Feature

A nagging persistence

Researchers dig deeper into why the cultural practice of female genital cutting continues — and how best to halt it.

In rural southeast Kenya, a 15-year-old girl is about to be initiated into womanhood. It is a time of celebration among her relatives as they prepare her for a ritual that almost every female in her ethnic group has undergone, for generations. Outside the village in a prepared spot, the girl lies on the hard-packed earth. The 67-year-old village circumciser, also a midwife, will take a sharp blade and cut away portions of her labia and clitoris.

To the circumciser, her work is a ritual that prepares the girl for marriage and a secure future. To some of the women who look on, it is cause to rejoice that she is joining their fully female ranks. To a 46-year-old leader in the community, the rite is a painful reminder of his own daughter who died from her procedure. To a Western outsider, it is a barbaric, torturous practice that is harmful to young girls and should be stamped out.

Female genital cutting (FGC) — the nicking, cutting or complete removal of the external female genitalia of young girls for no medical reason — presents social scientists with one of the strongest challenges to cultural relativism. On the one hand, they support the idea of pluralism, that cultural practices can only be judged within the context in which they occur, not by superimposing Western ideas about gender, sexuality and feminism. Within its own cultural context, FGC is an important religious or traditional ritual that is viewed as necessary for marriageability or a rite of passage to womanhood.

On the other hand, most anthropologists, including those who have studied the practice in detail, agree that it should be abandoned for the individual and societal harm it causes. Generally non-consensual, FGC often occurs under unsanitary conditions, which can lead to complications, infections and even death. It may make sexual intercourse painful and is frequently associated with other practices such as early marriage and childbirth, curtailing the education and advancement of women1,2.

The continued controversy swirling about FGC has impeded efforts to characterize the scope of the problem and how it should best be addressed. The topic is so contentious, the practice so intimately private, that collecting reliable data — on the persistence of and beliefs about the practice, and the effects of interventions — is riddled with challenges. Some advocates hold a zero-tolerance attitude toward FGC, and speaking the practice's very name can present a minefield: while some use the terms ‘female genital mutilation’ or ‘female circumcision’, Nature Human Behaviour uses the neutral term FGC, which has been adopted by many academics studying the practice.

Through all this, FGC stubbornly persists, despite the fact that it is broadly outlawed and that millions of dollars are spent each year by non-governmental organizations (NGOs) and governments to try to eradicate it, especially across a swath of middle Africa.

In February 2016, fresh scrutiny arrived when the United Nations Children's Fund (UNICEF) raised its estimate of the numbers of girls and women who have been cut to a total of 200 million globally — partly due to population growth and partly due to inclusion of data on the practice in Indonesia and Iraq for the first time. The report also noted that although FGC among girls aged 15–19 has declined over the last 30 years, the numbers of cut girls will continue to rise because of population growth — unless interventions become more effective3.

Senegalese representatives from 59 communities officially renounce female genital cutting and early and forced marriages at a ceremony in Kidira, eastern Senegal, Sunday 12 March 2006. Image: EPA EUROPEAN PRESSPHOTO AGENCY B.V. / ALAMY STOCK PHOTO

Some economists say it's time for a new approach. Their work, itself controversial, questions long-held views on FGC — that communities either all follow the practice, or all give it up – and thereby challenges the very underpinnings of many interventions.

Interventions should stop trying, as most do, to sway entire villages, these scientists say. They should instead target cracks in support for the practice: the influential community leader who has decided his daughters will not be cut, or the husband and wife who are divided on the fate of their daughters.

Anthropologists who have studied the practice for decades within communities say it's not so simple. They say there is intense community pressure to continue FGC, even when individuals may not want to continue — and thus community-level interventions remain the best tools for lasting change.

If there is one view on which all agree, it is that changing human behaviour is never easy, and that it must, in this case, originate from within the communities that carry out FGC.

Slippery statistics

FGC is practiced in at least 30 countries, with more than half of the affected females in Indonesia, Egypt and Ethiopia, UNICEF reports. The vast majority is carried out on girls aged 15 years or younger, and in 2008, the United Nations and World Health Organization declared the practice of FGC a violation of human rights.

