Towards a better estimation of prevalence of female genital mutilation in the European Union : a situation analysis

Background:Female genital mutilation (FGM) is a harmful cultural practice that is predominantly documented inAfrica, but also occurs in other parts of the world. Due to migration, women who have undergone FGM can also befound in the European Union (EU). Due to a lack of systematic representative surveys on the topic in EU, theprevalence of FGM and the number of women and children subjected to the practice remains unknown. However,information on the magnitude of the problem in the EU is necessary for policy makers to design and trackpreventive measures and to determine resource allocation.Methods:Between March 2015 and May 2015, we performed a situation analysis consisting of a critical interpretivesynthesis and SWOT-analysis of available at the time peer reviewed and grey literature document on nationalprevalence studies on FGM in the EU. Studies estimating the prevalence of FGM and the number of girls and womensubjected to the practice in the EU were mapped to analyse their methodologies and identify their Strengths,Weakness, Opportunities and Threats (SWOT). Distinction was made between direct and indirect estimation methods.Results:Thirteen publications matched the prioritized inclusion criteria. The situation analysis showed that both directand indirect methodologies were used to estimate FGM prevalence and the number of girls and women subjected toFGM in the EU. The SWOT-analysis indicated that due to the large variations in the targeted population and the availablesecondary information in EU Member States, one single estimation method is not applicable in all Member States.Conclusions:We suggest a twofold method for estimating the number of girls and women who have undergoneFGMinthe EU. For countries with a low expected prevalence of women who have undergoneFGM, the indirect method will providea good enough estimation of the FGM prevalence. The extrapolation-of-FGM-countries-prevalence-data-method, based on thedocumented FGM prevalence numbers in DHS and MICS surveys, can be used for indirect estimations of girls and womensubjected to FGM in theEU. For countries with a high expected prevalence of FGM in the EU Member State, we recommendto combine both a direct estimation method (e.g. in the form ofa survey conducted in the target population) and an indirectestimation method and to use a sample design as developed bythe FGM-PREV project. The choice for a direct or indirectmethod will ultimately depend on available financial means and the purpose for the estimation

Debating medicalization of Female Genital Mutilation/Cutting (FGM/C) : learning from (policy) experiences across countries

Background: Although Female Genital Mutilation/Cutting (FGM/C) is internationally considered a harmful practice, it is increasingly being medicalized allegedly to reduce its negative health effects, and is thus suggested as a harm reduction strategy in response to these perceived health risks. In many countries where FGM/C is traditionally practiced, the prevalence rates of medicalization are increasing, and in countries of migration, such as the United Kingdom, the United States of America or Sweden, court cases or the repeated issuing of statements in favor of presumed minimal forms of FGM/C to replace more invasive forms, has raised the debate between the medical harm reduction arguments and the human rights approach. Main body: The purpose of this paper is to discuss the arguments associated with the medicalization of FGM/C, a trend that could undermine the achievement of Sustainable Development Goal 5.3. The paper uses four country case studies, Egypt, Indonesia, Kenya and UK, to discuss the reasons for engaging in medicalized forms of FGM/C, or not, and explores the ongoing public discourse in those countries concerning harm reduction versus human rights, and the contradiction between medical ethics, national criminal justice systems and international conventions. The discussion is structured around four key hotly contested ethical dilemmas. Firstly, that the WHO definition of medicalized FGM/C is too narrow allowing medicalized FGM to be justified by many healthcare professionals as a form of harm reduction which contradicts the medical oath of do no harm. Secondly, that medicalized FGM/C is a human rights abuse with lifelong consequences, no matter who performs it. Thirdly, that health care professionals who perform medicalized FGM/C are sustaining cultural norms that they themselves support and are also gaining financially. Fourthly, the contradiction between protecting traditional cultural rights in legal constitutions versus human rights legislation, which criminalizes FGM/C. Conclusion: More research needs to be done in order to understand the complexities that are facilitating the medicalization of FGM/C as well as how policy strategies can be strengthened to have a greater de-medicalization impact. Tackling medicalization of FGM/C will accelerate the achievement of the Sustainable Development Goal of ending FGM by 2030

The medicalisation of female genital cutting : harm reduction or social norm?

