Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Tuesday, December 11, 2007

Pressure to Eliminate an Age-old Practice: Discussion of failures in Egypt’s attempts to ban Female Genital Mutilation – Sarah Munson

Introduction

Although mortality has long been a risk associated with the age-old practice of female circumcision, the recent deaths of two young Egyptian girls due to complications of the procedure have been heavily publicized in the international media creating a renewed pressure for the government to intervene. Worldwide efforts to eliminate these practices are failing; there are an estimated 100-140 million girls and women who have undergone some form of circumcision, with an additional 3 million girls expected this year. The prevalence remains high in Egypt as well as 27 other countries around the world, mainly in Africa, Asia, and the Middle East (1). Adding to the problem, the international community vastly underestimates the complexity of socio-cultural factors surrounding and perpetuating this tradition.

There are a number of terms used to describe this practice, including female circumcision, female genital cutting, female genital operations, female genital torture, or female genital mutilation. The chosen term will effectively elicit different responses. While advocates of these practices use circumcision, for the purpose of this paper, female genital mutilation (FGM) will be used. The background, including cultural beliefs and previous efforts to limit the practice, is important for understanding why an effective intervention is imperative. Three of the most recent intervention programs will be critically considered in light of tradition, politics, and social science theory. These include the 2007 government issued ban, an intervention program developed by the National Council on Childhood and Motherhood, and the UNICEF supported local non-governmental organization, Better Life Association for Comprehensive Development (BLACD). Social Cognitive Theory reveals how these approaches to reducing the prevalence of FGM, all different in scale and design will fall short.

Background: Statistics, Definitions, and Health Consequences

Female Genital Mutilation (FGM) is defined by the World Health Organization, UNICEF, and the United Nations Population Fund (UNFPA) as “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” (7). Ninety-six percent of women in Egypt have endured some form of FGM, while 90% of girls were between five and 14 years old when they underwent FGM. The procedures are more recently performed by health care professionals, but are also still practiced by midwives without anesthetic or by barbers using scissors, razors, or knives. There are no known health benefits, yet many feel that “it is an integral part of their cultural and ethnic identity” and that it is necessary for purity, beauty, and chastity (6).

There are four types of FGM divided into Type I, II, III, and IV as defined by the World Health Organization in collaboration with UNICEF and UNFPA:

Type I – excision of the prepuce, with or without excision of part or the entire clitoris.

Type II – excision of the clitoris with partial or total excision of the labia minora.

Type III – excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening, also called infibulation.

Type IV – pricking, piercing, or incising the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue; scraping of tissues surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri cuts); introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it; and any other procedure that falls under the definition given above (1).

Infibulation, seen in Type III, is the most severe form of FGM and accounts for an estimated 15% of all procedures. Comprising nearly 80% of all procedures is the excision of the clitoris and the labia minora, seen in Type II (7).

It is not surprising that these procedures result in an appalling array of health complications. Often FGM is performed without anesthesia, causing overwhelming pain and clinical shock. Infections are common due to unregulated conditions under which FGM may be performed; HIV/AIDS has become a greater concern, but more commonly blood poisoning known as septicemia and bacterial diseases such as tetanus occur (1).

In the long-term cysts, abscesses, keloids (thick, raised scars), damage to the urethra, painful intercourse (dyspareunia), and difficulties with childbirth can occur. The physical health complications are generally coupled with a variety of psychological and psychosomatic disorders. These have been difficult to measure as women commonly suppress these symptoms and deny psychological effects. These may include impaired cognition, recurring nightmares, panic attacks, prolonged stress, and long-term trauma. This psychological detriment can create farther-reaching problems like inhibiting the ability for women to obtain an education. The battle to reduce FGM begins with empowering and educating women; the WHO emphasizes these effects of FGM on a girl’s education in building a stronger argument against FGM (7,1).

