considered and addressed people’s perceptions on the issue, leaving those of circumcisers barely acknowledged. Although the practice is generally confined to the secret world of women, it does not mean that circumcisers cannot be influential. Indeed, circumcisers can play an important role in prevention. In order to address this gap, and having as background an extensive ethnographic field work, a transversal descriptive study was designed to explore Somaliland circumcisers’ knowledge and attitudes towards FGM/C.
The study was conducted in Awdal, Maroodijeeh and Togdheer regions, which covered city towns, districts, villages, and rural locations. The methodology of data collection was exploratory approach that looked into what previous studies had overlooked. Key Informant Interview was employed as a tool of data collection. The sampling strategy of the study was non-probability sampling specificically purposive sampling.
Results show 82.8 percent of circumcisers are currently continuing to perform FGM/C,while 17.2 percent have stopped the exercise due to ;trainings and awareness they received bringing behavioural change, alternative income generation activities and attitudinal changes especially how they view FGM from religious perspective. On average there are five circumcisers per location, and the mean age is 52 years. About 47 percent of the circumcisers have encountered challenges such as parents disagreeing on whether to have their daughters circumcised or not. Some girls were able to run away for fear of the process, and also some have been injured by the knife during the process. About 63.8 percent of the circumcisers prefer Sunna circumcision, while 14.2 percent prefer infibulations (pharonic) circumcision.
The driving factors behind them practising the art was clear that 42% circumcisers practice FGM for financial reasons, 24% practice it because that is the only skill they know, while 21% practice to fulfil cultural beliefs, 8% practice because of religion and other related beliefs, and 3% circumcisers practice because the community demand it, while 1% practice it as a hobby.
The circumcisers’ opinion on FGM/C in Islam; 65% believe that FGM/C type 3(infibulations or pharonic) are forbidden or haram but Sunna is allowed, 26% believe all types of FGM are allowed as a religious Efforts aimed at the abandonment of Female Genital Mutilation/Cutting (FGM/C) in the communities where it is deeply rooted have extensively considered and addressed women’s perceptions on the issue, leaving those of men barely acknowledged. Although the practice is generally confined to the secret world of women, it does not mean that men cannot be influential. Indeed, men can play an important role in prevention. Results show ethnic identity, more than religion, as the decisive shaping factor on how men conceive and value FGM/C. The greater support towards the practice is found among traditionally practicing groups. A substantial proportion of men intend to have it performed on their daughters, although reporting a low involvement in the decision-making process, with very few taking alone the final decision. Only a minority of the respondents were aware of FGM/C health consequences, but those who understand its negative impact on the health and well-being of girls and women are quite willing to play a role in its prevention, while 8% could not tell whether FGM/C is halal (permissible) or haram (forbidden). However, none of them could cite a verse in Qur’an or hadith for their religious justification.
In terms of livelihood; 53.8% of circumcisers sustain all their living by performing FGM while 46.2% do more other things apart from FGM.On future financial prospects; 41.3% of the circumcisers believe that future is promising, while 55.7% believe future financial dynamics is decelerating. When it comes to stopping the trade, 95.5% circumcisers would stop the exercise if alternative livelihoods are found for them.
Female Genital Mutilation/Cutting (FGM/C) is defined by the World Health Organization (WHO)  as all procedures involving partial or total removal of the external female genitalia, or injury to the female genital organs, for nontherapeutic reasons. The WHO classifies the practice into four types: type I (clitoridectomy), type II (excision), and type III (infibulations) are ordered according to a growing level of severity, while type IV comprises all other harmful procedures performed on the female genitalia for nonmedical purposes (e.g., pricking, piercing, incising, scraping, and cauterization). According to the WHO latest data, 140 million women and girls in the whole world are thought to have been subjected to the practice, and 3 million girls are at risk of having it performed every year. FGM/C constitutes an extreme form of discrimination and violation of the human rights of girls and women, with health consequences now acknowledged and documented. In the short term, the practice can result in shock, haemorrhage, infections, and psychological consequences, while in the long term it can lead to chronic pain, infections, keloids, fibrosis, primary infertility, increase in delivery complications, and psychological sequela/trauma [2–7]. FGM/C has been practiced for centuries, having acquired a deep cultural meaning. Under a shared vision of the world where life is understood in cycles, FGM/C had been linked with the moment in which a girl becomes a woman in many societies.
