Where Have We Been and Where are We Going Approaches to Abandoning Female Genital Cutting

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Where Have We Been and Where are We Going?
Approaches to Abandoning Female Genital Cutting
U.S. Agency for International Development
MAQ Mini-University, Washington, DC
May 12, 2003
Abdelhadi Eltahir, MD, MPH USAID/GH/PRH
Julie Chitty, RN, MS, FNP-C, MPH USAID/GH/RCS
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Definitions
FGC is a harmful, traditional practice that
violates the health and human rights of women and
hinders development (USAID FGC Policy)
FGC is a variety of operations involving partial
or total removal of the female external genital
organs
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Types of FGC

• Type 1- Cutting of part or all of the clitoris
  (Clitoreditomy)
  
• Type 2- Cutting of the clitoris with partial or
  total excision of the labia minor/small lips
  
  
• (Excision)
• Type 3- Cutting of part or all of the external
  genitalia and stitching/narrowing of the
  
• vaginal opening (Infibulation)
• Type 4- Unclassified. A group of other procedures
  on the external genitalia, including
  
• pricking, piercing, stretching or
  incising the clitoris or labia or both
  
• cauterization incision to the vaginal
  wall scraping or cutting or both of the
  
• vagina and surrounding tissues and/or
  the introduction of corrosive
  
• substances or herbs into the vagina.

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Why is FGC performed?
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Who performs the procedure? Ethiopia, 2000
Stan Yoder, MACRO, DHS
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Who performs the procedure? Nigeria, 1999
Stan Yoder, MACRO, DHS
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Who performs the procedure? Egypt, 2000
Stan Yoder, MACRO, DHS
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Where FGC/FGM is reported
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FGC Prevalence among women 15-49 yrs
Egypt 97 Djibouti 98 Sudan 89 Eritrea 90 E
thiopia 85 Somalia 98 Sierra Leone 90 Mali 9
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Gambia 80 Guinea 98
18.2
Chad 60 Burkina Faso 60 Benin 50 Liberia 60

Guinea 50 Togo 50
0.7
2.6
0.9
2.5
7.9
2.3
1.9
0.2
0.3
2.7
1.9
0.3
2.1
27.2
14.9
1.1
5
0.9
3.9
3.6
0.8
1.6
1.1
Kenya 50 Central AR 43 Nigeria 40 Ghana 30

Cote dIvoire 43 Mauritania 25
5.3
7.9
11.5
8.7
Uganda 5 DR of Congo 5 Tanzania 10 Cameroon
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Niger 20 Senegal 20
Figures in countries are total numbers of women
in millions
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FGC is a Multi-Sector Issue
Protecting human rights is a major component for
sustaining democracy, African women have decided
that FGC is a human rights issue and its
elimination efforts will be more successful if it
is embarked on from a human rights perspective.

• DEVELOPMENT
• POLITICAL
• GENDER
• HUMAN RIGHTS
• HEALTH

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FGC is a Health Issue
Immediate Health Consequences
Pain, hemorrhage, shock, acute urine retention,
infection, and failure to heal.
Long term consequences urinary tract infecti
on, dermoid cyst (pictured), pelvic infections,
infertility, keloid scars, dyspareunia, fistulae,
and obstructed labor. Mental and Psychosocial
Impact
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FGC Violations of Human Universal Rights

Human Rights (1948) Childrens Rights Convent
ion (1989) Elimination of Violence against Wom
en (1993) Womens Rights (1979) Discriminat
ion against women (1990) The Banjul Charter (19
81) African Charter on Human and Peoples Rig
hts

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Legislations Against FGC in African Countries
Guinea - 1965 Ghana - 1994 Burkina Faso - 19
95 Djibouti 1995 Egypt Ministerial Decree 19
97
Ivory Coast - 1997 Tanzania - 1998 Togo - 1998
Senegal 1999
Benin2003 Niger2003
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Medicalization

• USAID Policy on FGC Medicalization
• Under no circumstances does USAID support the
  practice of FGC by medical personnel
  
• Prevalence remains high
• Legitimization of the practice
• The long term effects remain

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USAID Policy on FGC Medicalization
Under no circumstances does USAID support the
practice of FGC by medical personnel
USAID FGC Policy
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Disadvantages Mitigations of Medicalization
Disadvantages Prevalence remains high Medical
ization legitimizes the FGC practice
The long term effects remain Psycho-social
disturbances
Mitigations Reduces pain temporarily Decrea
ses hemorrhages
Decreases infection
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Approaches to Date

• Health Risk Approach ? Medicalization
• Conversion Strategy Educating circumcisers and
  providing them with alternative income
  
• Law Enforcement as Vertical Intervention

• Alternative rites of passage
• Participator Education Program for Women
• Positive Deviance Approach
• Integration and awareness raising of RH/FP
  Program
  
• Vertical Institutionalization

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Lessons Learned

• Sensitizing groups of people and adapting
  anti-FGC messages to fit the local context
  Policies and interventions must fit the local
  context and must adapt or be adaptable to
  cultural norms regarding rites of passage
• Integrating FGC abandonment into a range of
  social and economic development initiatives that
  focus on womens empowerment
  
• Developing alternative rituals to substitute for
  cutting ceremonies
  
• Empowering women through participatory techniques
  to collectively decide about FGC and negotiate
  community support
  

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Lessons Learned cont

• Involving community stakeholders in discussions
  to evaluate the costs and benefits of continuing
  or abandoning FGC
  
• Validating and praising individuals who have
  challenged or deviated from conventional societal
  expectations and explored successful alternatives
  to cultural norms, beliefs or perceptions
• Working with health workers to help them treat
  FGC-related complications and to empower them to
  be advocates against FGC for medical,
  psychological, and human rights reasons

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Examples

• TOSTAN APPROACH
• Participatory Education for Women Empowerment
• Literacy training
• Analytical skills and problem solving
• Health Information
• Human Rights principles
• RITES OF PASSAGE APPROACH
• A structured program of activities with
• Community-level sensitization
• Public rituals including training for girls in
  family life education (FLE)
  
• Public ceremony similar to traditional rites
  without cutting the girls

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Expansion Integration
Ethiopia Horizontal Expansion
Mali Vertical Institutional-ization
USAID Mission Pathfinders CARE
PRIME
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Principles of Positive Deviance Approach

PD Major Knowledge Strong Belief Advocacy skills
Identifying more PD
Encouragement by NGOs
Mobilized PD
Community
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USAID Funded Activities by Cooperating Agencies
Mali PRIME
Egypt CEDPA Pop Council
Burkina Faso FRONTIERS
Sudan CARE
Senegal FRONTIERS TOSTAN
Ethiopia CARE USAID Mission
Kenya CARE FRONTIERS, PRIME
Guinea FRONTIERS
Nigeria PCS, FHI
Ghana Navrongo RC Pop Council
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Conducive Environment for Total FGC Abandonment
Integration into other programs
Multi-sector approach Consistent and tiered p
rogramming Anti-Medicalization Efforts Politic
al will Anti- FGC Legislation Increasing role
of Men and Religious leaders
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Future Directions

• Comprehensive approach
• Integration
• Focused high-priority countries
• Mission integration of FGC into the program