibulated women—deinfibulation and reinfibulation can be and are
performed (e.g., Levine, 1999; Thierfelder et al., 2005). Albeit not unquestioned (see, e.g., Johansen, 2007),
the perception remains in the exile environment that through FGM/C,
especially infibulations, girls bear witness of moral status and
virginity (Johansen, 2007; Johnsdotter, 2002; Khaja, 2004).
As with marriage, it must be recognized that the concept of virginity
holds great importance in many practicing communities in that a family's
and indeed the whole wider group's honor depends on girls’ chastity
(Johansen, 2006; Khaja, 2004). Kassamali (1998)
writes that in patrilineal societies, family honor is customarily
closely associated with women's sexual behavior. As an example, in
Sudanese society “the greatest measure of a family's honor is the sexual
purity of its women. Any transgression on the part of the woman
disgraces the whole
family” writes Lightfoot-Klein (1989, p. 375).
The
results showed that the argument of religion coexisted on two levels,
reflecting the fact that a “true” Islamic position on FGM/C is
impossible to claim, given those involved argue from their own
interpretation of the written sources. There are four Islamic law
schools, of which three regard FGM/C as recommended and one, the Shafi’i
law school, regards FGM/C as compulsory. Each manifests differently,
however, in various countries according to sociocultural practices
(Roald, 2001).
For example, FGM/C is virtually nonexistent in several countries that
adhere to the Shafi’i law school (e.g., Palestine, Lebanon, Syria), but
it is almost universal in others (e.g., Somalia; Roald, 2001). Lightfoot-Klein (1989)
concluded that FGM/C is not practiced in an overwhelming majority of
Muslim societies. Further, the genesis of FGM/C cannot be attributed to
Islam as the practice was evident in pre-Islamic Arabia, the Middle
East, and Africa (Barstow, 1999; Giladi, 1997; Grassivaro & Viviani, 1988).
What is important is to draw attention to the fact that Islamic
scholars interpret written sources differently. Additionally, while
researchers believe that today's position of the Islamic scholars urges
Muslims practicing FGM/C to adopt the most moderate form of FGM/C, many
Muslims nevertheless understand clitoridectomy and infibulation to be
religious duties (Giladi 1997; Kassamali, 1998).
Because many parents who consider whether to perform FGM/C on their
daughter are illiterate or religious texts are out of reach for them,
they listen to Imams, who often endorse the practice (Gali, 1997). Grassivaro and Viviani (1988)
write that FGM/C to lay people is seen as an authentic way to be
religious, a sign of religious devotion. Further, linked to the
discussion above, while some salafi Islamists consider FGM/C as a means
to heighten female sexual desire, others regard it as a tool to reduce
sexual desire (Roald, 2001). It seems that religious
faith intersects with culture and sexuality in important ways.
As
with religion, the findings showed that another consideration of FGM/C
coexisted on two levels: FGM/C was seen as conferring health benefits
while simultaneous viewed as having adverse health implications. Belief
in purported benefits of FGM/C in general and hygiene in particular
seemed to reflect that respondents found cut female genitals somehow
cleaner. Conversely, participants were concerned about the intrapersonal
level consequences following FGM/C, especially pain and women's reduced
sexual responsiveness. According to leading health organizations, there
are no known health benefits to FGM/C (WHO, 2008),
and a recent meta-analysis confirmed that, statistically, a woman who
has been subjected to FGM/C is more likely to experience pain during
intercourse and reduction in sexual satisfaction and desire than a woman
whose genital tissues have not been cut (Berg & Denison, 2012).
Concerning men, one of their worries was interpersonal: women's
suffering during intercourse. As one man in Johansen's study (2007)
said, “How can I enjoy sex when it causes pain to my wife?” (p. 272). In
fact, men's interest in FGM/C ostensibly center on FGM/C's role in
preserving morality and honor, not providing sexual enjoyment (e.g.,
Johansen, 2007; Johnsdotter, 2002), contrary to what some female respondents suggested (e.g., Johnsdotter, 2002) and literature indicates (Khalifa, 1994).
