Female genital mutilation in Sierra Leone

Background: The prevalence of female genital mutilation (FGM) in Sierra Leone is the seventh highest in Africa, yet little research has been done on its effects on girls and women. Objectives: This thesis aims to provide knowledge on the effects and experiences of girls and women, and the views of adolescent boys, about FGM which is performed within the initiation ceremony of the Bondo Society in Sierra Leone. Methods: The thesis is built around four articles (I to IV) analysing data collected in the Northern and Eastern Provinces of Sierra Leone as well as in the Western Urban Area of Freetown. Women and girls (n=1018) were recruited for articles I – III, and adolescent boys (n=75) for study IV. Results: Most of the decisions (65.1%) for FGM were made by females, with males deciding in 30.7% cases. Although the operation of FGM is performed mainly by traditional excisors, medicalization was reported in 13.2% of cases. FGM-related health complications were reported by 84.5% of the 258 respondents, the most common ones being bleeding, delay in or incomplete healing, and tenderness. Fever was reported by 46%, suggesting a more severe infection, but significantly more often among pre-pubertal girls. A total of 85.8% of those with FGM-related health complications sought treatment. A total of 47.6% received treatment from a traditional healer; 40.1% from a traditional excisor; and 8.6% from a nurse. Three forms of FGM were identified: type Ib (31.7%), type IIb (64.1%); and type IIc (4.2%). Results from logistic regression analysis for the outcome variable FGM showed that increasing number of previous pregnancies, rural residency, religion (Islam), being married and illiterate are factors associated with higher prevalence of FGM. There was a high level of agreement between reported and observed results for FGM status – 99%. However, respondents could not accurately describe the cutting extent, and we found that the DHS FGM module responses were not reliable for determining FGM type. Most adolescent boys (69.6%) considered Bondo a bad practice because of FGM, whilst some considered Bondo good because it is the culture and safeguards against stigmatization. A third of boys reported that girls face complications from FGM such as bleeding, fainting and death. The majority of boys (61.4%, n=43) would marry a non-Bondo member because they are viewed as more healthy and pleasant to have sex with. Qualitative analysis of the open ended responses from the boys identified three stages: “Becoming, Being and Belonging”. At “Becoming” – where FGM is performed, boys saw economic burdens for boys and health burdens for girls”. At “Being” a new status and respect was conferred on girls through public celebration. At “Belonging”, the boys lamented their lack of access to the Society, but were proud of new skills and value the girl now has. Interpretation: The results described in this thesis highlight the role men play in the decision making process for joining Bondo/FGM. The indication that FGM-related health complications are high is a cause for public health concern. That health professionals perform FGM is a serious cause for concern, as well as the lack of visibility of FGM-related health complications in the health care system. It may be possible within certain contexts in Sierra Leone to use self- reporting responses as a proxy measurement for FGM status, but not for form of FGM. Adolescent boys express ambivalence towards the practice, lamenting the potential harmful health effects of the FGM to the women and the economic burden the ceremony places on men, but also see the value of the Bondo initiation ceremony. Conclusion: This thesis suggests that the practice of FGM in Sierra Leone merits much more attention in research and policy in order to further identify and understand the effects that the practice has on girls and women

Impact of age on harm risks of Female Genital Mutilation: analysis of Demographic and Health Surveys

This paper investigates the problem of Female Genital Mutilation (FGM), also known as ‘Female Genital Cutting’ or ‘female circumcision’. Evidence in this paper is based on ‘Demographic & Health Surveys’, carried out in numerous countries. It explores four of the medical problems caused by Female Genital Mutilation: excessive bleeding; infection; urination problems; and swelling. This paper focuses on the age at which the circumcision took place, and the Type of FGM. This paper confirms previous evidence that FGM is harmful. For FGM Types I and II (clitoridectomy and excision) and IV (other), victims are more vulnerable to these four problems if they are older when circumcised; whereas for FGM Type III (infibulation), victims are more at risk if they undergo FGM at a younger age. Investigations into medical responses to FGM problems are reported