Four types are defined by the WHO. In type I, all or part of the clitoral prepuce, or hood, and sometimes the external portion of the clitoris are removed. Type II adds to that the total or partial removal of the labia minora, and sometimes excision of the labia majora. Type III, often referred to as infibulation or sewing shut, narrows the vaginal orifice by cutting and repositioning the labia minora and/or the labia majora. Type IV includes pricking, piercing, incising, scraping and cauterization. A 2008 report by the United States Agency for International Development (USAID) estimated that about 10% of cut women undergo the most severe kind, type III.

The reasons that communities cite for practicing FGC are almost as varied as the communities themselves: tradition, family honour, feminizing the genitals, preserving chastity and virginity, purity and cleanliness, marriageability, coming of age ritual, and religious beliefs. According to a 2012 report by The Hastings Center, a bioethics think-tank, FGC in Africa is typically controlled, managed and carried out by women and the vast majority of societies that practice FGC also carry out parallel male genital cutting practices4.

FGC persists despite government laws that ban it in nearly every practicing country, as well as decades of intervention efforts in some areas. And yet in the 29 countries that collect data on FGC, more than 60% of both men and women aged 15–49 years say in surveys that they think the practice should end.

Don't be misled, says Daniel Sifuna, an education researcher at Kenyatta University in Nairobi, Kenya who published an in-depth look at FGC among the Wardei, a rural herding community in southeastern Kenya, this year1. “What people tell you in doing research and what they do when you go away are two different things.” Even his group, which recruited 22 Wardei community members to help lead interviews and discussions, worked hard to reassure people that they could speak freely.

This reliance on what people say — about their attitudes towards FGC, or their own cut or uncut status — poses a major challenge for researchers. They know that the demographic and health-survey responses are likely to be biased, yet these are the most complete data available.

Despite this, economists are managing to glean valuable patterns by applying statistical filters to large datasets. In one such study5, Marc Bellemare of the University of Minnesota in St Paul and his doctoral student Lindsay Novak waded through health surveys of more than 300,000 women in 13 countries, taken between 1995 and 2013. They found that attitudes on FGC, and women's own cutting status, varied within single households.

Women who reported having undergone FGC were 16 percentage points more likely to support the practice. And the largest source of variation in attitudes toward FGC — 87% — was at the household or individual level, across nearly all countries and years5.

“It means that women living in two different households in the same village are likely to have different opinions,” Novak says. And that, she says, suggests that decisions on cutting are made by households, not villages or regions. Other research supports this contention, and flies in the face of a prominent hypothesis about why FGC persists.

In 1996, political scientist Gerry Mackie, then at the University of Oxford, proposed that FGC, like the cultural practice of Chinese foot-binding, followed the game theory concept of a ‘coordination problem’6. People in a community that practiced FGC were coordinating with each other to all follow the practice because it ensured marriageability of the community's girls. Ending it would take similar levels of coordination, with the entire, or nearly entire, community deciding to stop and uphold uncut girls as desirable for marriage. Without that en masse shift, the social pressure to continue, even if a person disagreed with FGC, would be extremely high. Bucking the norm would mean spinsterhood and economic doom for a daughter, and dishonour for a family.

Mackie's idea was influential: it led many NGOs, including those funded by UNICEF, to aim FGC interventions at the community level — villages, or groups of villages that intramarry. A prime example is the 3-year, educational Community Empowerment Program run by the NGO Tostan, which works in six West African countries. The programme stresses the human rights to be healthy and free from violence, lays out evidence on the dangers of FGC and encourages open discussion. Community members have the opportunity to publicly declare that they have committed to stopping the practice.

“We've never said that it's 100% — that all who make a public declaration will abandon FGC,” says Tostan's founder and chief executive officer Molly Melching. “But it's building the critical mass.” She says that when people see imams, village chiefs, doctors or neighbours they've known for 50 years pledging to reject FGC, it's a powerful force. So much so that the community-led model has been adopted by the Joint Programme on FGC run by UNICEF and the UN Population Fund (UNFPA), which reports that more than 12,700 communities have made declarations — signed commitments or verbal announcements, sometimes with community celebrations.

The idea, as Mackie articulated, was that if FGC follows a social coordination norm, then when enough people decide to stop cutting, at a certain tipping point the entire community will abandon the practice. But does that happen? Economist Ernst Fehr of the University of Zurich in Switzerland worked with two researchers — sociologist Sonja Vogt and human evolutionary ecologist Charles Efferson, both also at Zurich — to test this in 45 communities from the state of Gezira, Sudan.