The Egyptian Department of Health Services conducted a survey in 2005 to collect data quantifying the far-reaching effects of tradition. There were 19,474 Egyptian women included in the study; revealed from this population was 96% prevalence of FGM among ever-married women between ages 15 and 49. The data also show varied prevalence due to place of residence, level of education, and financial status. Women of higher education and in the highest wealth quintile have a reduced prevalence: 92% and 87%, respectively. Women with greater wealth and higher education have a more objective view of FGM and its risks, as wealth relieves some of the financial and social pressures that typically bind young women to these practices. Ninety-nine percent of women in rural Lower Egypt have been circumcised. This rural and less wealthy population shows an increased amount of support for FGM; it is more important for the family to receive the greatest bridewealth possible for their daughters’ marriage. Women supporting the continuation of FGM comprise 2/3 of the surveyed population and there is very little recognition among women of the potential health consequences. In addition, 60% of ever-married women feel that FGM is a requirement of religion (8).

Despite the use of religion as justification for FGM, the practice predates both Christianity and Islam. Evidence from Egyptian mummies show that forms of female circumcision existed some 5000 years ago (1). The cultural roots of this practice reach so deep that it seems nearly impossible to change. Studies by the New Women Research Center in Cairo, Egypt have shown that women claim two main reasons for FGM. First, circumcision reduces a woman’s sexual desire, ensuring the preservation of her virginity before marriage. Second, circumcision accelerates the achievement of femininity; this can also be seen as a rite of passage into womanhood (2). In addition to the aforementioned, many other factors sustain the tradition. These include coming of age and reason for celebration, ensuring the prospects of a husband, enhancing male pleasure during sex, promoting cleanliness and beauty, and for religious purification (6).

Tradition, Intervention, and Social Science Theory

With an understanding of the practices of Female Genital Mutilation and the associated health concerns, this section will focus on the current happenings in Egypt. Social Cognitive Theory will be applied to three interventions to show how each lacks key elements for success. First will be the recent June 28, 2007 government issued ban. Second will be the National Council of Childhood and Motherhood, a government agency working to reduce the prevalence of FGM. Finally, the intervention techniques of the Better Life Association for Comprehensive Development (BLACD) a non-governmental organization in Minya, Upper Egypt will be discussed.

In a New York Times international podcast, Michael Slackman, Cairo Bureau Chief and New York Times correspondent, referred to the “confluence of events” shaping Egypt’s recent stand on FGM as “the perfect storm” (9). This refers to an unprecedented merging of powers in Egypt following the international broadcast of the deaths of two young girls in the summer of 2007. On June 28, the Minister of Health and Population issued a decree criminalizing FGM. Coinciding with this decree was a statement released by the highest religious authority of Egypt, Al-Ashar Supreme Council of Islamic Research, saying FGM had no place in Islamic law. Additionally, Ali Gomaa, Egypt’s grand mufti declared FGM “haram,” or prohibited by Islam.

Representing the common opinion of Egypt’s leadership, television advertisements and billboards have become commonplace; the broadcasts air on state television channels and billboards have been placed in urban and rural communities alike (9). Susan Mubarak, wife of President Hosni Mubarak, has become very vocal on the issue and in support of the National Council of Childhood and Motherhood. This combination of international pressure, government influence, non-government organizations, religious leaders, local activists, and the media has resulted in Egypt’s strongest fight against FGM.

Although the government is able to shut down clinics and discourage the practice, the ban has not yet passed legislation; without formal legislation FGM cannot be punishable by law. Even if legislation is enacted many are skeptical that punishments will be enforced. Similarly, the use of media fails to account for geographic regions where television may not be available. In addition to these apparent gaps, there are many other reasons this ban will be ineffective. Primarily, the government issued ban does not account for the power of social norms, environment, and self-efficacy as embodied by Social Cognitive Theory and Social Expectations Theory.