A study conducted in 2014 on Assessment of the Prevalence, Perception and Attitude of Female genital Mutilation in Somaliland showed that the prevalence rate of FGM/c was
99.8% ,and out of this most of the girls/women(96.7%) were circumcised by a traditional circumciser or a traditional birth attendant(TBAs);3.3 % reported that it was performed by health workers. The type of FGM that was commonly performed in both the rural and urban areas was infibulations. Although the type of FGM known as Sunna (non-infibulations) was not clearly understood by the respondents, Two-thirds of the women supported Sunna to be performed in the health facilities for their daughters.
The practice of FGM/C was perceived to be performed as a fulfilment of cultural obligation and Islamic religion requirement, and the study further established that mothers are the ones who mainly lead in the decision for cutting their daughters as majority (90.5%) of the respondents thought it is impossible to eradicate the practice.However,9.3% of the women interviewed at MCHCs had decided to abandon FGM/C and some of the religious leaders admitted that their daughters were not cut. They also recognized Pharonic type of FGM to have no religious basis and had committed themselves to campaign for eradication of FGM through religious platforms in the mosques.Postive changes were also observed with 90% of the mothers accepting Sunna type of FGM/C from the Pharonic type and majority of the youths wanted FGM eradicated completely.
The study also recommended that priority should be given for further research on different FGM/C perspectives especially on the aspect of the circumcisers engaged in FGM/C as a source of income generating activity (NAFIS, 2014).This would help the anti-FGM/C organizations to develop feasible programs that would target the circumcisers to abandon the practice as the need to generate income from carrying out FGM/C will be met by alternative income generating activities (WHO, 2008).
The broad objective of this research was to map and investigate the factors that influence circumcisers to practice
FGM/C in Awdal, Maroodijeeh and Togdheer regions.
The specific objectives of the study were:
1. To establish the demographical factors of FGM/C circumcisers in Awdal, Maroodijeeh and Togdheer regions in Somaliland.
2. To establish how circumcisers gain the skill of FGM/C in these regions.
3. To identify the three main factors that influence circumcisers to practice FGM/C in these three regions.
4. To map circumcisers who abandoned circumcision, figure out the reasons of quitting the practice and examine if they could be engaged in future anti-FGM/C programs.
5. To find out alternative skills and professions circumcisers would prefer if they have to abandon circumcision.
As a result of NAFIS Network 2014 study, NAFIS and partners decided to undertake another study that would map out and give a deeper understanding of the previous study, and also provide valuable information that will be used to develop feasible anti-FGM/C programs and policies.
2. Materials and Methodology
2.1. Study Design
The study applied both qualitative and quantitative approaches using an exploratory and descriptive cross-sectional survey which was conducted between September 26th to November 25th 2015.
2.2. Study Area
The study was conducted in Awdal, Maroodijeeh and Togdheer regions in Somaliland. The areas were selected because they are the three most populated provinces in the country and in addition anti-FGM/C campaigns and other related interventions have been concentrated throughout decades in these areas.
2.3. Study Population
A total number of 128 FGM/C circumcisers were recruited and key informant interviews were conducted.
2.4. Sample and Sampling Technique
The study adopted a non-probability sampling method which used purposive sampling technique to select the study participants. The sample size represented approximately 70% of the total population of FGM/c circumcisers in Awdal, Marooodijeeh and Togdheer regions proportionately which is more than 30 participants required as a sample size for key informant interviews in each region.
Women who are currently circumcising girls or women.
Women who at some point in their lifetime circumcised girls or women.
2.5. Data Collection Methods and Tools
This study adopted a mixed data collection methods. Quantitative data and qualitative data were collected from the interview using the Key Informant Interview guide.