The team chose Gezira in part because FGC is performed there on girls around the age of 6 years, before they begin primary school, in a ritual that includes painting their feet with henna. That meant the team could sidestep the unreliable morass of self-reports and measure rates of cutting based on an external measure: photographs of the girls' feet as they started school.

If cutting was coordinated, there should be one of two rates in any given community: near 0% or near 100%. Instead, the team found a continuum: 0%, 100% and everything in between, in one community to the next. People who cut and those who didn't were effectively living door to door7. “We were pretty surprised,” says Vogt. But their local Sudanese data collectors were not. “They said, ‘Why wouldn't it be like this? Some people do cut and some people don't cut.'”

The findings, published in 2015, imply that the money and effort that NGOs or governments put into interventions to tip attitudes at the community level might be missing their mark, Fehr says. Groups like Tostan, he adds, spend millions each year without knowing if their programmes work. “We impose very high standards on the pharmaceutical industry for developing pills, but we have a very low standard when it comes to policy interventions for social change.”

Mackie and others sharply disagree with the study findings. Mackie's leading criticism is that the 45 communities studied in Gezira, which were based on territorial districts, do not accurately reflect the very small, tight-knit intramarrying groups found in that area. In a 42-page rebuttal that is as yet unpublished, he analysed health-survey data from 25 countries and found that within 24,000 ethnic group clusters (the ones most likely to intramarry), 93% had cutting rates above 90% or below 10%. “That is the distribution that the social-norms model predicts,” he says.

Each side holds fast to its views. Mackie says that his coordination model is also supported by copious data from surveys and ethnographic and journalistic accounts. Fehr rebuts that relying on self-reported data for a forbidden practice is a huge mistake, and that the field must shift away from that, and also rigorously test interventions.

Ellen Gruenbaum, whose 2001 book The Female Circumcision Controversy is considered a leading reference on FGC, takes issue with both sides. As a medical and cultural anthropologist at Purdue University in West Lafayette, Indiana, she has lived among, and studied, FGC-practicing groups in Sudan and Sierra Leone for three decades. And she says that the social pressure is real. “There is a norm that people are trying to meet. People are motivated by a fear of being shamed, being ridiculed or being dishonoured if their daughters are not circumcised.”

But she also dismisses the ‘all or none’ theory of cutting. In the communities where she has done her ethnographic work, she never saw that pattern with FGC. “Conversations are going on everywhere, people have discussions and differing opinions.”

Backlash

One thing seems clear: a heavy, outside hand — outlawing the practice and prosecuting practitioners — can backfire. Indeed, medical anthropologist Fuambai Ahmadu says that cutting among many groups in her native Sierra Leone has gone underground, with initiation ceremonies held in private.

And one 2015 report highlighted an alarming consequence of putting laws against FGC into place. The study, by Belgium-based economist Guilia Camilotti, found that in years and regions where an anti-FGC law was enforced in Senegal, girls were cut, on average, one year in age earlier, as infants and toddlers, perhaps because of heightened secrecy8.

Female cutting ceremony, Makeni Town, Sierra Leone, April 2002. Image: LOUISE GUBB / CONTRIBUTOR/CORBIS HISTORICAL/GETTY

Even in the face of criminal prosecution, FGC persists, whereas other outlawed cultural practices such as Chinese foot-binding and Sudanese facial scarring fell away within one generation. What might account for such durability?

Perhaps the practice's near invisibility, says Mackie, who now co-directs the Center on Global Justice at the University of California San Diego. Another reason could be FGC's ties to self-identity, says Ahmadu, who as a young adult voluntarily underwent FGC with her ethnic group, the Kono in Sierra Leone. She says that FGC persists because women value it as an empowering part of their culture — not an oppressive rite, but one that defines gender and identity as a woman.

All Women Are Free to Choose, an NGO she launched in Washington DC and Freetown, Sierra Leone, advocates for circumcised women who support the practice. She says that many interventions will fail because they are based on a false premise: “They think if they just frame it the right way, women will ‘get it’ and they will stop.”

Stressing the medical harm hasn't worked in interventions because women have decided the cultural benefits of the practice outweigh its costs, according to an oft-cited 2008 paper9 by anthropologist Bettina Shell-Duncan of the University of Washington in Seattle, a leading expert on FGC. It has not helped that the medical facts surrounding FGC were so “difficult to establish”, she added.

