FGM in Eastern Ethiopia: why is it prevalent and what should we do about it?

March 02, 2022

FGM in Eastern Ethiopia: why is it prevalent and what should we do about it?

According to WHO definition, female genital mutilation (FGM) refers to all procedures that involve partial or total removal of the external female genitalia, or other injury inflicted on the female genital organs, for reasons that are not medical. WHO classified FGM into four major parts. Type I: “Sunna”/clitoridectomy is the partial or total removal of the clitoris and/or the prepuce. Type II: Excision is the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type III: Infibulation is the narrowing of the vaginal orifice with a creation of a covering seal by cutting and repositioning the labia minora and/or the labia majora, with or without excision of the clitoris. Type IV: All other harmful procedures to the female genitalia for nonmedical purposes (eg, pricking, piercing, incising, scraping, and cauterization). The practice is mostly performed on girls between the ages of 0 and 15 years.

In 30 African, the Middle East, and Asian countries where FGM is common, >200 million girls and women alive today have been cut, and 3 million are at risk for the practice each year in Africa. The practice is internationally recognized as violation of the rights of both girls and women. It reflects a culturally deep-rooted inequality where there is an extreme form of discrimination between sexes. All types of FGM have immediate (short-term) and long-term health complications depending on the type performed and the hygienic conditions. Immediate health complications include severe pain, excessive bleeding, genital tissue swelling, shock, and death. Long-term health complications include urinary problems, infection, menstrual problems, sexual problems, infertility, psychological problems, increased risk of childbirth complications, and newborn deaths. A study in six African countries also revealed that women who underwent infibulation type of FGM were more likely to have a caesarean section with extended hospital stay, postpartum hemorrhage, and perinatal death.

Female genital mutilation (FGM) is a worldwide problem, and it is practiced by many communities in Africa and Asia as well as immigrants from those areas. Like many other developing countries, FGM is widely practiced in Ethiopia, especially among Somali, Afar and Harari ethnic groups. Despite intensive campaigns against FGM in Ethiopia, since 2011, it is still being practiced in these communities. In Ethiopia, FGM is mainly carried out by traditional birth attendants or traditional “doctors,” normally old women, who are paid in cash, or in kind, for executing the process. This practice is one of the biggest contributing factor for the high maternal mortality in the country and is considered as a major national public health problem, as it affects not only the physical and mental well-being of more than half of the Ethiopian population but also the socioeconomic development of the country.

According to the Ethiopian Demographic Health Survey, the estimated prevalence of FGM in girls and women (15–49 years) was 74.3%. However, there is a great variability in the prevalence of FGM among different regions in Ethiopia, ranging from 29% and 27% in Tigray and Gambela regions, respectively, to 82% in Harari and 97% in Somali regions. Similarly, the reason for the practice varies among ethnic groups in Ethiopia. Many Ethiopian ethnic groups perform FGM as a rite of passage. Contrastingly, the Somali and Afar ethnic groups perform FGM with the belief that it is required by religion and a means to ensure virginity.

Reasons for the practice of FGM

In Somali region, the most important reason reported regarding FGM is a requirement for marriage. Participants in a research that was published in Dove Press about the attitudes around FGM in Eastern Ethiopia reported that the community prefers the infibulation type for marriage. However, the findings indicated that in recent days, the majority of young discussants preferred to marry an uncircumcised girl while men who supported the continuation prefer the “Sunna” type. Those discussants who supported the infibulations type stated:

· “If the bride is not infibulated, the Somali man, after digging a hole in front of the door of the bride’s family, returns her to her parents. This is to mean “your daughter is open like this hole, so I don’t want open girl because she is not virgin and she will not be faithful to her husband.” This act totally disappoints the family and results in a heavy depression on their side. That is why the society practices infibulations until recent time.” [a 56-year-old male Somali]

· “A Somali man who lives in America came to marry a girl from Somali region. He asked his relative to find him a girl who has undergone infibulations believing that infibulations is the set criterion to select a girl for marriage. His father found him one beautiful girl and performed all the procedure that should be finalized before the marriage ceremony takes place. However, after the marriage ceremony was carried out, the father finally learned that she was uncircumcised; he soon returned her to her family. I still remember how much the girl’s family was saddened.” [a 55-year-old female Somali]

In Harari region, circumcision is not considered a criterion for marriage. The major reason for circumcision to be performed was claimed to make the girl calm and sexually inactive so that she can be faithful to her husband. However, the results of a study revealed that these days the vast majority of the Harari people are convinced that circumcision is unnecessary, and the majority of them claim that they will not circumcise their daughter in the future. A 45-year-old male Harari who supported the reason stated:

· “I don’t know what was in the past, but to my knowledge we did circumcision to calm the girl. If she is not circumcised, she will be sexually active, and as a result, she will not be faithful to her husband.”

