"FGM includes procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons.  The procedure has no health benefits for girls or women.  Procedures can cause severe bleeding and problems urinating, and later cysts, infections, infertility as well as complications in childbirth and increased risk of newborn deaths.  More than 125 million girls and women alive today have been cut in the 29 countries in Africa and Middle East where FGM is concentrated.  FGM is mostly carried out on young girls sometime between infancy and age 15.  FGM is a violation of the human rights of girls and women.  It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. ... FGM violates a person's rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death"
[World Health Organisation, source].

"We must not pussyfoot around FGM and child marriage but confront them and prevent them"
[Anne Marie Waters, source].

The purpose of this study is to provide a brief insight into factors relating to both the persistence and abandonment of FGF/Cutting in Africa (the aforementioned will now be referred to as FGM/Cutting).

The author identified the subject for this study when observing that FGM/Cutting currently affects up to 140 million females worldwide [WHO 2013].  This is further supported by Oloo et al [2011], who also note that these women continue to live with the sequential effects of FGM/Cutting and who predominantly live in 28 of the 55 African countries (Western, Eastern, North Eastern Africa) [Oloo et al, 2011; Berg and Denison, 2012; Terry & Harris, 2013].

Persistence

The purpose of this section is to consider factors encompassing the persistence of the practice of FGM/Cutting.

FGM/Cutting is noted to be a practice/tradition that can be traced back many centuries and is thought to originate in Ancient Egypt.  Whilst the practice straddles different cultures, it is also noted to have undergone cultural transformation [WHO, 2001; Whitehorn et al, 2002; Oleleparakuo, 2011].

The World Health organization states: "FGM/Cutting includes procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons" [WHO, 2013].  This statement is extended by Unicef, indicating it also to be a "violation of Human Rights on a massive scale" [Unicef, 2007].  Although FGM/Cutting procedure is frequently cited as causing both immediate and long term physical complications - and in some circumstances leading even to death [WHO, 2012; WHO, 2013], it is worth noting that the procedure is attributed to the female on a more holistic level, involving not only the physical but also the psychological and sexual wellbeing [Whitehorn et al, 2002].

Commentators classify the practice into 4 main categories: Clitoridectomy, Excision, Infibulation., and Other [WHO, 2013].  However, Denniston & Milos [1997] elucidates the above further by describing the group noted as 'Other' as Defibulation and Refibulation.  This 'Other' results in the female being cut and uncut (infibulated and defibulated), in order to allow intercourse as a bride or in labour/delivery of a baby [Denniston & Milos, 1997].  The procedures are both invasive and controversial, as the onus to conduct these surgical procedures is placed with the Traditional Birth Attendant, and lead to apparent cases of infection and recto-vaginal fistulas [Denniston & Milos, 1997].

Commentators cite many factors pointing to the perpetuation and persistence of FGM/Cutting within practicing communities, including sociocultural, hygienic, aesthetic, spiritual/religious, and psychosexual [WHO, 2001; Oleleparakuo, 2011; Kaplan et al, 2013; NSPCC, 2013].  However, as WHO [2012] notes, the communities practising FGM/Cutting are responding to social conventions/norms, in order to remain included and safe within the family network.  The reverse would be exclusion leading to discrimination, loss of family honour, and stigmatisation through their rejection of the existing social expectations, values, and beliefs of both previous and present generations within the community [Unicef, 2010].

Salient to the traditional practice, FGM/Cutting is seen as an absolute pre-requisite to marriage and to expect tradition to become pliable/annulled would be seen as an unrealistic notion, thereby resulting in the placing of social sanctions upon the noncompliant individual by the community [Unicef, 2010].  Furthermore, WHO [2012] continues, to opt out of the agreement with the larger group of the community would actually cause even further negative risks for that female in comparison to the physical risks attributed by undergoing FGM/Cutting [WHO, 2012].

Although the physical risks re FGM/Cutting are widely recognised, Oleleparakuo notes that deeply rooted beliefs, values, and attitudes influence the persistence rather than change within communities [Oleleparakuo, 2011; also see WHO 2001].  The beliefs are noted by commentators to include specifically Rites of Passage, female honour and modesty, religious obligation, and marriageability.  Chiefly, these attributes are of great significance within societies where the position of the female is on the low social echelon - thereby making FGM/Cutting a 'need' rather than an 'informed decision/want' [Unicef, 2009].  Whitehorn et al further argue that a woman's honour is based on being cut - and that not to be cut is seen as effectively dishonouring herself and her family, as well as making herself a social outcast, incurring various sanctions [Whitehorn et al, 2002].

