Nahid

[*] , Pamela Green, Eiman Sharief

Nahid Toubia, MD, is President of RAINBO (Research, Action,

and Information Network for Bodily Integrity of Women).

Linda

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.

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Introduction��

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.

Female

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 20^th

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.

During

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).