2.6. Data Collection Procedures
Data was collected by three (3) teams, each in every region which consisted of one supervisor and three data enumerators. Before collecting data the teams were trained on interview techniques and ethics. The data collection period lasted 1 day in each region and data triangulation was also done by collecting data from existing reports and studies that provided insights on the factors associated with the prevalence of FGM circumcisers in Somaliland.
2.7. Data validity and reliability
Researchers ensured data validity and reliability. Validity of the key Informant Interview guide was ensured by a pre-test that was conducted after the data collection team was trained and as a result the key informant interview guide was modified to guard against the threat of instrumentation and also testing.
To ensure data quality 16 circumcisers were reinterviewed randomly from the three regions under study to ensure data consistencies, accuracy, validity and preciseness.
2.8. Data Analysis
After data collection, data was cleaned, organized and was entered and analysed using Scientific Program of Social Studies (SPSS) and lime Survey. Qualitative data was analyzed by categorization of the data into themes while quantitative data was presented in frequencies and percentages and was presented in tables and pie charts. Qualitative data was analyzed thematically through the contents and was presented in narrative form.
2.9. Ethical Considerations
The study observed ethical principles by introducing the study respondents to the purpose of the study and giving all the details including the benefits of carrying out research. This followed a consent form which was signed by all the respondents. They were given the choice to withdraw from the study at any given time if they felt so; privacy was observed when collecting the data and confidentiality by not revealing the identity of the study respondents during and after data collection was also maintained.
3. Results and Discussions
Socio-demographic characteristics of FGM circumcisers are shown in figure1.The findings of the quantitative and qualitative data were presented concurrently. The results were reported in respect to filling the gaps identified in the specific objectives of the study and validated previous studies conducted on FGM/C circumcisers. The study investigated the demography of FGM/C circumcisers in Awdal, Maroodijeeh and togdheer regions in Somaliland and established how circumcisers acquired skills to practice FGM/C, the main factors that influenced circumcisers to practice FGM/C, the reasons circumcisers abandoned the practice and the alternative skills and professions they preferred if they had to abandon circumcision.
Out of a sample of 128 circumcisers mapped, 40.6% resided in Maroodijeeh, 30.5% in Togdheer, and 28.9% in Awdal regions respectively. 3
Figure 1: Percentage of FGM/C circumcisers as per the district
The majority of the circumcisers;56.7% resided in the urban,18% in rural,14.9% in semi-urban areas and 11% in official IDP camps(State house,Stadium,Mohamed Mooge and Koosaar camps) respectively.
Figure 2: Type of Residence for FGM/C circumcisers
The mean age for the FGM/C circumcisers was 52 years with the youngest and oldest being 25 and 83 years old. Most of the circumcisers, 75.2% were married, 18.4% widowed, 3.2% divorced and 3.2 were single. In terms of education level; majority-64.8% never went to school, 13.3% had attended Elementary Schools, 5.5% Quranic School, 3.9 secondary schools, 4.7% college and 3.9% university.f3
Figure 3: Level of education of FGM/C circumcisers
When it comes to types of FGM/C,86% 0f circumcisers defined them in four types.Pharonic Fatima(pharonic Fadumo) was defined as circumcision where parts of the labia minora and the labia majora are removed then pulled together through inserting stitches.Pharonic korus type was defined as cutting the labia minora and labia majora and then sewing and closing the vaginal orifice completely leaving a small opening for urine.Sunna kabeer type was described as similar to pharonic Fatima type but slightly different.Sunna Saqeer was defined as the genitals are made to slightly bleed and no stitches are inserted.
Figure 4: Types of FGM/C defined by circumcisers
Majority of the circumcisers,(78%) performed both Pharonic and Sunna type of FGM/C but Pharonic is least performed as compared to Sunna.The study also established that 22% performed only one type, that is ,15% performed Sunna only while 7% performed Pharonic type only. Most of the circumcisers pointed out that they don’t practice both Pharonic and Sunna kabeer because they cause much harm to the girls. For instance, there is so much cutting, bleeding, infections, loss of the menstrual periods, kidney problems and many others.