As
presented in the results section, exile communities considered the
anti-FGM/C laws in Western countries and host society discourse's
rejection of the practice as important macrolevel factors slowing its
continuation. Since the early 1980s most Western countries have
instituted legislation as their main FGM/C intervention tool (European
Parliament, 2004; Leye & Sabbe, 2009), although neither their implementation nor effectiveness have been extensively studied (Johansen, Bathija, & Khanna, 2008; UNICEF, 2005a).
While it is possible that the existence of a law in their host country
may have influenced the community members’ responses to questions about
whether they would continue the practice, the results suggest positive
implications from FGM/C-related legislation. Migrating to a new social,
political, and cultural context with specific laws seems to have led
some to question the normalized practice of FGM/C.
In
sum, the findings show that like other socially entrenched practices
with benefits and sanctions anchored in a broad system of collective
behavior, FGM/C derives from a complex belief set, in which reasons are
at once ideological, material, and spiritual. As suggested above,
important factors materialize at multiple levels: intrapersonal (e.g.,
health consequences), interpersonal (e.g., sexual enjoyment), meso
(e.g., cultural tradition), and macro level (e.g., religion,
legislation). Despite the grouped presentation of factors, the mutually
reinforcing connections among the conditions influencing the practice
should be recognized. For example, as shown in the conceptual model,
some factors are perceived as both fueling and slowing the continuation
of the practice. It demonstrates a migrant perspective of living in two
worlds, where the multiple contexts and discourses surrounding FGM/C are
negotiated and there is a cultural accommodation taking place. It also
illustrates that FGM/C among exile communities is a tradition in
transition with, in time, a likely transfer of relative weight to
discontinuing the practice. In principle, then, the results are in
agreement with Mackie (1996),
who suggests that FGM/C as the “natural” way has become a belief trap.
He explains that FGM/C is a self-enforcing belief, in which the cost of
testing it has become so high that it traps people. Outside the realm of
doxa, however, it seems that people are in a state of transition, which
stimulates and enables them to reflect on values of home and host
communities.
The results suggest that
anti-FGM/C laws and actual court cases showing the effects of the law
can be used as a deterrent within the communities concerned. The
relevance of continuously and consistently informing citizens about the
fact that FGM/C is prohibited by law and a human rights violation is
indicated. While laws in themselves are not enough, they signal
expectations by a government regarding the practice and they can work in
a complementary fashion with prevention strategies, such as awareness,
and educational intervention approaches by creating enabling
environments for change. Findings are in agreement with UNICEF (2005b),
suggesting that comprehensive social support mechanisms and awareness
raising campaigns may be advantageous. Strategies of this kind may
foster greater public discussion and reflection, such that previously
nondiscussed costs of FGM/C may emerge as people share their
experiences.
Future approaches should target
stakeholders at the intrapersonal through to the macro levels. What is
crucial is that information, messages, and activities are tailored to
their audiences. Specifically, the results show that programs can also
build upon existing beliefs about detrimental consequences from FGM/C
and that the practice is not a religious obligation. The findings
indicate advantages in establishing an alliance with religious leaders,
who often function as norm authorities (WHO, 2008).
Health promotion professionals can also aim to modify or remove
continuance factors identified, such as correcting women's
misperceptions regarding male sexual pleasure and informing community
members of the greater likelihood of sexual problems with FGM/C.
Regarding the other factors, findings showed that parents wanting their
daughters to be successful in marriage and material opportunity chose
the strategy of FGM/C. When migration removes pressure, and alternative
options for social and economic survival other than FGM/C seem possible,
parents and other community members will consider refraining from
FGM/C. As one parent in Upvall and colleagues’ study (2009)
stated, “If my daughter finishes school, learns how to drive a car, and
gets a job, she doesn't need a man whether she is circumcised or not”
(p. 364). This speaks to the importance of educational opportunities and
economic independence for women.