Today, female genital cutting is increasingly practised by trained healthcare providers. While opposition to medicalised female genital cutting (FGC) is strong, little is known about the underlying motivation for this medicalisation trend in practising communities. We formulated three hypotheses based on medicalisation theories. The medicalisation of FGC: (i) is stratified and functions as a status symbol, (ii) functions as a harm-reduction strategy to conform to social norms while reducing health risks and (iii) functions as a social norm itself. Conducting multilevel multinomial regressions using the 2005, 2008 and 2014 waves of the Egyptian Demographic Health Survey, we examined the relationship between the mother's social position, the normative context in which she lives and her decision to medicalise her daughter's cut, compared to the choice of a traditional or no cut. We found that an individual woman's social position, as well as the FGC prevalence and percentage of medicalisation at the governorate level, was associated with a mother's choice to medicalise her daughter's cut. Further research on factors involved in decision-making on the medicalisation of FGC is recommended, as an in-depth understanding of why the decision is made to medicalise the FGC procedure is relevant to both the scientific field and the broader policy debate

Exploring the association between perceived male attitudes and female attitudes toward the discontinuation of Female Genital Mutilation/Cutting in Egypt

IntroductionThere are 200 million girls and women alive worldwide that have undergone the practice of Female Genital Mutilation/Cutting (FGM/C) and 4 million girls are at risk of undergoing the practice each year. FGM/C provides no known health benefits, while puts a plethora of medical, psychological, and sexual health risks into perspective. One of the countries where the prevalence of FGM/C is the highest in the World, even though local authorities legally banned the practice in 2008, is Egypt. Within the Egyptian context, there are several complex socioeconomic, religious, and cultural drivers that influence the familial decision making of the daughters being cut. Female attitudes hold great significance in the process, because mothers and female family members are typically the prime decision makers at the daughter's circumcision. However, whilst FGM/C is often performed to enhance marriageability and address male preferences, in practicing communities there is little to no open communication between men and women about the practice, making women rely on their perceptions on FGM/C related expectations of men. Even though the connection between female and perceived male attitudes toward the discontinuation was established almost 20 years ago, since then to our knowledge little is known about the further characteristics of this association. Therefore, this study aims to explore the association between female and perceived male attitudes within families of a younger cohort and moreover attempts to provide a more layered picture of it within different levels of education.MethodsTo explore the relation between female and perceived male attitudes toward the discontinuation of FGM/C we conducted a 3-step binary logistic regression model.ResultsOur results show that women are significantly less likely to favor a continuation of FGM/C if they think men are disapproving of the practice, compared to women that think men want it to continue. The strength of this association partially varies between the different levels of education as it is less pronounced at the level of secondary education, compared to the reference group.DiscussionIn alignment with previous findings in the literature, women were more likely to support the discontinuation of FGM/C if they believed that men want the practice to discontinue as well and vice versa. At a higher level of secondary education however this association is less pronounced. This result concludes that the role of perceived male attitudes should be an important factor associated with female ones and studied further, and underlines the importance of education in women empowerment

To medicalize or not to medicalize : is that the question? Exploring medicalization of female genital cutting in Egypt and Kenya

Today, medicalization is one of the major shifts within the practice of female genital cutting (FGC). Medicalization, as defined by the WHO, refers to any situation in which the practice is performed by a trained health professional, at a public or private clinic, at home, or elsewhere. The question “to medicalize or not to medicalize” is a hot topic in the debate on FGC, typically answered by policy makers through the implementation of an anti-medicalization discourse. Yet, in this Ph.D. dissertation, we argue that the discussion on medicalization is often built on moral and ethical arguments, with little empirical grounding. More specifically, we argue it is essential to incorporate the view of practicing communities themselves in the debate. The overarching research questions within this Ph.D. dissertation are “Why do mothers opt to medicalize their daughters’ cut and how does this decision relate to her social position within her community?”. In this dissertation we aim to identify the social correlates of the shift towards medicalization, and the meaning and motivation behind them. In Egypt, we examined the association between mothers’ social position, social norms surrounding the practice, the mothers’ daughters’ risk to be cut and the possible medicalization of this cut. In Kisii County, Kenya, we explored the mothers’ motivation to medicalize their daughters’ cut and we discussed the shift towards medicalization in relation to other shifts in the practice. The first important conclusion of our research is that increasing medicalization and decreasing FGC prevalence can coexist. Increasing medicalization percentages do not necessarily increase girls’ risk to be cut. Moreover, we indicated three major drivers behind mothers‘ choices to medicalize their daughters’ cut. Firstly, mothers argue that they opt for a medicalized cut to reduce the health risks related to the cut. They seek a less harmful but still culturally acceptable alternative. Secondly, the medicalization of FGC is socially stratified. Thirdly, medicalization may act as a social norm itself. In conclusion, we state that the debate about medicalization should be more nuanced and that the general discourse on medicalization should be challenged and empirically grounded. Before we are able to answer the question “to medicalize or not to medicalize”; many more questions lay before u