Changing cultural attitudes towards female genital cutting.

As globalization brings people with incompatible attitudes into contact, cultural conflicts inevitably arise. Little is known about how to mitigate conflict and about how the conflicts that occur can shape the cultural evolution of the groups involved. Female genital cutting is a prominent example. Governments and international agencies have promoted the abandonment of cutting for decades, but the practice remains widespread with associated health risks for millions of girls and women. In their efforts to end cutting, international agents have often adopted the view that cutting is locally pervasive and entrenched. This implies the need to introduce values and expectations from outside the local culture. Members of the target society may view such interventions as unwelcome intrusions, and campaigns promoting abandonment have sometimes led to backlash as they struggle to reconcile cultural tolerance with the conviction that cutting violates universal human rights. Cutting, however, is not necessarily locally pervasive and entrenched. We designed experiments on cultural change that exploited the existence of conflicting attitudes within cutting societies. We produced four entertaining movies that served as experimental treatments in two experiments in Sudan, and we developed an implicit association test to unobtrusively measure attitudes about cutting. The movies depart from the view that cutting is locally pervasive by dramatizing members of an extended family as they confront each other with divergent views about whether the family should continue cutting. The movies significantly improved attitudes towards girls who remain uncut, with one in particular having a relatively persistent effect. These results show that using entertainment to dramatize locally discordant views can provide a basis for applied cultural evolution without accentuating intercultural divisions.

Determinants of disagreement with female genital mutilation/cutting of future daughters and awareness of the ban among Egyptian university students.

BACKGROUND: Egypt is one of three countries where half of female genital mutilation/cutting (FGM/C) victims live, despite its ban. To inform policy on the awareness of this ban and the impact of other interventions, this study sought to assess FGM/C-related knowledge, perceptions, and determinants of disagreement with FGM/C and circumcision of future daughters among university students. METHODS: A cross-sectional study was conducted using a self-administered questionnaire in a random sample of 502 male and female students in Menoufia University between September and December 2017. Bivariate and multivariable logistic regression analyses were performed. RESULTS: Students were 21.0 ± 1.6 years old; 270 (54.0%) were males, 291 (58.0%) were non-medical students, and 292 (58.2%) were rural residents. 204 (46.7%) students were not aware of the ban and their main source of information about FGM/C was educational curricula or health education sessions (162, 37.0%). Only 95 (19.0%) students had good knowledge about FGM/C. 217 (43.3%) students were neutral towards discontinuing FGM/C. 280 (56.2%) students disagreed with FGM/C. 296 (59.3%) students disagreed with circumcision of their future daughters; independent determinants of this outcome were awareness of the ban (ORa = 1.9) and disagreement with: FGM/C preserves females' virginity (ORa = 5.0), has religious basis (ORa = 3.8), makes females happier in marriage (ORa = 3.5), enhances females' hygiene (ORa = 2.1). CONCLUSIONS: Knowledge about FGM/C and its ban is low, even in this educated population. FGM/C is still misperceived as a religious percept. Maximizing the utilization of health education and curricula might help increase anti-FGM/C attitudes among university students with neutral perceptions and initiate the much-needed momentum for elimination.

United to end female genital mutilation: an on line knowledge platform for professionals and public.

Introduction: An estimated of 500,000 women and girls in the European Union (EU) have undergone female genital mutilation (FGM), with a further 180,000 at risk every year. Meeting the needs of these women and girls demands multidisciplinary action. This paper presents the United to End Female Genital Mutilation (UEFGM) knowledge platform, which is part of an EU-funded project. The platform is designed as a practice tool to improve the knowledge and skills of professionals who are likely to come into contact with women and girls affected by FGM.Method: Literature review was applied in regard to FGM along with expert validation process for the development of the modules particularly the e-learning section, expert and stakeholders' meetings for the other pillars of the Platform.Results: Three pillars were developed in the Platform: a) e-learning, b) country specific focus and c) live-knowledge discussion forum. The Platform explores related knowledge, skills, good practices, shared knowledge among professionals. UEFGM serves professionals and public as well in EU and worldwide.Conclusion: UEFGM comprises e-learning with a country-specific focus and a live discussion forum in which knowledge is shared between professionals worldwide. UEFGM discusses FGM and all related matters in a culturally- and gender-sensitive manner. It is a unique multidisciplinary and multilingual educational resource that has been found useful in everyday practice.

Knowledge and perspectives of female genital cutting among the local religious leaders in Erbil governorate, Iraqi Kurdistan region.