Nonetheless, some research participants argued against their counterparts with the following assertions:

· “What people say about FGM is simply that it is a harmful traditional practice the community performs without being aware of the consequences. I think what is said about the effect of circumcision on a girl (that it makes her calm and sexually inactive) is false. If it were true, an uncircumcised girl would exhibit extraordinary sexual behavior.” [a 30-year-old male Harari]

· “Yes, it is not the clitoris, which makes girls active or not, it is the environment, the family, and the friends which control their behavior. If we need a better generation, we have to work on the education of our girls. If they are educated, they know what to do and what not to do. I, personally, will not circumcise my future daughter, and I will teach to all my friends that it is a harmful culture which should be stopped.” [a 26-year-old male Harari]

FGM as a religious requirement

The majority of the people in these regions believe that, except the “Sunna” type of FGM, excision and infibulations are not religious requirements. “Sunna” gained great support from the religious groups that follow or favor it. There were a lot of disputes or debates among groups on whether or not “Sunna” should be considered a religious requirement in Somali region. Nonetheless, after a long deliberation, they reached consensus as “Sunna” should be regarded as a religious requirement. The following statements of research participants substantiate this:

· “In the Muslim religion, we believe that if we are not circumcised, we feel that we are totally against our religion. Allah will never accept us whatever we pray. This is the reason we allow our daughters to practice FGM.” [a 56-year old-female Somali]

· “The community believes that it is a good culture and they have to pass their daughters through circumcision. Even if “Sunna” is supported by our religion, the society believes that all circumcisions are considered religious requirements. The majority of the families in Somali region believe that they will not get benefits during marriage and their daughters will never get married unless they have gone under circumcision.” [a 60-year-old male Somali]

· “Sunna” is supported by our religion, but there is nobody who knows how to perform the “Sunna” type of circumcision. If we let the circumcisers do it, they will do the excision or the infibulations type because they are good in doing them (excision and infibulations). So, they can’t do the “Sunna” type as this type of circumcision deals with cutting the tip of the clitoris. Hence, it needs training.” [a 45-year-old male Somali]

The majority of the participants in Harari region confirmed the belief that FGM is not a religious requirement and nothing is written about female circumcision in Quran and in the Bible. Two participants stated that “Sunna” type of circumcision is not supported by religion.

· “I believe female circumcision is not a religious requirement; it is just a common tradition. As I am a member of the young generation, I have to teach the community. My friends and I do not believe that the “Sunna” type is a religious requirement.” [a 27-year-old male Harari]

· “People say that the “Sunna” type is supported by religion. Since I am a religious leader, I know my religion very well and teach Quran, but I didn’t come across any text which supports “Sunna” as a type of circumcision that represents Islam. I was, even, asked in many training centers and I explained what I know. On my part, “Sunna” is not a religious requirement. Whatsoever the case might be, I don’t support any type of circumcision.” [a 55-year-old male Harari]

Attitudes toward continuation of FGM

The majority of female participants from Somali region strongly supported the continuation of the practice of FGM. Despite the harmful effect of FGM, mothers in Somali region allow their daughter to go through the procedure fearing the stigma and the discrimination. This is because where almost all the women have been circumcised, being uncut has become a social stigma, as uncut woman may have little chance of getting a husband. Thus, it is not surprising that there is pressure by mothers and relatives to allow their daughters to undergo female circumcision. Some discussants from the Somali region stated the following to express their support for the continuation of FGM practice:

· “We Somali women know the harmful effect of FGM. We are suffering throughout our life. Despite all this, no Somali mother wants her daughter left unmarried due to this existing culture, “Marriageability” that is why we support its continuation.” [a 52-year-old female Somali]

· “It is our culture and supported by our religion. If you ask each family independently, nobody agrees with the abandonment, because it affects the family’s honor.” [a 42-year-old male Somali]

· “Yes, I am also supporting my friend’s idea; it is difficult for the Somali people to abandon FGM within a short period of time. If we think FGM has severed health effect, let us shift it to the less harmful type (Sunna type).” [a 45-year-old female Somali]

There are a few women who have a negative attitude toward the abandonment of FGM from Harari region. One of these women’s expressions was:

· “I personally do not accept the total abandonment of FGM from our region, because it is our culture.” [a 52-year-old female Harari]

This study revealed that mothers are the decision makers to female circumcision in both the regions. The majority of the participants explained that mother plays a major role in female circumcision. An initial assumption is that they want to optimize their daughters’ future prospects, and also have a fear of violating the tradition. This finding is similar to another finding, which states that mothers or grandmothers were the major ones who organize circumcision to their daughters. Another similar study also supports this finding in which the majority of the circumcisers who circumcised women in secret places were women themselves. This surprisingly suggests that women are both the victims of FGM as well as the victimizers. FGM in Somali and Harari regions of Ethiopia is performed only by traditional female circumcisers as it is believed to be their source of income. Because circumcision is regarded as the business and irreplaceable source of revenue, female circumcisers delegate their daughters to perform the procedure regarding circumcision which further continues the cycle of this harmful practice.

Because of the reasons discussed above, FGM continues to be highly practiced in eastern Ethiopia. Aside from the religious ties to this practice, strong ancestral sociocultural roots also contribute to the prevalence of FGM in these regions. Most other regions in Ethiopia, though still having cultural ties to this practice, don’t perform it as regularly since it’s not that deeply enshrined in their rituals and activities around marriage. For instance: the rate of FGM in Tigray is less than 29% and when compared to women in this region, Somali, Harari and Afar women are three to four times more likely to undergo this procedure. When it comes to research around the issue, findings have shown that the risk factors for increased prevalence are wealth, increasing age, rural residence and having Islamic faith while protective factors are maternal education. Compared to women with no education, FGM prevalence is significantly lower for women who attended primary, secondary and tertiary level education. Also, compared with traditional religious belief, women of Muslim faith have a higher prevalence of FGM. Two other main factors that contribute to the prevalence of FGM were unemployment and lower household wealth. In conclusion, I believe the higher rates of FGM in the Somali, Harar and Afar when compared to other regions are due to the lower rates of literacy and employment for women as well as the prevalence of Islamic belief and people’s association of those teachings with the practice of FGM. This is aside from deeply rooted cultural norms and the value that is assigned to circumcised and virgin women as a prerequisite to evaluate their marriageability.

Attitude toward discontinuation of FGM

Some male research participants from Somali region and the majority of the participants from Harari region had positive attitude toward the abandonment of FGM. Young discussants in both the regions had an intention to marry an uncircumcised girl and a positive attitude toward the discontinuation of FGM. The discussants stated the following while expressing their support of discontinuation of the practice from Harari region:

· “Previously, we used to hear that girls did not want to be friends with uncircumcised girls thinking that it was a shame as it was regarded as disrespecting their religion, but these days the situation is changed. If a girl is circumcised, the uncircumcised ones ignore her and they don’t want to be her friends. I personally support the discontinuation of the practice.” [a 25-year-old female Harari]

· “Previously we were told by our mothers and grandmothers that we will not get married unless we go through this harmful tradition, but these day’s some of our uncircumcised friends were married. We females do not need to be circumcised, we need the total abandonment of the practice.” [a 20-year-old female Harari]

· “It is enough; let our daughters live healthy life. Why do we damage them? I strongly support the discontinuation of FGM from our region.” [a 30-year-old female Harari]

· “Yes, I support the abandonment of FGM from our region. When I was a kid, my grandmother told me that FGM is a good practice for girls. But I hear and see that me and females in my age, in my village, are suffering a lot due to the harmful effect of FGM. We do not like it, but we are silent due to fear of the community.” [a 28-year-old female Harari]

Likewise, Somali men expressed their feelings supporting the discontinuation of the practice as follows:

· “I personally learned a lot about the harmful effect of FGM. I have two daughters, 3 years and 7 years old. I did not want my daughters to go through this harmful traditional practice. But my wife took them far for vacation and did the circumcision without my knowledge. So, knowing the harmful effect has no meaning unless we all are united to abandon the practice from our region.” [a 35-year-old male Somali]

· “What I wanted to say is we know that FGM is a well-established culture. We cannot say we can bring about a change within a short period of time. We Somali people believe that our daughters will not get husbands unless we do the required procedure. But I believe that today’s situation is by far better than that of the situation that existed long ago. So, let us work together and do our level best to bring about desirable and sustainable changes.” [a 45-year-old male Somali]

Considering culture and tradition as the main bottleneck for change, one young discussant strongly suggested on the behavioral change of mothers:

· “I agree on the discontinuation of FGM, but first, it is women who hold the key to ending the practice.” [a 30-year-old male Somali]

Curative interventions

When a social convention or a social norm is in place, decision-making is an interdependent process, in which a choice made by one family is affected by and affects the choices made by other families. This implies that parents choose what is best for their daughters and get them ready and prepared for a proper marriage. On the other hand, an uncircumcised girl will have a problem with getting married and will be socially rejected. Under these circumstances, FGM can be seen as the best way for the parents to ensure marriageability. Even the girls wish to be circumcised to get acceptance by the society. As studies have reported, men are the major supporter of the discontinuation of the practice. Hence, their preference for marriage will be the uncircumcised girl. In this case, when circumcision will no longer be a criterion for marriage, mothers will be free from stigma and discrimination by not doing the procedure. Thus, involving both males and females in the anti-FGM campaign should be a priority issue in abandoning FGM from the region.

There needs to be a lot of work done in the Somali, Afar and Harar regions for the fight against FGM. Female genital mutilation is a firmly constituted cultural practice in these regions. Due to this reason, it is obviously difficult to stop it within a short period of time. It is the old belief or culture mothers uphold that makes them perform FGM without considering the danger and the problem it involves. This reveals that creating awareness, time and again, is extremely essential to bring about desirable behavioral changes on the society to achieve the desired goal of banning and eliminating female circumcision. Because of this, awareness raising seminars and workshops are usually organized for the community at school level through the youth and women’s associations in these regions. The government also provided loans to circumcisers in order to enable them create other types of jobs for themselves. Furthermore, the government started to implement Articles 565 and 566 of the already existing penal code that makes FGM practice punishable by imprisonment from 3 months to 10 years. All of these efforts are commendable and should be continued to be enforced on a regular basis.

A study by the United Nations International Children’s Emergency Fund states that FGM is performed in line with tradition and social norms and to uphold their status and honor of the entire family. Therefore, in order to bring significant change, women are potentially the best agent in the abandonment of FGM if they are educated and empowered. This is because the prevailing socioeconomic dominance of men on women limits the ability of women to oppose FGM, and thus, a substantial change in women’s attitude is likely to occur only through education and women empowerment. Another effective way of raising awareness is through drama and music. People will be very interested in obtaining information or getting lessons communicated via drama and music to make audiences internalize the needed information. There are some shocking stories and places to be heard and seen where the harm of FGM was performed. So, it will be a good teaching aid and convincing strategy to use. For instance, a 60-year-old male Somali in the study expressed his memory on the harmful effect of FGM as follows:

• “Female genital mutilation was common in the old days. I remember there is a place which we call “YESETOCH MEKABIR” (Women’s Grave). This is to mean 8 women had been circumcised on one day and all of them died on the same day, and were buried in one place. That is why the place is called “Yesetoch Mekabir” (Women’s Grave). By showing this place and teaching the community the health risk that mutilation involves, we can bring about desirable behavioral changes.”

Another study done in the Hargeisa district (Somalia) states that men are more likely to support the continuation of the practice than females, and the vast majority of men preferred to marry circumcised women. This may be due to the reason that many religious leaders in Somalia defend that the Sunna type is a religious requirement and is harmless. In such areas where religion is the major reason for the perpetuation of this practice, FGM abandonment is difficult. This is unless we involve religious and community leaders in the campaign to fight the practice and strengthen the national laws against FGM. In contrast, majority of the participants from Harari region, who did not support FGM, stated that the practice was contrary to religious precepts and, moreover, had received information in mosques and churches in favor of the abandonment of FGM. There positive outlook towards this abandonment further proves the need for the cooperation of religious leaders in the anti-FGM campaign.

The best approach to end FGM is to address behavioral changes through creating a common understanding among the entire community. The stigma and discrimination that allow the practice to continue will be tackled by the social convention theory. According to the theory, it is described that performing FGM is an equilibrium state in which decisions made by one family is interdependent on decisions made by other intermarrying families in the communities. When this happens, we can say FGM is a social convention, it has become a social rule that all the people in this community have to follow, and it is based on the expectation that the other has done the same. It is difficult to abandon the practice alone because that will affect the future marriage prospect to the daughter. But if all families in one community choose to not support the FGM procedure, then circumcision would not be an issue for being marriageable, and they can avoid harming the girl’s health. According to this statement, the challenge is for families to move together. Families will abandon FGM only when they believe that all others will make the same choice. And for the sake of the physical, emotional as well as mental health of the women in that society, this should be given a top priority and actively improved and continued.