Concerning skills acquiscion to perform FGM/C, 41% acquired it from their peers or traditional birth attendants, 21% learned from their mothers, 18% got it their grandmothers and 10%learned from their aunts.
Most of the circumcisers (42%) perform the practice because it’s a way of earning a living, while 24% do it as a profession and skils that need to be perpetuated, 21% perform it because it is their heritage from ancestors, 8% do it because it is a religious obligation, 3% do it because it is out of social demand for the service and 1% practise it because their habit and norm.f5
Figure 5: Pulling factors that motivate circumcisers to continue performing FGM/C
As far as circumcisers’ opinion regarding FGM/C and Islam, 65% stated that pharonic types are forbidden (Haram) in Islam, whereas 26% said it was permissible (Halal), 8% of them did not know whether it forbidden or permissible. f6
Figure 6: Circumcisers opinion regarding Pharaonic type of FGM and Islam
As regards religious reward to circumcisers for practicing FGM/C was concerned, 69.4% believed that they will not be rewarded for continuing the practice while 27.4% believed they will be rewarded for practicing FGM/C.
The majority(51.9%) of the circumcisers did not doubt about the position of FGM/C in Sheria while 48.1% had doubts about FGM/C and its position in Sheria.Most(77.4%) of circumcisers have never had any discussions with fellow circumcisers regarding the position of religion on practicisisng FGM/C.Only 22.6% had discussions with fellow circumcisers.
Regarding the cultural factors and myths influencing the practice of FGM/C, 42% agreed that circumcision prevents girls and their families from being subjected to insults and shame, while 18% believed that circumcision adds value to girls.
Majority (58%) of circumcisers had heard positive stories about FGM/C when they were young. Those circumcised, their marriage, personalities and behaviour would be of high value than those uncircumcised. Other stories were like;’’The infibulated girl was clean to pray and the foods she cooks was fit to be eaten. However, 31% of circumcisers heard negative stories about uncircumcised girls, for instance their marriage would not receive applause from the community.
When it comes to preservation of Somali culture and tradition by practicing FGM/C, 88% of the circumcisers believed that circumcision was one of the pivotal elements in preservation of the culture while 8% did not believe. As far as the social prestige the FGM/c circumcisers are bestowed by the community, 92.5% stated that they received respect from the community while 7.5%did not believe in that concept.On the question of who was the main circumciser, 50% believed they are the main circumcisers while 50% said they represented the second main circisers.
As regards financial factors driving circumcisers into the FGM/C practice, each circumciser had on average provided FGM/c services to 17 households per year, and therefore, each had served on average 813 households since starting the practice. Majority(92%) of the circumcisers agrred that the most lucrative type of FGM/ was pharonic though leastly practiced they charged $35 per girl, while 8% believed that sunna earned them more which they charged $17 which was very much practised. Majority (53.8% circumcisers earned their living by practicing FGM/C, while 46.2% did not. Out of those who earned a living from FGM/C, 43.9% of them performed solely FGM/C, whereas 56.1% performed circumcision as well as had other jobs.Therfore; it was clear that practising FGM/C was a profitable business for circumcisers.
The average circumcisers’ years of experience were 17 years, and the range of their ages was between 25 to 83 years. The source of demand for FGM/C services showed that 58% demand was by mothers, 18% but both parents,8% by young men,7% by grandmothers,6% by young female adults,3% by the father and 1% by the circumcisers themselves.f7
Figure 7: Demand for FGM/C services
As concerns circumcisers’ demand when they relocate to new areas,67% asserted that they will not be able to get clients since there are already known circumcisers in the new locations.However,on the other hand 36.8% were confident that if they relocate to rural areas they will still have a market for their services.