BACKGROUND: Religious leaders are one of the key actors in the issue of female genital cutting (FGC) due to the influential position they have in the community and the frequent association of FGC with the religion. This study aimed to assess the knowledge and perspectives of the local religious leaders in Erbil governorate, Iraqi Kurdistan Region about different aspects of FGC. METHODS: In-depth interviews were conducted with a sample of 29 local religious leaders. A semi-structured questionnaire was used that included questions about their knowledge, understanding, and perspectives on different aspects of FGC such as the reasons for practicing it, their contact and communication with the community regarding the practice and perspectives about banning the practice by law. RESULTS: Participants believed that FGC is useful for reducing or regulating the sexual desire of women to prevent adultery and engagement in pre and extramarital sexual relations and to enhance hygiene of women. They indicated that there is no any risk in doing FGC if there is no excessive cut. Most participants indicated that FGC is attributed to the religion and some considered it a tradition mixed with the religion. People rarely ask the advice of the religious leaders regarding FGC, but they frequently complain about the effects of the practice. Participants did not support having a law to ban FGC either because they thought it would be against the religion's advice on FGC or it will not work. CONCLUSIONS: The local religious leaders lack adequate knowledge about different aspects of FGC particularly the health consequences. There are different and disputing viewpoints about the reasons for practicing FGC, and there is poor support for having a law banning the practice. There is an essential need for enhancing the knowledge of the local religious leaders regarding FGC and its adverse effects on the women's health.

Educating about female genital mutilation.

Female genital mutilation (FGM) is illegal in the UK but nevertheless practised in some immigrant communities. Effective educational approaches are required to inform policy and to direct resources, often in the voluntary sector. The opinions in this article arise from discussions with professionals and members of FGM-practising communities. We highlight the importance of sharing experiences and expertise across health and social care professionals as well as working in partnership with culturally sensitive Non-Governmental Organisations. Enlisting the support of men and religious leaders is crucial to breaking down barriers in male-dominated communities and dispelling myths about FGM being a 'requirement' of faith.

FGM and midwifery practice.

Midwives in the UK should have appropriate education in order to provide optimum care for women with female genital mutilation (FGM) and know how to safeguard any children who could be at risk. In addition to this, women with FGM have a right to progress though their pregnancy and beyond, safely and confidently, in a supportive environment, and must be empowered to do so. Efforts are being strengthened by the government to tackle the issue of FGM and prevent further cases; therefore all those working in maternity care need to ensure they are equipped to deal with this issue. This article focuses on some of the factors that should be considered in the identification and referral of women with FGM, the planning of their maternity care and related safeguarding issues.

A survey on knowledge of female genital mutilation guidelines.

The increase in immigration from countries with a high prevalence of female genital mutilation (FGM) has highlighted the need for knowledge and sensitivity in this area of healthcare in high-resource countries. We have surveyed with an online questionnaire 607 members, fellows and trainees of the Royal College of Obstetricians and Gynaecologists (RCOG) on knowledge about the RCOG guidelines for FGM. Completed training and more practical experience with women affected by FGM significantly increased knowledge. Many respondents were not aware of specialist services locally (22.9%) or how to access them (52.3%). Some areas of insufficient knowledge were identified, in particular in relation to psychiatric morbidity, HIV, hepatitis B and pelvic infection. More specialized training efforts might improve this aspect.

Religious differences in female genital cutting: a case study from Burkina Faso.

The relationship between religious obligations and female genital cutting is explored using data from Burkina Faso, a religiously and ethnically diverse country where approximately three-quarters of adult women are circumcised. Data from the 2003 Burkina Faso Demographic and Health Survey are used to estimate multilevel models of religious variation in the intergenerational transmission of female genital cutting. Differences between Christians, Muslims, and adherents of traditional religions are reported, along with an assessment of the extent to which individual and community characteristics account for religious differences. Religious variation in the intergenerational transmission of female genital cutting is largely explained by specific religious beliefs and by contextual rather than individual characteristics. Although Muslim women are more likely to have their daughters circumcised, the findings suggest the importance of a collective rather than individual Muslim identity for the continuation of the practice.

Eradicating Female Genital Mutilation/Cutting: Human Rights-Based Approaches of Legislation, Education, and Community Empowerment.

Female genital mutilation/cutting is a form of violence against women and girls. It includes all procedures that involve the partial or total removal of external genitalia or other injury to the female genital organs for non-medical reasons. It is estimated that over 200 million girls and women worldwide have suffered the effects of this practice and that approximately 3.6 million girls and women are at risk each year. Female genital mutilation/cutting violates several human rights outlined under the Universal Declaration of Human Rights, the Convention on the Elimination of all Forms of Discrimination against Women, and the Convention on the Rights of the Child. Human rights-based approaches to eradication include, but are not limited to, the enforcement of laws, education programs focused on empowerment, and campaigns to recruit change agents from within communities.

Health information interventions for female genital mutilation.