And yet reframing interventions as based on human rights brings other potential pitfalls, Shell-Duncan wrote. They impose Western views of rights, do not fully consider women's agency, and highlight inconsistencies, such as not banning male genital cutting and female genital cosmetic surgeries.

She points to programmes like Tostan's that are “grounded in local understanding and employing respectful community dialog” as making the best strides toward ending FGC.

Another programme that receives praise from experts is Saleema, a national initiative in Sudan. The Khartoum-based initiative aims to change attitudes toward an uncut girl by describing her with the Arabic word ‘Saleema’, meaning that “she's whole, perfect, and natural,” explains Samira Amin, one of the initiative's founders. Non-cutting behaviour, she says, “must have and enforce the same positive values — health, being clean, purified, more appealing in sexuality — that were conventionally associated with cutting.”

The Saleema initiative brands itself and uncut girls with a colour scheme of bright orange, yellow and light green. It runs a ‘born Saleema’ maternity hospital intervention to keep newborn girls uncut as well as animated television ads to get communities talking. Samira says she sees signs of progress. Communities that have accepted the Saleema concept for their girls are proud to declare it by wearing the initiative's colours. “Never would a man normally put these colours into his traditional dress in Sudan — that means the movement is working.”

Also potentially encouraging is a 2016 analysis by Sudan's Central Bureau of Statistics, and UNICEF. It noted a 25% drop in cutting in girls aged 0–14 years compared with women aged 30–34 years. It also found that 14% of women across Sudan used the word ‘Saleema’ to refer to uncut girls, and that mothers using the word were less likely to have cut daughters than those who did not2.

The report clearly states that this is not evidence of a causal relationship. Across Sudan, the overall prevalence of FGC is still 87%.

Change from within

How can the dial be shifted? Sifuna, for his part, believes education is key — for with literacy comes critical thinking and increased communication around anti-FGC efforts.

Others suggest the answer lies in coaxing communities toward new rituals still imbued with the same cultural significance as FGC, be it marriageability, purity or coming of age. In 2010, the American Academy of Pediatrics, while condemning FGC overall, proposed that US paediatricians be allowed to offer a ritual, clitoral ‘nick’ so that girls were not taken elsewhere for more extreme procedures. Met by fierce backlash from anti-FGC advocates, the academy quickly withdrew its recommendation.

Popular entertainment may have a part to play, too. In a recent study, Fehr, Vogt and Efferson screened a movie drama with a FGC subplot to 189 individuals and more than 7,700 people in 88 community showings, in Gezira. In several versions of the movie, an extended family debated the idea of abandoning cutting and at the end of the film, a respected, elderly grandfather decides the family will stop. The scientists found improved attitudes toward uncut girls in a word-association test that measures subconscious attitudes, compared with a control film with no FGC subplot. Although the effect from the community screenings was weak (albeit statistically significant) a week later, the researchers were encouraged that the film shifted attitudes at all, after just one viewing10.

Gruenbaum herself has long imagined a soap opera subplot on FGC that might run on national television for six months, with everyone — husbands and wives, colleagues at work, young and old — talking about it the next day. Her decades in the field have made clear that this is nowhere near as simple a matter as to cut or not to cut, that members of cutting communities weigh an intricate mix of concerns — tradition, aesthetic values, marriageability and health — when deciding.

“It's a multi-sided issue,” she says. “And there can be negative consequences to changing a cultural practice you don't understand.”

References

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    , & J. Anthropologic. Res. 72, 337–356 (2016).

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    FGM/C and Child Marriage in Sudan: Are There Any Changes Taking Place? (Central Bureau of Statistics Sudan, UNICEF, in the press).

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    Female Genital Mutilation/Cutting: A Global Concern (UNICEF, 2016).

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    The Public Policy Advisory Network on Female Genital Surgeries in Africa. Hastings Cent. Rep. 42, 19–27 (2012).

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    , & J. Dev. Econ. 116, 252–265 (2015).

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    Am. Sociol. Rev. 61, 999–1017 (1996).

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    , , , & Science 349, 1446–1447 (2015).

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    , , , & Nature 538, 506–509 (2016).

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  1. Kendall Powell is a freelance science journalist based in Lafayette, Colorado, USA.

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Correspondence to Kendall Powell.