Models And Indicators
To Measure Progress In Stopping Female Genital Mutilation
[*] , Pamela Green, Eiman Sharief
Nahid Toubia, MD, is President of RAINBO (Research, Action,
and Information Network for Bodily Integrity of Women).
Morrison is Senior Lecturer at Medical Statistics and Epidemiology
Division, London School of Hygiene and Tropical Medicine.
Jane Chege, PhD is Program Associate at Population Council, Johannesburg,
Pamela Greene, PhD, is Director of Programmes, Marie Stopes Society,
Freetown, Sierra Leonne.
Eiman Sharief, MSc PH, is Senior Programme Officer, RAINBO.
It is estimated that around 130 million women worldwide have undergone procedures
involving removal of female genitalia for cultural or other non-therapeutic
reasons and that these procedure are performed on a further 2 million girls and women every year (WHO 1998). The terms female circumcision, female genital mutilation
(FGM) and female genital cutting (FGC) have been used in the literature
and will be used interchangeably throughout this paper to describe
these procedures. The World Health Organisation (WHO) has categorised
into three main types (WHO, 1998). See
circumcision is predominantly found in North East Africa and in
sub-Saharan African countries north of the equator.� The practice
and type of operation is often specific to particular ethnic groups
so that prevalence varies greatly within and between countries.
Around 85% of operations are thought to be Type I or II, with
the other 15% consisting of infibulation (Toubia 1993). It is
usually performed on girls or young women under non-sterile conditions
by traditional operators, but more recently medical professionals
have become involved, especially in urban areas.
The earliest documented efforts against
the practice are found in the first half of the 20th
century, in laws enacted by colonial administrators. These had
little effect other than outcry by the local communities (Rahman
and Toubia 2000). Later, the emerging medical establishment in
newly independent Africa generated information on the harmful
effects of the practice based on clinical studies mostly of infibulated
women. (Shandall1967; Rushwan 1980; Abdel Aziz 1980)
This paved the way for international involvement
particularly through the World Health Organization (WHO) who organised
a conference in 1979 (WHO/EMRO 1979) in which a resolution was
passed to eradicate not only infibulation but all
forms of female circumcision. This was counter to some who argued
for medicalisation of milder forms. The increasing involvement
of the international community was not without controversy and
questions arose about the right of outsiders to get involved in
changing the culture and traditions of others and the form that
involvement should take. In 1984, the United Nations supported
the formation of the Inter-African Committee against Harmful Traditional
Practices (IAC). This was an acknowledgement by the international
community that efforts against the practice should be lead by
African women. The IAC, which has around 26 national affiliates,
adopted education on the health risks of female circumcision
as its main approach, targeting communities and sometimes practitioners.
A fundamental problem with an anti-FGM
effort based on messages about health risks was the consequence
it produced of diverting the practice to midwives, nurses and
doctors (medicalising) to reduce or eliminate the health risks.
Similarly, while the high prevalence and severity of health risks
associated with Type III operations is not doubted, questions
have been raised about how common the severe physical effects
of Types I and II are (Obermeyer et al 1999; Morison et al 2001).
The importance of a rights-based approach, rather than an over-emphasis
on health risk, has therefore become increasingly apparent. The
rights-based approach opposes FGM on the basis of women’s and
girls right to bodily integrity and psychological and sexual
health, regardless of physical complications.
the 1990s other technical and advocacy organizations entered
the field of FGM trying out new intervention approaches or modifying
old ones. In 1999 WHO with the assistance of PATH documented the
global situation in terms of anti-FGM efforts (WHO/PATH 1999).
In 2001 the Population Reference Bureau developed a web-based
synthesis of current information on prevalence, attitudes and
efforts to end the practice (PRB 2001). This paper reflects part
of the work undertaken by the technical and advocacy organisation
RAINBO together with a group of researchers and advisors to analyse
the content and effects of some of the approaches used in the
past twenty years in closer detail.�
The objectives of this paper are to:
challenges of gathering reliable prevalence and incidence
data to monitor changes in FGM practice.
models to measure change in FGM behaviour and identify criteria
for defining success of interventions.
these criteria to evaluate interventions implemented so far
and their relative degrees of success.
the information gathered in objectives 2 and 3 to propose
indicators to evaluate and monitor progress.
The proposed indicators are part of a suggested
framework being developed for design and evaluation of future
interventions targeted against the practice of FGM. A
full description of the framework is described in the report of
the technical consultation (RAINBO 2002; Toubia and Sharief 2003).
The work of RAINBO and the international
technical committee (ITC) was based on a review of literature,
most of which consists of reports rather than peer-reviewed papers,
evaluating FGM interventions. It also incorporates personal experiences
and research of the ITC members as well as synthesis of presentations
and discussions that took place at a technical consultation workshops
in Cairo in May 2001 (RAINBO 2002).