Gaps and
uncertainties in current research knowledge are highlighted. More
research is needed especially among men. There would be advantages in
researching the role of Islam in attitudinal change, the informational
needs of the various FGM/C communities in Western locales, and avenues
for effective dissemination of information. Groups who seek to encourage
communities to discontinue FGM/C need to explore ways to address the
belief set that sustains the practice. Although the results suggest
factors perpetuating and hindering FGM/C are fairly consistent across
the many exile communities in the West, to optimally inform prevention
efforts research should be done locally because the factors may vary
somewhat across locations and time. The findings here form a clear
starting point.
Strengths and Limitations
A
strength of this systematic review is the comprehensive and systematic
literature search as well as systematic process for identifying and
analyzing relevant publications. A further strength is the inclusion of
several study designs. This type of integrative approach, sometimes
referred to as mixed studies review, is an emerging form of literature
review in the health sciences (Dixon-Woods et al., 2006; Ploye, Gagnon, Griffiths, & Johnson-Lafleur, 2009).
Such reviews, by consolidating often scattered literature on a defined
topic, provide detailed and highly practical understanding of complex
health issues (Dixon-Woods et al., 2006; Ploye et al., 2009).
The integrated results informed the review's conclusions and
implications for research and practice that are optimally relevant for
researchers, practitioners, and policymakers trying to understand FGM/C
and behavior change, as well as groups contemplating prevention
activities.
Advantages notwithstanding, the
systematic review has some limitations. First, it may be subject to
publication bias because it is not always possible to identify, and
retrieve, all studies addressing the question of the systematic review.
In contrast to effectiveness reviews, however, for synthesis of views
studies this is probably a minor problem as it is unlikely that one
large additional study would drastically change the results. Second,
some caution is warranted in interpreting the results because about half
of the studies had low methodological quality. Third, given the
integrative nature of the synthesis it is possible that other review
authors would produce a different overall model. The methods for
conducting integrative syntheses are evolving, and there is no agreement
about which approaches are best for particular types of data or
questions (Dixon-Woods et al., 2005).
Last, it is important to recognize that the identified factors are as
perceived by exile communities living in Western countries in the 1990s
and 2000s. Factors perceived as important likely change over time.
Relatedly, it was not always clear whether the respondents in the
included studies referred to situations in their home community or in
their current exile setting. This is likely not problematic because many
factors are, as described here, important in both contexts. FGM/C is
embedded in cultural systems that transgress geographical boundaries.
Understandably, this review does not mean to imply that there is
unanimity among FGM/C practicing communities—the reasons for FGM/C are
not everywhere the same—what the results show are recurring and dominant
factors found in the recent literature involving exile communities in
Western countries.
CONCLUSION
This
systematic review summarized 21 empirical studies examining the factors
perpetuating and hindering FGM/C as perceived by exile FGM/C
communities living in Western countries. The integrative evidence
synthesis identified that the practice of FGM/C derives from a complex
belief set, in which cultural tradition takes precedence within a frame
of sexual–moral and religious reasons that are sustained through
community mechanisms. The results showed that within this intricate web
of cultural, social, religious, and medical pretexts for FGM/C,
conditions hindering its continuance existed, such as a legal framework
and national discourse against FGM/C. Illustrated in a conceptual model,
the reciprocal and dynamic relationships that these factors formed
indicated that among practicing communities now living in a Western
country, FGM/C is a tradition in transition.
Acknowledgments
We
are grateful to the Norwegian Knowledge Centre for Violence and
Traumatic Stress Studies for providing financial support for the
systematic review. Thank you to librarian Sari Ormstaad, and to Atle
Fretheim, Simon Lewin, Hilde Holte, Owolabi Bjälkander, and Hilde Lidén
for valuable comments on earlier drafts of the systematic review.
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