Kaplan et al [2013] supports the above, noting it to also be symbolic - the physical (FGM/Cutting) confirming/accepting femininity and initiation through a rite of passage; making herself worthy to belong to the community.  Salient to this rite of passage into womanhood, Oloo et al [2011] proposes that FGM/Cutting is a celebration in which females are given gifts and food, and show that they have accepted FGM/Cutting as an absolute pre-requisite for marriage.

Conversely, Oloo et al [2011] also suggest that 'sanctions' are applied from the community to any uncut female.  These sanctions/stigma identify the female as unmarriageable and mark them out to be treated with contempt and isolated from the group/community.  In addition, as the lone female is likely to face a future without a husband and children, she will be faced with harsh economic consequences - the absence of income, protection, and security [Oleleparakuo, 2011].

Kaplan et al [2013] proposes that the reason for the vast majority of females undergoing FGM/Cutting within a practising community is to ensure that the females remain virgins until their wedding night.  Whitehorn et al [2002] note however, that no such obligations is rendered to the males to ensure their virginity/chastity.  Kaplan et al [2013] further suggests that the above serves as a guide to illuminate gender inequality and oppression of women within Patriarchal African societies - much of which, interestingly, is perpetuated by women [Whitehorn et al, 2002; Edouard et al, 2013; Kaplan et al, 2013].

To reiterate, FGM/Cutting has been noted to be an ancient tradition rooted in tradition/culture dating back approximately 5000 years [Oleleparakuo, 2011].  It is entrenched within communities through mediators of social norms encompassing beliefs and values attached primarily to marriageability,  and which ultimately reinforce the safety and economic wellbeing of females within a community [Unicef, 2009; Oleleparakuo, 2011; Oloo et al, 2011; WHO, 2012; Kaplan et al, 2013].

Finally, Kaplan et al [2013] suggest that women have ultimately facilitated and perpetuated FGM/Cutting, by assuming it as a 'women's issue'; one in which men are not involved.  In addition, the suggesting of parallels between the tradition and a 'special value' denoting their femininity, ultimately allows women to cope with the experience and justify their discrimination [Kaplan et al, 2013].

Abandonment

The purpose of this section is to consider factors facilitating abandonment of the tradition of FGM/Cutting.

Authors suggest that although the practice has drawn much attention - albeit negative - over the last 1-2 decades, the practice both in and out of Africa continues [Kluge, 1996; WHO, 2012; Brown et al, 2013].  Moreover, by criminalising the practice, what is less certain is whether the continuance of FGM/Cutting has been driven underground within the very countries/communities in which it had, historically, been been overtly practiced [Kluge, 1996; Brown et al, 2013; Edouard et al, 2013].  Central to the possibility of any legislation is the questionable notion that legislation alone will promote behaviour change, rather than the practice continuing unabated [Kluge, 1996; Brown et al, 2013].  However, WHO [2012] note recent evidence of less support for FGM/Cutting in practising communities, and actual reductions in younger generations accompanied by abandonment [Unicef, 2010; WHO, 2012].

Intrinsic to abandonment is the responsibility, not so much by the individual families, but by the families comprising the whole community [Unicef, 2007; WHO, 2012; Brown et al, 2013].  Unicef [2007] endorse this notion further by citing Mackie's account [1996], describing similarities between foot binding in China and infibulation in Africa.  Indeed, both practices are seen to be driven by self-enforcing social conventions, targeted specifically to the female gender, and promoting chastity/fidelity as a pre-requisite for marriage.  These are noted and presented as virtual universal customs specific to those cultures, whilst also most notably being practised by women upon women, even when the individual women themselves may be opposed to the named custom [Unicef, 2007].

Although it has been historically fashionable to adopt a 3-pronged individual level approach to abandonment regarding FGM/Cutting, predominantly to raise awareness of of Human Rights, Legislation, and Health issues, Brown et al [2013] proposes that it would be unrealistic to expect change without acknowledging the "wider sociocultural context of FGM/Cutting", resolving that a "one size fits all" approach is unlikely to foster change [Unicef, 2007; WHO, 2012; Brown et al, 2013].

Historically, the preferred mode of instigating change within communities has been through time-constrained Health Education messages [Brown et al, 2013].  However, this has ignored ignored a norms and beliefs system which equated women with being 'marriageable' or 'unmarriageable'.  Consequently, there needed to be a paradigm shift inclusive of a collective abandonment, rather than an individual abandonment soley responding to directive messages/campaigns [Unicef, 2007].  Indeed, even if an individual/family desired to respond to the Health Education messages, the decision would not be without recourse to stigmatisations/ostracisation [Unicef, 2010; Brown et al, 2013].

