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Research overview
Systematic review

Factors promoting and hindering the practice of female genital mutilation/cutting (FGM/C)

What are the factors promoting and hindering the practice of FGM/C, as expressed by stakeholders residing in Western countries?


  • Issued/Revised: 2010
  • By: The Knowledge Centre for the Health Services
  • Berg RC, Denison E, Fretheim A. Factors promoting and hindering the practice of female genital mutilation/cutting (FGM/C), The Knowledge Centre for the Health Services. Research overview 2010. ISBN (digital): 978-82-8121-377-7, ISSN (digital): 1890-1298. Available at www.fhi.no/en

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Key message

Background: In November 2008, the Norwegian Knowledge Centre for Violence and Traumatic Stress Studies (NKVTS) commissioned the Norwegian Knowledge Centre for the Health Services (NOKC) to conduct a systematic review about the factors promoting and hindering female genital mutilation/cutting (FGM/C), from the viewpoints of stakeholders residing in Western countries. The review would answer the question: What are the factors promoting and hindering the practice of FGM/C, as expressed by stakeholders residing in Western countries?

Methods: We searched systematically for relevant literature in international scientific databases, in databases of international organisations that are engaged in aspects related to FGM/C, and in reference lists of relevant reviews and included studies. Additionally, we communicated with professionals working with FGM/C related issues. We selected studies according to pre-specified criteria, appraised the methodological quality using checklists, and summarized the study level results in tables before performing an integrative evidence synthesis. Our conclusions were summed in a conceptual model.

Results : We included and summarized results from 25 studies, of which 16 were qualitative investigations, eight were quantitative studies, and one was a mixed-methods study. There were three stakeholders groups: exiled members from communities where FGM/C is practiced, health workers, and government officials.  The results of these stakeholders' perceptions showed that the continuance of FGM/C is largely attributable to six factors: cultural tradition, the interconnected factors sexual morals and marriageability, religion, health benefits, and male sexual enjoyment. Factors perceived as hindering its continuance included health consequences, that it is not a religious requirement, that it is illegal, and that host society discourses reject FGM/C.

Conclusion : Our results show that an intricate web of cultural, social, religious, and medical pretexts for FGM/C exists. However, more research is needed to understand the totality and interconnectedness of factors promoting and hindering FGM/C among exiled members of practicing communities.

Summary

Background
Female genital mutilation/cutting (FGM/C) is a traditional practice that 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." The current WHO classification describes four types of FGM/C: Type I, clitoridectomy , involves partial or total removal of the clitoris and/or the prepuce. Type II, excision , involves partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type III, infibulation , involves narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris. Type IV, other , involves all other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping, and cauterization.

FGM/C is practised in more than 28 countries in Africa and in some countries in the Middle East and Asia. Countries with very high prevalence, over 70%, include Egypt, Ethiopia, Mali, Sierra Leone, and Somalia. However, there is great variation in prevalence across countries, reflecting ethnicity, tradition, and sociodemographic factors. The limited data available suggest that FGM/C is occasionally practised by immigrant communities in a number of Western countries, such as Norway, Sweden, Switzerland, and the United Kingdom.

FGM/C is associated with several health risks such as severe pain, bleeding, shock, infections, and difficulty in passing urine and faeces. Caesarean section, blood loss, and increased perinatal mortality are associated birth risks. Women who have been subjected to FGM/C are also more likely to experience increased pain during intercourse, reduction in sexual satisfaction and reduction in sexual desire compared to women who have not been subjected to FGM/C.

FGM/C is recognized as a harmful practice which abrogates human rights. It is prohibited by law in several African and Western countries. As Western governments have become more aware of FGM/C among immigrant communities, legislation has generally been used as the main intervention tool. However, some countries have given priority to prevention strategies, such as awareness raising and education.

We asked the following question: What are the factors promoting and hindering the practice of FGM/C, as expressed by stakeholders residing in Western countries?

Methods
We searched systematically for literature in the following scientific databases: African Index Medicus, Anthropology Plus, British Nursing Index and Archive, The Cochrane Library (CENTRAL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects), EMBASE, EPOC, MEDLINE, PILOTS, POPLINE, PsychINFO, Social Services Abstracts, Sociological Abstracts, and WHOLIS. We also searched in databases of international organisations that are engaged in research concerning FGM/C, manually in reference lists of relevant reviews and studies included in this systematic review, and communicated with experts engaged in FGM/C related work. We searched for studies that used the following study designs: systematic reviews, cohort studies, case-control studies, cross-sectional studies, and qualitative studies.

Two of the authors independently assessed studies for inclusion according to pre-specified criteria and considered the methodological quality of the studies using checklists. We summarized the study level results in tables. We utilized an integrative evidence approach by which we first performed a synthesis within study types and then a synthesis between study types. Results from the quantitative data set served as our point of departure and the synthesis was aggregative, i.e. we summarized data by pooling conceptually similar data from the two sets of studies. Our conclusions were summed in a conceptual model.

Results
We identified 5,998 publications and included 25 studies presented in 29 publications that fulfilled the inclusion criteria. This included 16 qualitative investigations, eight were quantitative studies, and one was a mixed-methods study. We failed to obtain full text copies of two potentially relevant records, despite extensive retrieval efforts.

We rated the study quality of 12 of the 24 mono-methods studies as low, eight as moderate, and the remaining four studies as having high study quality. We evaluated the qualitative and quantitative components of the mixed-methods study separately, and these were judged as high and moderate, respectively.

Among the 2,440 study participants there were three stakeholders groups: immigrants from communities where FGM/C is practiced, health workers, and government officials. With respect to members of communities practicing FGM/C (n= 1,709), about 80% of the participants were women and about 20% men. These participants were mostly from northern Africa and the horn of Africa, and the most typical current residency was Scandinavia or Canada.

The results showed that there were six key factors perceived as promoting and four key factors perceived as hindering the practice of FGM/C. We found that the continuance of FGM/C was largely attributable to culturaltradition, the interconnected factors sexual morals and marriageability, religion, health benefits, and male sexual enjoyment. The belief that FGM/C was an important cultural tradition was the most influential factor. The practice was seen as deeply rooted in the communities' social systems and the compulsory nature of FGM/C was reflected in community mechanisms enforcing it. Further, FGM/C was perceived as a cornerstone of moral standards, the maintenance of which helped to ensure the marriageability of women. 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. Health benefits and male sexual enjoyment (the latter was a perception among women only and refuted by men) were less influential factors reported in the included studies.

Key factors perceived as hindering the continuance of FGM/C included its health consequences, that it is not a religious requirement, that it is illegal, and that the host society discourses reject FGM/C. With regards to the first factor, both male and female participants were conscious of the consequences following FGM/C. Further, most members of practicing communities knew and appreciated the illegal status of FGM/C in their Western host countries. Many participants stated that FGM/C was not an Islamic duty and put this forth as an important reason why they would not continue the practice. Lastly, the host society discourses' rejection of FGM/C was seen among both exiled members and government officials as a factor hindering the practice. 

The conceptual model showed that some factors coexisted, simultaneously promoting and hindering FGM/C, suggesting that FGM/C among exiled communities is a tradition in transition.

Conclusion
Our results show that an intricate web of cultural, social, religious, and medical pretexts for FGM/C exists. However, more research is needed to understand the totality and interconnectedness of factors promoting and hindering FGM/C among exiled members of practicing communities.

This is a publication from the Norwegian Knowledge Centre for the Health Services. The Knowledge Centre became part of the Norwegian Institute of Public Health 01/01/2016.