There were three reasons given by circumcisers regarding reasons why they are abandoning FGM/C practice. The training circumcisers had received from anti-FGM/C workers, healthcare providers (doctors) and religious leaders (Sheikh) regarding the harmful effects of circumcision changed the perception and attitude of some of them regarding FGM/C, hence deciding to quit. Also some of the circumcisers were ready to quit the practice if and when sustainable alternative means of generating income were provided for them. One of circumcisers quit the practice when she was arrested put in prison by the police due to an over bleeding process she had performed on one of the girls that led to loss of a lot of blood.
The majority of the circumcisers (54%) did not face challenges in their working environment.However, 46% of the circumcisers faced problems such as; overbleeding, reopening and restitching whenever the opening was too small to pass urine, handling unconscious and fainting even coma cases. Due to lack of anaesthesia girls got injured i.e. cut elsewhere not intended, and even circumcisers themselves got injured in the process. There were also cases of infections which were blamed on the circumcisers. In the end some of them were not paid for the work done.
Between Pharonic and Sunna on one hand,67% of the circumcisers preferred Sunna to Pharonic.On the other hand 14.3% preferred pharonic to Sunna because they believed in a proverb that states: ‘An open pot or bowl is no equal to a pot or bowl that has cover and is shut.’ Which ment that those girls who had undergone pharonic were not exposed to risks or any harm, for instance, rape. Few of the circumcisers (0.06%) did not like(were afraid) to deliver women who had been infibulated because the process needed a lot of cutting and stitching them again and sometimes this led to fistula due to prolonged birth, hence this required medical practitioners which they were not. Some,(11.4%) of the circumcisers preferred all their jobs,0.038% did not like to perform circumcision and 0.009% did show whether were satisfied with their profession or not.
Potential alternative jobs circumcisers would prefer;93% preferred being given trainings to develop other marketable skills such as tailoring, improving their traditional midwifery skills, and the ministry of health(MOH) to employ them as traditional birth attendants(TBAs).They also in addition, income generating alternatives such as selling vegetables, small shops, charcoal kiosks and butchery. Those in rural areas needed their housing, more livestock and agricultural support provided for them if they were to abandon circumcision.f8
Figure 8: Percentage of circumcisers who will quit when given alternative jobs
On the financial prospects of practicing FGM/C in future, the majority (55.7%0 of the circumcisers believed it was decelerating because parents were turning to midwives, health workers and auxiliary nurses for circumcision.However, 41.3% saw it as promising. Most (95.5%) of the circumcisers would stop circumcisions if they got alternative source of income.f9
Regarding the future prospects of FGM/C, 66% were sure that it has a future in Somali community. This is because circumcised women are valued, and its only circumcision, more so infibulations as the only way the bridegrooms are sure their brides did not have sex before them.Uncirmcised women are subjected to redicule and are of less value in the society. Only 34% favoured uncirmcised women because those who underwent the process have more often than not developed health complications, for instance, passing urine, stitching and reopening, tears and cutting women receive when they get married and when giving birth.
In conclusion, most circumcisers (70%) favours circumcised girls, while 36% favour uncirmcised girls.
Most of the circumcisers reside in Maroodijeeh region as compared to other two (Togdheer and Awdal) regions.Thats, majority dwell in urban settings while fewer live in rural and semi-urban (IDP Camps) settings. The age of circumcisers ranges between 25-83 years old. Most of them were married, while others were widowed, divorced and single. In regards level of education, majority never went to school, while others attended elementary, quranic and secondary school, while fewer attained college and University education.
Majority of the circumcisers acquired circumcision skills from family members who included their grandmothers,mothers,or aunts, that is, the practice ran from one generation to the next through the family line.However,fellow peers who were FGM/c circumcisers or traditional birth attendants also played a key role in the transfer of the skills. The transfer of skills was confined within individuals living in the same village or in the refugee camps. Most of the circumcisers performed both pharonic and Sunna type of FGM/C.Sunna type of FGM/C is more performed than pharonic type. Circumcisers don’t perform pharonic and Sunna kabeer types because they cause so much harm to the girls.