A variety of theories have been developed in the field of social and behavioral sciences to explain individual behavior. Albert Bandura’s Social Cognitive Theory combines a series of individual characteristics with a series of environmental factors that both influence behavior. The individual characteristics include self-efficacy, behavioral capability, perceived expectations, self-control, and emotional coping. Equally important, the environmental factors include vicarious learning, reinforcement, and conscious operating (12). Each of these factors must be addressed to change behavior. To effectively implement a program to reduce FGM, it is helpful to focus on the how the individual consciously operates in their immediate environment and whether these individuals have the perceived self-efficacy and behavioral capability necessary in achieving the goal of the intervention.

Bandura emphasizes the idea of vicarious learning; actions can be predicted by examining what is observed within the environment. The environments where this procedure is most common greatly impact the decision to practice FGM. Egypt persists as a strongly patriarchal society; however, families, peers, and entire communities insist that this practice continue to maintain social order. Men in Kafr Al Manshi Abou Hamar were outraged at the government ordered closing of a clinic that had routinely offered circumcisions after a 13 year-old girl bleed to death. One man protested, “even if the state doesn’t like it, we will circumcise the girls!” As men control the majority of decisions made regarding their families, especially their daughters, they drastically hinder the eradication of FGM (9).

The opinions of older women also influence a girl’s perception of FGM. Her ability to oppose circumcision cannot exist in an environment where the people she trusts the most require this of her, as “people tend to describe FGM as a form of violence that is performed by women on women” (2). Girls have very few alternatives if their family feels strongly that FGM is required. They may mean being cut by force or sent away from the home without resources to provide for themselves. These harsh alternatives represent the extent to which Egyptians believe FGM is necessary to assimilate girls into society. Fears of sexual liberation and rebellion have the potential to brand both the girls and the families with shame. The lavish ceremonies that generally accompany FGM, where families are honored and girls receive gifts, are outward proof of adherence to tradition. In any case, the girl’s wishes are often irrelevant (6). The greater challenge “rests in persuading people that their grandparents, parents, and they themselves have harmed their daughters” (9). The social pressures that exist are significant and have proven difficult to change.

The National Committee on Childhood and Motherhood has attempted to address these societal pressures. This governmental agency works to close the gaps left by the government ban geographically, socially, and legislatively. They work in 120 villages around the country to locally promote women’s rights. In February of 2000, the President officially recognized the National Council of Childhood and Motherhood as a governmental agency in a decree. Their initiatives include monitoring and evaluating the existing policies towards women, researching women’s issues and collecting data, proposing public policies for development and empowerment of women, drafting laws related to women, and training women to raise awareness and promote their rights. The NCCM operates with reasonable efficacy and adequate resources provided by the government (11).

Mosheira Khattab, head of the NCCM has declared their position with regard to FGM. They aimed to have the government ban replaced by law in November of 2007 and are currently still working for a prompt enactment of legislation. The NCCM has opened a hotline to anyone interested in obtaining information and aim to keep the information unbiased and allow people to make rational decisions based on the obvious harms and risks. The hotline represents an intervention based on the Theory of Reasoned Action, which incorporates three major factors in behavioral change: attitude, subjective norms, and behavioral intention. Unfortunately, the NCCM neglects the influence of environmental factors; they think that if they can simply change people’s attitudes, the behavior will follow. Social Cognitive Theory demonstrates that “attitudes and subjective norms are not sufficient determinants of intentions and that intentions are not a sufficient impetus for action” (10).

Social Expectations Theory is similar to Social Cognitive Theory but it only takes into account two very important aspects of behavior: intention and social norms. Social norms are defined as “customary codes of behavior in a group or culture, together with the beliefs about what those codes mean” (12). The customary codes of behavior that exist in Egypt are strict ways of defining identity and roles in society. If the NCCM incorporated a way to deal with social norms into their interventions they may be able to change the social environment, making it more acceptable to oppose FGM. Basing change on the rationale of informed individuals has logical implications but will fail in application. Egypt is a country where individual level change can only happen if the social environment is accepting.