Felavhjälpande vid en totalentreprenad - Om ansvarsfördelningen avseende felavhjälpande vid en totalentreprenad med ABT som avtalsinnehåll

Omfattningen av felavhjälpandeskyldigheten i ABT 06, det entreprenadavtal som reglerar totalentreprenader, framkommer inte av bestämmelserna i ABT 06. Det framkommer inte heller om det finns någon begränsning av det ekonomiska ansvaret för avhjälpande. I ett fall från 2018 (NJA 2018 s. 653) konstaterade HD, med hjälp av avtalstolkning, att entreprenören var skyldig att svara för kostnader i samband med felavhjälpande trots att avhjälpandekostnaderna avsåg arbeten som låg utanför entreprenaden. Det huvudsakliga syftet med denna uppsats är därmed att utreda, med hjälp av en rättsdogmatisk metod, ansvarsfördelningen mellan entreprenör och beställare avseende kostnaderna för felavhjälpande vid en totalentreprenad. HD har arbetat fram en tolkningsmetod genom sina avgöranden för hur ett entreprenadavtal ska tolkas om det är ofullständigt. Domstolen har fastslagit att ledning kan hämtas från den dispositiva rätten, med ett särskilt intresse för köplagen och allmänna rättsprinciper, som ett led i tolkningen. Entreprenad- avtalet har dock särdrag som förväntas få utrymme vid avtalstolkningen. De yttre ramarna för hur vidsträckt en tolkning kan vara är när entreprenad- avtalets särdrag åsidosätts eller när en utfyllande regel passar mindre bra in i ett entreprenadsammanhang. Angående felavhjälpandebegreppets omfattning enligt dispositiv rätt framkommer det att avhjälpandeskyldigheten anses innefatta, förutom avhjälpandet av själva felet, direkta och nödvändiga kostnader i samband med felavhjälpandet i syfte att få en avtalsenlig prestation. Mycket talar därför för att det råder en allmän rättsprincip om att felavhjälpandeskyldigheten kan omfatta mer än bara felet som sådant, nämligen direkta och nödvändiga kostnader, med det bakomliggande syftet att beställaren har rätt att få entreprenaden i avtalsenligt skick.The scope of the obligation to make good defects in the Swedish standard construction contract ABT 06, does not appear in the provisions of the contract. It is also not clear if there are any limitations on the financial responsibility for making good defects. In a case from 2018 (NJA 2018 p. 653), the Swedish Supreme Court found, with the help of contractual interpretation, that the contractor was liable to pay for making good defects, despite the fact that the costs related to work outside the contract. The main purpose of this thesis is thus to investigate, by means of a legal dogmatic method, the responsibility between the contractor and the client regarding the costs of making good defects. The Supreme Court has elaborated an interpretation method through its decisions on how a standard construction contract should be interpreted if it is incomplete. The Court has ruled that guidance can be taken from optional law, with a particular interest in the Sale of Goods Act and general legal principles, as a part of the interpretation. However, the standard Construction contract has attributes that are expected to be given room within the interpretation. The external framework for how broad an interpretation can be is when the feature of the construction contract is breached or when a supplementary rule fits poorly into a constructional context. Regarding the scope of the obligation to make good defects according to optional law, it appears that the obligation to make good is considered to include, in addition to the defect itself, direct and necessary costs in connection with the defect in order to obtain a contractual performance. There is therefore much reason to believe that there is a general principle of law that the duty to make good defects can cover more than just the defect as such. Namely direct and necessary costs, with the underlying purpose that the client has the right to have the contract in contractual condition

Reliability of Reported Status, and Accuracy of Related Demographic and Health Survey Questions

