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Methods, Models And IndicatorsTo Measure Progress In Stopping Female Genital Mutilation


    Models And Indicators

    To Measure Progress In Stopping Female Genital Mutilation


    Toubia, Linda Morison, Jane Chege

    [*] , 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,

    South Africa.

    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

    these operations

    into three main types (WHO, 1998). See

    Figure 1.


    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 1990’s 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:

      1. Discuss

        challenges of gathering reliable prevalence and incidence

        data to monitor changes in FGM practice.

      2. Discuss

        models to measure change in FGM behaviour and identify criteria

        for defining “success” of interventions.

      3. Apply

        these criteria to evaluate interventions implemented so far

        and their relative degrees of success.

      4. Utilise

        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).