Prevalence and belief in the continuation of female genital cutting among high school girls: a cross - sectional study in Hadiya zone, Southern Ethiopia

Female Genital Mutilation (FGM), also known as Female Genital Cutting (FGC), consists of all procedures that involve partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other non-medical reasons [1–3]. An estimated 100 million to 140 million girls and women worldwide have undergone female genital mutilation/cutting (FGM/C) and more than three million girls are at risk for cutting each year on the African continent alone [4]. Although the practice is highly prevalent in western, eastern, and north-eastern Africa, it also occurs in some countries of Asia and Middle East and certain immigrant communities in North America, Europe and Australia [5, 6]. In Africa, there was a significant regional and geographical variation of prevalence of the practice ranging from nearly 90% or higher in Egypt, Eritrea, Mali and Sudan to less than 50% in the Central African Republic and Côte d’Ivoire, to 5% in the Democratic republic of Congo and Uganda [6–8].

While there is no religious base for this practice, most people think it is performed for religious reasons. FGM dates back over 2,000 years and exists nowadays across most religious, racial and social boundaries, supported by centuries of tradition, culture and false beliefs [9]. As FGM is a cultural practice, efforts to end it require understanding and changing the beliefs and perceptions that have sustained the practice over the centuries [4].

Despite some 25 years of efforts to ban FGM in many countries around the world, the practice is still far from being eradicated [10, 11]. In Ethiopia, the prevalence of FGM was 80% in 2000 and only a 5% decrease had been observed in 2005. During these years, the occurrence in Ethiopia’s Southern Nations, Nationalities and Peoples Region (SNNPR), of which the Hadiya Zone is a part, was 71% and 74.8%, respectively [12, 13]. According to a follow-up survey in 2006, the rate of decrease among Hadiya was only 5.2%, and the prevalence was 70.9% [14], indicating the need for further studies and interventions to address the problem.

Where previous studies have focused on mothers' perspectives only, the aim of this study is to assess the prevalence and the beliefs of female students regarding the continuation of FGM. So, obtaining the data from the girls, themselves victims, who will be the future mothers, will expand on the literature and give direction to policy makers and other interested persons. The findings of this study will also help to design appropriate interventions to halt the practice among the new generation of females in the area.

In this study we found a very high prevalence of FGM in the area and circumcision of girls occurs at early adolescence with a mean age of 11 years. Girls support circumcision to avoid stigma associated with being uncircumcised. Apart from traditional circumcisers, health professionals were involved in female circumcision. Group circumcision was a common practice in the area.

The Ethiopian Penal Code states that female circumcision is illegal and punishable by law [15], However, eight out of ten girls reported having been circumcised, suggesting the practice is still in place. Combined with cultural taboo and stigma associated with being uncircumcised it seems less likely for the practice to vanish in the area in the near future. This figure is very high compared to both national and some other Sub-Saharan African countries. For example, the 2005 EDSH report indicates the total prevalence in Ethiopia and SNNPR was 74.3% and 71.0%, respectively [13], whereas the prevalence among the age group of 15–19 years in the whole country was 62.1% [13]. The rate reflected in this study was also extremely high compared to other East African nations. A study from Tanzania showed FGM prevalence among high school leavers was 10% and that of Kenya at 15% among age group of 15–19 years [4, 16]. FGM prevalence within the same age cohort in other African countries was even higher for example 97% in Somalia [4].

A review of existing literature shows that the age of female circumcision in Ethiopia can vary greatly according to ethnicity and region. In the Amhara ethnic group/region, for example, circumcision might be initiated as early as eight days to one month after birth while Adere and Oromo conduct FGM among females aged from 4 years to puberty [17]. Other studies conducted in Hadiya Zone indicate the age of circumcision for girls can extend as high as 17 years [18]. In our study, however, circumcision of girls occurred at early adolescence with a mean age of 11 years.

Regarding pervasiveness of FGM in the Hadiya Zone, a 1996 baseline study showed the prevalence of female genital cutting among the Hadiya ethnic group as 74.8%. A follow-up national survey conducted 10 years later in 2006 showed a reduced prevalence of 70.9% [14]. Both studies reported lower numbers than the results found in this study. The difference in the magnitudes may be due to the age group of the samples included and/or the population sampled in each study. As most Hadiya girls are circumcised during early adolescence, this may have affected the estimates from the 1996 and the 2006 studies as the reports included younger, pre-adolescent children in their samples.