Established in 1995 in Minya, Upper Egypt, the Better Life Association for Comprehensive Development (BLACD) has followed a “Rights Based Approach” to improving the quality of life among the poor and deprived people in Egypt. They currently work in five areas of development: democracy and human rights, education, housing, economic empowerment, and health. Their first experience in fighting FGM was in 2004 when they began holding community meetings, collecting data on local opinions, training doctors, midwives, teachers, and girls to promote women’s rights. The meetings have featured religious leaders and trained doctors offering opinions negating the medical, social, and religious justification for the practice. BLACD receives funding and sponsoring for many of the meetings and training sessions from UNICEF (13).

Much of the research initiated by BLACD follows the appropriate steps; before developing programs of action, extensive time and effort has been spent in assessing the obstacles and evaluating the most effective intervention. However, one program developed by BLACD in 2006 utilizes individuals who have already chosen to stand against FGM to promote their views. “Positive deviants” as they are referred to, “undertake awareness-raising activities within their community to educate people on the harms of FGM and persuade them to abandon the practice” (5). This program, like that of the NCCM, fails to account for social environmental factors.

As mentioned before, Social Cognitive Theory stresses the influence of the environment on individual behavior. The “positive deviants” target young girls who are rarely the ones who choose to undergo FGM. Mothers, fathers, sisters, brothers, extended family members, and peers all contribute to the environment surrounding the individual. To be effective, the program must deal with this social environment, targeting families in addition to young girls for the possibility of change.

Although advocates of FGM emphasize the importance of tradition and culture, the practice goes beyond this, embodying an entire national identity. According to Adia Seif El Sawali, “it has to do with the perception of one’s role in the world, with a complete self-image” (2). It is this very concept that creates tension within the international community, mainly ‘the West,’ and pushes for a change in these harmful practices. Egyptian identity has become increasingly important to preserve, and FGM is a way to resist cultural imperialism.

The girls who are coming forward as positive deviants and promoting change risk being sent away from their families, socially ostracized, or killed. An example comes from the New York Times article, ‘Voices Rise in Egypt to Shield Girls from an Old Tradition.’ Fatma Ibrahim, a 24-year-old woman, claims she is still haunted by her experience with circumcision. She was 11 and her parents told her she was at the doctor for routine blood tests. The doctor put her to sleep and when she woke, she was unable to walk. She hopes to spare other women the trauma she has had to endure by volunteering as a positive deviant, but says, “my parents at home don’t know that I work in FGM, and if they find out, they’ll kill me” (9).

The fact that this violent practice continues today is representative of Egyptian values. If interventions can address these core values they may be able to change the social environment such that girls can take comfort in making their own decisions. Influential international powers are appalled that this government has allowed such a prolonged and invasive violation of basic human rights, and the resulting pressure is important to fuel the eradication of FGM, but it is equally important that appropriate interventions, modeled after appropriate theories of behavior, be developed.

As discussion of the topics surrounding FGM, including women’s rights, female sexuality, and the short and long-term risks, has become more candid at the international and local level, the pressure for the government to better address these issues grows. This pressure peaked in 1994 making the United Nations International Conference on Population and Development “a turning point in the approach taken to address FGM” (2).

Female genital mutilation found its way into the conference alongside issues such as development aid, financial commitments, and other public policies through the Program of Action to aid children and women. As stated in section 4.17 of the program, “one of the aims should be to eliminate excess mortality of girls, wherever such a pattern exists.” Later in section 4.22, more specifically, “governments are urged to prohibit female genital mutilation wherever it exists and to give vigorous support to efforts among non-governmental and community organizations and religious institutions to eliminate such patterns” (3).

Although the government and the UN recognized FGM in the resulting program, it was a heated topic of debate during the conference. In response to the discussion of such topics as abortion, FGM, and reproductive rights, citizens unassociated with the conference were aggressively vocal. They feared their government would act in accordance with international pressure rather than account for its citizens’ beliefs. However, “reform is often a top-down process in which national laws are developed to change rather than reflect local attitudes” (14). This has certainly become the case in banning FGM, where “governmentally enforced laws that touch on personal aspects of people’s lives in Egypt can invite hostility rather than respect for the law” (2). The local opinion was that these discussions were “attempts to violate our traditions, our culture, our norms, vis-à-vis a Western agenda that wants to negate us as a nation” (2).