In resolving change it would appear that abandonment would be identified in terms of 'helping' communities to stop the practice, rather than a prescriptive Health message criticising the current tradition/practice.  According to Unicef [2010], in order to unpick abandonment, a process inclusive of a bottom-up approach, whereby the community drives the discussion and decision, is more likely to ultimately lead to a public decision/commitment to abandon FGM/Cutting, rather than a prescriptive top-down approach.  This view is also held by other authors who identify that non-directive approaches set by community members themselves are more likely to lead to social change and consequently dissolve the previous solidified social norm underpinning FGM/Cutting [Beattie in Gabe, Calnan and Bury, 1991; Diop and Askew, 2009; Brown et al, 2013].

It would be unrealistic to expect one family to suffer the stigma associated with a daughter 'unfit' for marriage, thus their interdependence with other intermarrying families within and surrounding the community both embed and reinforce the status quo [Brown et al, 2013].  Despite this, Mackie and Le Jeune [2009] propose that change comes about with just a "core group" of individuals who set in motion the change and who then seek to to convince others to abandon and publicly renounce current practice [Mackie and Le Jeune, 2009; Unicef, 2010; Brown et al, 2013].

The above process is noted to encompass the "critical mass", both of the immediate community and local intermarrying communities, known as "diffusion" [Unicef, 2010; Brown et al, 2013].  Authors concur that this facilitates a "tipping point", supporting a consensus of abandonment regarding FGM/Cutting, that would permanently change social norms and practice [Mackie and Le Jeune, 2009; Brown et al, 2013].  It would appear that identifying a specific reason for actual abandonment is both unclear and complex.  However, authors agree that current influences encompassing culture, globalisation, media, and communication are all influential factors leading to a "tipping point", whereby to change is acceptable and not detrimental [Diop and Askew, 2009; Mackie and Le Jeune, 2009; Unicef, 2010; Brown et al, 2013; Edouard et al, 2013].

Conclusion

FGM/Cutting has been noted to affect up to 140 million females worldwide [WHO, 2013], whilst an estimated further 3 million females are also at risk regarding FGM/Cutting each year [Unicef, 2007].  This illuminates the fact that up to 8,000 females have had their bodies irreversibly changed and their basic human rights violated within a 24 {...} period [Unicef, 2007; Oloo et al, 2011].

However, because it is widely recognised to be an emotive practice/tradition, efforts to end FGM/Cutting began decades ago [Unicef, 2010].  Nevertheless, despite much growing intervention and attention, resistance to change was militant within communities, who believed these efforts were an attack on their culture/beliefs [Mackie and Le Jeune, 2009; Unicef, 2010].  Nevertheless, authors have argued that ethical critiquing from outside a community has been defensible due to fundamental principles holding on the grounds of just being a human being [Kluge, 1996; Mackie and Le Jeune, 2009].

Recognising that all families love their children, whilst also subjecting them to harmful practices has led to strategies that acknowledge, encompass, and involve communities in discussion [Diop and Askew, 2009; Berg and Denison, 2012; Edouard et al, 2013].  Understanding a multifaceted view point that underpins social norms attached predominantly to marriageability has allowed abandonment to begin within once-entrenched practising communities [Oloo et al, 2011].  Dialogue involving communities has led to a paradigm shift reversing the social norm underpinning FGM/Cutting.  Self-enforcing beliefs involving notions of female honour/chastity, rites of passage, and religious obligation as being interdependent with marriageability, has begun to be recognised by some  communities for what it is: an outward cost simply symbolising female honour/chastity/fidelity [Mackie and Le Jeune, 2009; Edouard et al, 2013].

Disconnecting FGM/Cutting from the honour/modesty code has allowed women to demonstrate fidelity without the external 'show' of FGM/Cutting, thereby dissolving the self-enforcing social norm/belief attached to marriageability [Mackie and Le Jeune, 2009].

Finally, authors note that individuals conform to social convention out of social reward: acceptance versus stigmatisations; therefore interventions require a multifaceted community viewpoint to address FGM/Cutting, rather than an over-simplistic mode of appealing to individual reasoning [Brown et al, 2013; Edouard et al, 2013].

Reference List

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Berg, R. & Denison, E.,  Interventions to Reduce the Prevalence of Female Genital Mutilation / Cutting in African Countries, (September 2012, Campbell Systematic Reviews).

Brown, K., Beecham, D., Barrett, H.,  'The Applicability of Behaviour Change in Intervention Programmes Targeted at Ending Female Genital Mutilation in the E.U.: Integrating Social Cognitive and Community Level Approaches', Obstetrics and Gynaecology International, Volume 2013, Article 324362.

Denniston, G., Milos, M.,  Sexual Mutilations: A Human Tragedy, (1997, Plenum Press, New York).

Diop, N., Askew, I.,  'The Effectiveness of a Community-Based Education Programme on Abandoning Female Genital Mutilation/Cutting in Senegal', Studies in Family Planning, (2009), 40, (4), pp.307-18.

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