Most circumcisers continue to practice FGM/C because they want to earn a living.Also, the practice is perpetuated because it is a profession and skill, it is their heritage from the ancestors and also as a religion obligation. In regards to religious factors there is a difference in religious belief regarding FGM practice the pharonic type of circumcision, some assert that pharonic type of FGM/c is allowed while to others FGM practice generally has a religious reward. None of the circumcisers could quote a verse from Quran or hadith to justify their religious basis for practising FGM/C and receiving reward as a result. There is also a mixture of view among the circumcisers regarding punishment by religion if they discontinued practising FGM/C.Most of circumcisers have no doubts about the position of FGM/c in Sharia while some have doubts. Cultural factors encourage perpetuation of the practice because failure to circumcise girls leads to stigmatization and insults from the community. Also the practice protects girls from engaging in sexual activities with men before marriage, and also from being raped or getting pregnant. The practice thefore prepares the girl for marriage and is embraced by the community and the husband to be positively. In respect to financial motivation, GM/C is a profitable business and circumcisers earn more when they perform pharonic in spite of its harmful health consequences. Despite having alternative sources of income some of the circumcisers still perform FGM/C.
Majority of circumcisers are not able to provide services whenever they relocate to new places because they are not known and also there are already circumcisers who are known in those areas. The trainings circumcisers received from anti-FGM/c workers, health care providers and also religious leaders (Sheikh) regarding the harmful of circumcision changed their perception and attitude regarding FGM/C made some to quit. Some who were provided with alternative means of generating income opted out of the practice. Some who through their operation resulted into complications and therefore being arrested by the police and ending up in prison had to quit the practice.
As far as alternative skils and profession circumcisers preferred if they abandon circumcision is concerned, most of them preferred being trained to develop other marketable skills such as tailoring and midwifery, then alternative income generating activities like selling vegetables, small shops, charcoal kiosks and butchery.However,the majority of the circumcisers favoured circumcised girls in the future.
The change of perception, attitude and practice towards abandonment of performing FGM/C depends on three key factors namely financial, religious factor and cultural factor. The outstanding factor is the financial aspect; therefore, provision of alternative source of income will be vital towards eradication of the practice. Outcome –focused programs should be developed to create alternative job opportunities for the circumcisers, A pilot project can be initiated to determine if the strategy will be feasible, however, the following considerations should also be made:
FGM/C is a profitable business and circumcisers who put down their tools may not be able to maintain their promise and when a group of circumcisers abandon the practice, others come forward to provide the services, income generation and loan programs require resources, time and commitment to succeed and often diverts attention from anti-FGM/C program implementation.
Focus on the circumcisers promotes their status and role in the society instead of exposing FGM/C as a harmful act.therefore,focusing on creating alternative sources of income as the sole strategy of eradicating FGM/C may not be feasible enough to eradicate the practice.Therefore,there is need to apply an integrative and multi-level approach by using all key actors and stakeholders that influence the practice in order to change the perception and attitude which is the proximate factor rather than focusing on financial aspect.
Though the study showed the transition change from pharonic to Sunna type of FGM/C rather than abandonment, key actors can still play a major role in campaigning towards total abandonment of all types. The key actors should include: Anti-FGM/C actors, religious leaders, health care professionals and the government which should also enact policies and laws that will punish circumcisers to discourage perpetuation of the practice.
Due to high level of illiteracy among the circumcisers, logical reasoning and critical thinking skills may be impaired which might affect their ability to make rational decisions to abandon the practice.Hence, trainings and awareness raising should also include literacy modules and critical thinking skills to develop their ability to make appropriate decisions.
The study also found out that majority of the circumcisers acquired the skills from family members.Hence anti-FGM trainings focusing on circumcisers should also include the family members in the trainings to ensure they are well informed about the ill effects of the practice and thus discourage transfer of skills across family lines.
The recently developed model by NAFIS Network called the’’12 champions model of change’’ can be an integrative approach that can bring together key players who can lead the process of change towards total abandonment of FGM/C.
There is need to conduct further studies on how best FGM/C circumcisers can be involved in leading the change process towards total abandonment of FGM/C.
The study report download from here
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