Objective. To determine forms of female genital mutilation (FGM), assess consistency between self-reported and observed FGM status, and assess the accuracy of Demographic and Health Surveys (DHS) FGM questions in Sierra Leone. Methods. This crosssectional study, conducted between October 2010 and April 2012, enrolled 558 females aged 12-47 from eleven antenatal clinics in northeast Sierra Leone. Data on demography, FGM status, and self-reported anatomical descriptions were collected. Genital inspection confirmed the occurrence and extent of cutting. Results. All participants reported FGM status; 4 refused genital inspection. Using the WHO classification of FGM, 31.7% had type Ib; 64.1% type IIb; and 4.2% type IIc. There was a high level of agreement between reported and observed FGM prevalence (81.2% and 81.4%, resp.). There was no correlation between DHS FGM responses and anatomic extent of cutting, as 2.7% reported pricking; 87.1% flesh removal; and 1.1% that genitalia was sewn closed. Conclusion. Types I and II are the main forms of FGM, with labia majora alterations in almost 5% of cases. Self-reports on FGM status could serve as a proxy measurement for FGM prevalence but not for FGM type. The DHS FGM questions are inaccurate for determining cutting extent

Female Genital Mutilation in Sierra Leone: Forms, Reliability of Reported Status, and Accuracy of Related Demographic and Health Survey Questions

Objective. To determine forms of female genital mutilation (FGM), assess consistency between self-reported and observed FGM status, and assess the accuracy of Demographic and Health Surveys (DHS) FGM questions in Sierra Leone. Methods. This cross-sectional study, conducted between October 2010 and April 2012, enrolled 558 females aged 12–47 from eleven antenatal clinics in northeast Sierra Leone. Data on demography, FGM status, and self-reported anatomical descriptions were collected. Genital inspection confirmed the occurrence and extent of cutting. Results. All participants reported FGM status; 4 refused genital inspection. Using the WHO classification of FGM, 31.7% had type Ib; 64.1% type IIb; and 4.2% type IIc. There was a high level of agreement between reported and observed FGM prevalence (81.2% and 81.4%, resp.). There was no correlation between DHS FGM responses and anatomic extent of cutting, as 2.7% reported pricking; 87.1% flesh removal; and 1.1% that genitalia was sewn closed. Conclusion. Types I and II are the main forms of FGM, with labia majora alterations in almost 5% of cases. Self-reports on FGM status could serve as a proxy measurement for FGM prevalence but not for FGM type. The DHS FGM questions are inaccurate for determining cutting extent

Female Genital Mutilation in Sierra Leone: who are the decision makers?

The objectives of this study were to identify decision makers for FGM and determine whether medicalization takes place in Sierra Leone. Structured interviews were conducted with 310 randomly selected girls between 10 and 20 years in Bombali and Port Loko Districts in Northern Sierra Leone. The average age of the girls in this sample was 14 years, 61% had undergone FGM at an average age of 7.7 years (range 1-18). Generally, decisions to perform FGM were made by women, but father was mentioned as the one who decided by 28% of the respondents. The traditional excisors (Soweis) performed 80% of all operations, health professionals 13%, and traditional birth attendants 6%. Men may play a more important role in the decision making process in relation to FGM than previously known. Authorities and health professionals’ associations need to consider how to prevent further medicalization of the practice.Les objectifs de cette étude étaient d'identifier les décideurs à l’égard des mutilations génitales féminines et de déterminer si la médicalisation a lieu en Sierra Leone. Des entretiens structurés ont été menés avec 310 filles choisies au hasard entre 10 et 20 ans dans les Districts de Bombali et de Port Loko au nord de la Sierra Leone. L'âge moyen des filles dans cet échantillon était de 14 ans, 61% avaient subi des MGF à un âge moyen de 7,7 ans (entre 1-18ans). En règle générale, les décisions sur les mutilations sexuelles féminines ont été prises par les femmes, mais 28% des interviewés ont mentionné le père comme étant celui qui a décidé. Les exciseuses traditionnelles (Soweis) ont effectué 80% de toutes les opérations, les professionnels de santé 13%, et les accoucheuses traditionnelles 6%. Les hommes peuvent jouer un rôle plus important dans le processus de décision en ce qui concerne les mutilations génitales féminines que précédemment connu. Les autorités et les associations de professionnels de santé doivent tenir compte de la manière de prévenir la médicalisation de cette pratiqu