Providing information and education to women and girls living with female genital mutilation (FGM) could be an important influence on their healthcare-seeking behavior. Healthcare providers also need adequate knowledge and skills to provide good quality care to this population. Recent WHO guidelines on managing health complications from FGM contain best practice statements for health education and information interventions for women and providers. This qualitative evidence synthesis summarizes the values and preferences of girls and women living with FGM, and healthcare providers, together with other evidence on the context and conditions of these interventions. The synthesis highlights that healthcare providers lack skills and training to manage women, and women are concerned about the lack of discussion about FGM with providers. There is a need for more training for providers, and further research to understand how health information interventions may be perceived or experienced by women living with FGM in different contexts.

Providing information to improve body image and care-seeking behavior of women and girls living with female genital mutilation: A systematic review and meta-analysis.

BACKGROUND: Female genital mutilation (FGM) has become recognized worldwide as an extreme form of violation of the human rights of girls and women. Strategies have been employed to curb the practice. OBJECTIVE: To conduct a systematic review of randomized and nonrandomized studies of the effects of providing educational interventions on the body image and care-seeking behavior of girls and women living with FGM with the view to ending the practice. SEARCH STRATEGY: CENTRAL, MEDLINE, and other databases were searched up to August 10, 2015 without any language restrictions. SELECTION CRITERIA: Studies that provided education to women and/or girls living with any type of FGM or residing in countries where FGM is predominantly practiced were included. DATA COLLECTION AND ANALYSIS: Two authors independently screened and collected data. We summarized dichotomous outcomes using odds ratios and evidence was assessed using the GRADE system (Grading of Recommendations Assessment, Development, and Evaluation). RESULTS: Educational interventions resulted in fewer women recommending FGM for their daughters and also reduced the incidence of FGM cases among daughters of women who received the educational interventions. CONCLUSION: These findings need to be validated with large randomized trials. PROSPERO REGISTRATION: 42015024637.

Supportive psychotherapy or client education alongside surgical procedures to correct complications of female genital mutilation: A systematic review.

BACKGROUND: Supportive psychotherapy, in individual or group settings, may help improve surgical outcomes for women and girls living with female genital mutilation (FGM). OBJECTIVES: To assess whether supportive psychotherapy given alongside surgical procedures to correct complications of FGM improves clinical outcomes. SEARCH STRATEGY: We searched major databases including CENTRAL, Medline, African Index Medicus, SCOPUS, PsycINFO, and others. There were no language restrictions. We checked the reference lists of retrieved studies for additional reports of relevant studies. SELECTION CRITERIA: We included studies of girls and women living with any type of FGM who received supportive psychotherapy or client education sessions alongside any surgical procedure to correct health complications from FGM. DATA COLLECTION AND ANALYSIS: Two team members independently screened studies for eligibility. MAIN RESULTS: There were no eligible studies identified. CONCLUSIONS: There is no direct evidence for the benefits or harms of supportive psychotherapy alongside surgical procedures for women and girls living with FGM. Research evidence is urgently needed to guide clinical practice. PROSPERO REGISTRATION: 42015024639.

Female genital mutilation in children presenting to Australian paediatricians.

OBJECTIVE: The WHO reports that female genital mutilation/cutting (FGM/C) is an ancient cultural practice prevalent in many countries. FGM/C has been reported among women resident in Australia. Our paper provides the first description of FGM/C in Australian children. DESIGN: Cross-sectional survey conducted in April-June 2014. SETTING: Paediatricians and other child health specialists recruited through the Australian Paediatric Surveillance Unit were asked to report children aged <18 years with FGM/C seen in the last 5 years, and to provide data for demographics, FGM/C type, complications and referral for each case. PARTICIPANTS: Of 1311 eligible paediatricians/child health specialists, 1003 (76.5%) responded. RESULTS: Twenty-three (2.3%) respondents had seen 59 children with FGM/C and provided detailed data for 31. Most (89.7%) were identified during refugee screening and were born in Africa. Three (10.3%) were born in Australia: two had FGM/C in Australia and one in Indonesia. All parents were born overseas, mainly Africa (98.1%). Ten children had WHO FGM/C type I, five type II, five type III and six type IV. Complications in eight children included recurrent genitourinary infections, menstrual, sexual, fertility and psychological problems. Nineteen children (82.6%) were referred to obstetrics/gynaecology: 16 (69.9%) to social work and 13 (56.5%) to child protection. CONCLUSIONS: This study confirms that FGM/C is seen in paediatric clinical practice within Australia. Paediatricians need cultural awareness, education and resources to help them identify children with FGM/C and/or at risk of FGM/C, to enable appropriate referral and counselling of children, families and communities to assist in the prevention of this practice.

