Health Education and Female Genital Mutilation

by Marina Koch

“FGM is not the cut, FGM is a process…know that it does not start the day a woman or a girl is mutilated or cut, it is a process that begins from the day a girl is born”-Asenath Mwithigah1

Female genital mutilation (also referred to as FGM, female circumcision, or cutting) has been practiced for thousands of years, and although mainly practiced in the Middle East and sub-Saharan Africa2 , there have been cases recorded in almost every continent. A female mummy from 5th century BC was found circumcised, 19th century institutionalized English women were sometimes subjected to the practice to “cure” masturbation3 , and for many cultures today, the practice of female genital mutilation is still an important rite of passage; for purposes relating to marriageability, fertility, and claiming one’s identity as a woman. FGM has a long, storied history that ranges in meaning from place to place, and is often sought to be protected by groups for the sake of preserving tradition, or - because in some areas it is believed to be required to conceive and/or birth a child or to be accepted in society - as a necessary measure for both the health and safety of the woman. Many groups, however, have developed strong oppositional campaigns to the continuation of the practice, and have demanded that the risks to emotional and physical health be recognized by legal, medical, and human rights institutions. In the 1990s, awareness of FGM started to grow, and in December of 2012, the United Nations General Assembly instituted a ban on FGM3 . As of today, it is outlawed in 84 countries2 , but this has not, unsurprisingly, eradicated the practice. In an effort to decrease the prevalence of FGM, many countries have utilized health education programs, in the hopes that providing communities with information on why FGM is harmful will spark a rejection of the tradition.

Health education programs have a history of being composed of volunteer groups from wealthy Western countries going into developing countries and delivering information in a way that is, unconsciously or not, infantilizing to the people they are addressing. In the early years of these programs, they often made assumptions that people who had been practicing FGM for hundreds of years didn’t know the health risks, or that every community practiced the same type of FGM, for the same reason4 . This colonially reminiscent tactic from advocates who sought to end FGM by stressing that it was a women’s health issue, fostered distrust in many communities. Thus came the shift to viewing FGM as a human rights issue, rather than a health issue. Despite this shift, health education remains one of the most prominent tactics of non-governmental organizations (NGOs) working to end the practice.

In the past, health education programs have proved successful regarding issues like HIV 5 and the Ebola virus6 , showing that the more a population learned about a health crisis, and how to prevent them, the fewer cases occurred within that population. In Pauw et al.’s study of a “household-based health education intervention” 5 that focused on HIV/AIDS prevention in Managua, Nicaragua, they found that condom use increased from 9% to 16% for women who had been a part of the program (VS a 2% increase in women who hadn’t been) and an increase of 31% to 41% for men who had participated5 . In Sudan, a study was conducted on how the amount of health education provided to medical professionals in the area and the general population, affected the severity of Ebola outbreaks in the country. Because “the prevalence of any epidemic is strongly dependent on the social behavior of individuals in a population”6 , the focus of many health education programs on Ebola was to approach loved ones of the dead or dying and provide information on how the disease is transmitted and how to avoid contracting it in both private settings and hospitals. The results of the study showed that health education programs contributed to having far fewer cases in the 1979 outbreak than in the 1976 outbreak6 . In many cases, health education programs have been shown to help decrease fear and myths surrounding health issues and increase awareness of prevention methods and treatment options.

There have also been cases of health education programs failing to help end a health crisis, and in some cases, worsening them. One of the most well-known examples of this phenomena was the introduction of the condition (and maybe more importantly, the term) anorexia nervosa to the Eastern hemisphere. In the mid-90s, a young Chinese girl, Charlene Hsu Chi-Ying, died in downtown Hong Kong from what we now know as anorexia7 . In the West, people had been getting diagnosed with the condition for decades at this point, but because of differences in culture, psychiatry, and public perception of mental illness, the concept of eating disorders had not become mainstream in China and other Asian countries, and this widely publicized case was the first of its kind. Western psychologists flooded to China armed with research papers, white savior complexes, and what we can only assume were good intentions, to educate both other mental health professionals and young Chinese citizens on anorexia. After being bombarded with information on why teenagers (particularly young women) develop anorexia, the warning signs, the consequences for mental and physical health, and the possible treatment methods, cases of anorexia in China and the surrounding countries skyrocketed. A study published by Wenyi Zhang showed that the number of Chinese citizens with eating disorders increased by over 60% from 1990 to 20198 . This health education program is an example of how the power of suggestion, and well-meaning but careless educators can negatively impact the health of a community (or not affect it at all, as in some other cases).