Since then it is clear that the government is unsure of how to appropriately confront FGM. In 1996, the Health Minister issued a decree prohibiting “all medical and non-medical practitioners from performing FGM in either public or private facilities, except for medical reasons certified by the head of a hospital’s obstetrics department […] [P]erpetrators are subject to the loss of their medical licenses and can be subjected to criminal punishments. In cases of death, perpetrators are also subject to charges of manslaughter under the Penal Code” (4). The decree was tried in the Court of Cassation, the highest appeals court in Egypt, and upheld as a government ban. Because of this medical exception, FGM has persisted in both medical and other facilities including barber shops and homes. Exacerbating this situation is the fact that doctors now have a new financial incentive to perform more surgeries at the expense of women (2). This has been the situation until the 2007 renewed government interest in eradicating FGM.

For the last decade, despite efforts by non-governmental agencies, little headway has been made in reducing FGM; this is painfully obvious with the 2005 survey showing 96% prevalence. The recent collaboration of the government with non-government organizations, religious leaders, and international organizations offer the potential for new agendas in achieving a significant decrease in FGM. This combination may be just right for addressing each individual and environmental factor for behavioral change called for in Social Cognitive Theory. Proving the importance of honoring basic human rights, promoting women’s rights, gaining male support, spreading information about health risks, and changing the social norms may, in combination, slowly eradicate FGM. Female genital mutilation has been practiced for over 5000 years and has acquired a complicated web of traditions that cannot be undone without careful analysis of both individual level and environmental level factors for effective interventions.

References

1.UNDP/UNFPA/WHO/World Bank Special Programme of Research,

Development, and Research Training in Human Reproduction. Progress in

Sexual and Reproductive Health Research: Female genital mutilation – new knowledge spurs optimism. 2006.

http://www.who.int/reproductive-health/hrp/progress/72.pdf

2. Sawala, Aida Seif El. The Political and Legal Struggle over Female Genital Mutilation in Egypt: Five Years Since the ICDP. Reproductive Health Matters 1999. 13: 128-136

3. Programme of Action of the UN ICPD. 1994. 4.17-4.22.

www.iisd.ca/Cairo/program/p04006.html

4. Office of the Senior Coordination for International Women’s Issues. Egypt: Report on Female Genital Mutilation (FGM) or Female Genital Cutting (FGC). 2001. http://www.state.gov/g/wi/rls/rep/crfgm/10096.htm

5. UNICEF: Fresh progress toward the elimination of female genital

mutilation/cutting in Egypt. http://www.unicef.org/egypt/FinalNewsletter.pdf

6. Althaus, Frances A. Female Circumcision: Rite of Passage of Violation of Rights? International Family Planning Perspectives 1997. 23: 130-133

7. World Health Organization Fact Sheet: Female Genital Mutilation

www.who.int/mediacentre/factsheets/fs241/en/print.html

8. 2005 Egypt DHS Survey of Female Circumcision. Link from New York Times website: http://graphics8.nytimes.com/packages/pdf/world/20girls.report.pdf

9. Slackman, Michael. Voices Rise in Egypt to Shield Girls from an Old Tradition. Article and Podcast, The New York Times September 20, 2007 front page, also website: http://www.nytimes.com/2007/09/20/world/africa/20girls.html?_r=1

10. Bagozzi, Richard. The Self Regulation of Attitudes, Intentions, and Behavior. Social Psychology Quarterly 1992. 55: 178-204

11. Official National Council for Women website:

http://www.ncwegypt.com/new-ncw/english/index.jsp

12. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett 2007

13. Website for Better Life Association for Comprehensive Development (BLACD) http://www.blacd.org/index.php?pagename=Projects&pageid=32

14. Peres, Sharon and Boyle, Elizabeth Heger. National Politics as International Process: The Case of Anti-Female-Genital-Cutting Laws 2000. Law and Society. 34: 703-737

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