Are there "stages of change" in the practice of female genital cutting?: Qualitative research findings from Senegal and The Gambia.

In recent years there has been growing interest in developing theoretical models for understanding behaviour change with respect to the practice of female genital cutting (FGC). Drawing on extensive qualitative data collected in Senegal and The Gambia, the research reported here explores whether and how theoretical models of stages of behaviour change can be applied to FGC. Our findings suggest that individual readiness to change the practice of FGC is most dearly seen as operating along a continuum, and that broad stages of change characterise regions or segments of this continuum. Stages identified by previous researchers for other "problems behaviours" such as smoking inadequately describe readiness to change FGC since this decision is often a collective rather than individual one. The data reveal that the concept of stage of change is a complex construct that simultaneously captures behaviour, motivation, and features of the environment in which the decision is being made. Consequently stages identified in this research reflect the multidimensional nature of readiness to change the practice of FGC. Limitations of stage of change models as applied to FGC include the fact that they do not capture important aspects of the dynamics of negotiation between decision-makers, and do not reflect the shifting nature of opinions of individuals or the constellation of decision-makers. Nonetheless, we suggest the application of stage of change theory may provide a useful means of describing readiness for change of individual decisions-makers and at an aggregate level, patterns of readiness for change in a community. How this construct can be employed in quantitative population research requires further investigation.

Evidence to inform education, training and supportive work environments for midwives involved in the care of women with female genital mutilation: a review of global experience.

OBJECTIVE: to identify how midwives in low and middle income countries (LMIC) and high income countries (HIC) care for women with female genital mutilation (FGM), their perceived challenges and what professional development and workplace strategies might better support midwives to provide appropriate quality care. DESIGN: an integrative review involving a narrative synthesis of the literature was undertaken to include peer reviewed research literature published between 2004 and 2014. FINDINGS: 10 papers were included in the review, two from LMIC and eight from HIC. A lack of technical knowledge and limited cultural competency was identified, as well as socio-cultural challenges in the abandonment process of the practice, particularly in LMIC settings. Training in the area of FGM was limited. One study reported the outcomes of an education initiative that was found to be beneficial. KEY CONCLUSIONS: professional education and training, a working environment supported by guidelines and responsive policy and community education, are necessary to enable midwives to improve the care of women with FGM and advocate against the practice. IMPLICATIONS FOR PRACTICE: improved opportunities for midwives to learn about FGM and receive advice and support, alongside opportunities for collaborative practice in contexts that enable the effective reporting of FGM to authorities, may be beneficial and require further investigation.

Evaluation of neonatal circumcision training for resident doctors in a developing country.

BACKGROUND: There is a high prevalence of neonatal circumcision (NC) in Sub-Saharan Africa. However, when providers do not have adequate training on the procedure, neonatal circumcision can result in complications. There are indications that the reported high complication rate of NC in the current setting might be a reflection of inadequate training of the providers. In order to establish a framework for better training of providers of NC, it may be necessary to evaluate the providers' opinions of their training and competence of the procedure. OBJECTIVE: The opinions of surgical, paediatric, and obstetrics-gynaecology resident doctors were evaluated for their exposure to, training on and perceived competence of neonatal circumcision. STUDY DESIGN: The resident doctors in surgery, paediatrics and obstetrics-gynaecology (OBGYN) at two teaching hospitals in southeastern Nigeria were surveyed using a self-developed questionnaire. The self-assessment survey evaluated the residents' exposure and training on NC, and their perceived competence of the procedure. The responses from the different specialties were compared. Data were analysed using Statistical package for Social Sciences (SPSS). RESULTS: The summary of findings is shown in Table below: The confidence in the ability to perform the NC did not significantly differ between the sexes (male 53/87 vs female 6/15; P = 0.22) and the level of training (SHO, Senior house officer 7/17, Registrar 24/42, senior registrar 28/43; P = 0.24). DISCUSSION: A substantial proportion of residents who encountered neonatal circumcision considered their training in NC to be sub-optimal, despite their perceived exposure to the procedure. Notwithstanding this deficiency of training, the majority of the residents planned to perform NC and this presaged an expectedly higher rate of complications. Well-thought-out and structured training, comprising lectures, workshops and hands-on training, for the resident doctors and the other providers of NC might address these shortcomings and minimise complications. This may further be strengthened with a government policy on circumcision. The limitations of the study included: (1) It was a self-assessment survey and this introduced bias in the assessment of competency; (2) There were no outcome measures in the survey for those who had practical exposure vs those who did not. CONCLUSION: The resident doctors perceived that their exposure, training and competence in NC might be sub-optimal. Curriculum modification that incorporates appropriate hands-on training in NC might address these deficiencies.