There have been many health education programs deployed to curb the prevelence of FGM, with varying rates of success. These results can be hard to measure numerically (how many cases of FGM before and after health education) in specific communities, as many cases are not reported, but we can look at community reactions and the rise or fall of the country’s national rates of FGM in the proceeding years. In an interview with The Atlantic, Bettina Shell-Duncan explains some of the shortcomings of health education programs, including instilling fear in communities that can prompt medicalization of the practice (which is not the goal of these campaigns) and researchers entering communities with little to no knowledge of their customs, language, or social structure4 . Pelting people with facts about a practice they’ve had, in many cases, hundreds of years of experience with, does not work. It both assumes that they do not know the risks that they’ve been exposed to for generations, and often instills fear that drives parents to have their daughters circumcised by medical professionals rather than traditional cutters, thus making the practice more modernized, not less acceptable.

An article in the Reproductive Health Journal found that “the effectiveness of FGM/C health education interventions depended on factors linked to sociodemographic factors: socioeconomic factors; traditions and beliefs; and intervention strategy, structure, and delivery” 9 and that successful programs considered all of these factors while in the field. The most common variable in health education programs that are well-received and effective in educating the targeted group, are those that empower community members, specifically local leaders, to spark discussions on the topic of FGM. Involvement of community leaders proved to be influential in swaying the opinions of the community. This tactic is supported by Asenath Mwithigah, who maintains that the most important aspect of any health education program is community involvement and a shared language1 . Using a community’s native language to share information is a big part of acknowledging their culture, in addition to adopting a community’s customs, by respecting their modes of dress, gender roles, and social hierarchy. Some studies found that the most effective campaigns have facilitators that are the same ethnicity as the target community or community members themselves, which “prevented a top-down approach”9 . In the past, health education programs have ignored these cultural aspects that, although not necessarily pertaining to the subject matter of their work, make a significant difference in how their message is received by community members.

Health education programs do see an increase in awareness of the risks of FGM, and sometimes influence the intentions of parents planning to have their daughters cut10 , but the biggest factor in changing opinions was the mother’s education11 . A 2022 study showed that mothers that achieved secondary and higher education were significantly less likely to have daughters that were cut11 . The study encouraged a multifaceted approach to the issue that emphasized female education, but also included public health programs, economic support, and legislative action11 . In turn, each of these factors influences the other, for example, “higher educational levels translate into better

economic and health opportunities that impact women’s health decisions”11 .

In another study, conducted in East Africa, it was found that “respondents who had primary and above levels of education and those who had heard anti-FGC messages were more likely to express the view that they did not intend to cut their daughters in the future”10 .

In the latter study, the health education program in one of the two countries involved, Ethiopia, was the product of CARE International teaming up with the Ministry of Health. It is not uncommon for non-governmental organizations to work with government organizations on health crises, which can often bridge the gap between the medical and legal sides of the issue, and allow more people to address it. The World Health Organization has been heavily involved with anti-FGM programs 12 and often partners with NGOs to approach international issues. The problem with organizations like the WHO is that they are often based in Northern Europe or the United States, and do not represent a very accurate image of our global population. Overwhelmingly, we see people from wealthy countries making decisions about the health and well-being of the global population, including for the poorer countries that remain underrepresented in international politics. In an article comparing global health education in high-income countries (HICs) and low-income countries (LICs), this disparity is clearly shown in “a

recent report on the governing board seats of global health organisations (that) found that 75% of board seats were held by nationals of HICs…further, 94% of the institutions

were headquartered in HICs”13 . Considering the findings that the closer to a community

an anti-FGM advocate is, the better they will be recieved 9 it is no wonder that health education programs have not worked as well as they were predicted to at stopping FGM, largely coming from such an overwhelmingly foreign source as they are.

,

Countries do sometimes experience lower rates of FGM after implementing health education programs10 , but it has been proven that empowering local leaders to discuss the topic more with their community1 , spreading information on human rights, and, above all else, giving women opportunities for higher education, is much more effective than telling people how they’re hurting their daughters, sisters, and wives. FGM undeniably negatively affects a woman’s sexuality every time it is performed, and often harms their overall reproductive health as well, but health education should be but a small part of anti-FGM campaigns, not the main focus. International human rights bodies (governmental and non-governmental alike) have, for the most part, accepted this shift from FGM as a health issue to FGM as a human rights issue, and as part of the 2012 global ban on FGM, the World Health Organization released a report that included a list of the human rights that FGM violates; “a person’s rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death”12 . We, as an international community, cannot turn our backs on the women and girls at risk of FGM, but we also cannot attempt to undo thousands of years of ceremony, by assuming that female genital cutting is just about the cut. Bibliography

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2. Female genital mutilation (FGM) frequently asked questions, UNITED NATIONS POPULATION FUND (2022),

https://www.unfpa.org/resources/female-genital-mutilation-fgm-frequently-asked-questio ns (last visited Dec 8, 2023).

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https://med.virginia.edu/family-medicine/wp-content/uploads/sites/285/2017/01/LlamasPaper.pdf (last visited Dec 9, 2023).

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