Similar to other studies [19–21], the main reasons given by the girls for the continuation of the practice were cultural considerations. This indicates the importance of culture, which rejects uncircumcised girls; it also supports other studies indicating that tradition and social importance were the main factors that subject a girl to circumcision [22, 23]. The fact that a third of those who support their circumcised status did so for hygiene reasons suggests a continued belief in an effectiveness of FGC and therefore also a reduced likelihood of the termination of the practice. This was consistent with other studies [11, 24]. Moreover, the involvement of health professionals in circumcising the girls may also contribute to the continuation as the community may think these silent referents were doing it for the enhancement of health.

The findings of the study have indicated that living in a rural area was associated with the high prevalence of FGC. This was consistent with Ethiopian DHS 2005 [13]. Studies from other countries have also shown that FGC prevalence is lower in urban communities [7, 25]. Grade level of the girls also had an association with the prevalence of female genital cutting in this study with the odds of being circumcised greater among grade 10 female students compared to grade nine students. This may support a slight decrease in the prevalence over time. However, there is similar age aggregate in batch grade 9 and 10; thus, this study could not differentiate the variation in a significant way. According to a study done in Guinea, the effect of age on female genital cutting was insignificant [22].

Religion had no association with the occurrence of female genital cutting at multivariate level. Other studies also indicate that female genital cutting is not a result of religion and neither the Bible nor the Koran mention FGM as a religious requirement and most faiths, including Islam, forbid physical violation of the human body [12, 19]. However, in other studies conducted in Sudan and in Ethiopia, followers of Muslim religion were more likely to be circumcised than other religions [12, 23, 26].

This study also indicated that increased education levels of both parents may contribute to the decrease of female genital cutting. Daughters from parents with an educational status below high school level were almost two times more likely to be circumcised compared with those with parental educational levels of high school and above, indicating the importance of parental education. In another study, it was also indicated that females with secondary education were four times more likely to oppose FGM [27] consistent with other studies [12, 13, 28, 29].

With regard to belief in the continuation of FGC, only 5.3% of the study’s respondents believe in the continuation of the practice. This implies that if any intervention is taken to the community against the continuation of the practice, changes in behaviour and belief may be achieved.

The location of the participant’s residence also had significant association with the belief in the continuation of female genital cutting in the bivariate analysis, but it disappeared in the multivariate analysis. This was similar with the results of a study conducted in Guinea, where residence had no association with the belief in the continuation of FGC [30], but it was not consistent with a study performed in eastern Ethiopia [31].

The present study also found that being from the villages where female genital cutting is practiced influenced the belief in the continuation of the practice among high school girls. Those who responded that FGC was practiced in their area were 2.33 times more likely to support the continuation compared to those who responded that the practice had stopped or they didn’t know. So, those from villages where FGC is practiced had self-commitment and cultural pressure to believe in its continuation.

The effect of thinking FGC is harmful or not was highly significant in this study. Those who thought female genital cutting is not harmful were more likely to favour the continuation of the practice when compared with those who thought that FGC is harmful to the girl who undergoes the process. Similarly, another study also indicated that as the number of perceived advantages of female genital cutting increased, the tendency to support the discontinuation of FGC declined [30]. Thinking that a girl has the right to say ‘no’ to circumcision was also independently associated with the belief in the continuation. Those who thought a girl has no right to deny her own circumcision were more likely to believe in the continuation of FGC. This indicates that it is important to create awareness among students on the issues of human rights, including international conventions that condemn harmful practices and the Ethiopian penal code which outlaws female genital cutting [12, 32, 33].

Circumcision status was also found to be associated with the belief in the continuation of the practice in the multivariate analysis (AOR = 8.22; 95% CI: 1.10, 61.8). However, the effect size is not precise because of a small number of girls who were not circumcised and favoured the continuation. Similar results were obtained in other studies [17, 30, 32].

This study assessed the prevalence and belief in the continuation of Female Genital Cutting among high school girls. However it has certain limitation.

Since it was institution based study, this study could not link the prevalence with specific geographic area of the zone and self-reported information may be subjected to reporting errors, missed values and bias. Despite the above limitations, our findings are important to help to design appropriate interventions to halt the practice among the new generation of females in the area.

From this study, we can conclude that the prevalence of FGM/FGC is still high in Ethiopia’s Hadiya Zone. Culture, stigma and hygiene were the most common reasons for the continuation of the practice. In addition, the fact that girls themselves demand to be circumcised to avoid shame and stigma is another reason for the continuation of the practice which should be handled carefully. As most of the girls were against the continuation of the practice regardless of their circumcision status, we can conclude that the practice will vanish if interventions are directed towards the alleviation of stigma at the community level. The persistence of the practice while the act is criminal is an issue that needs further study.

Local organizations in collaboration with religious institutions and community leaders should work together to engage in a process of change within the entire community by arranging awareness creation programmes on the harmfulness of the practice especially in the rural areas of the zone. Use of wider media coverage of positive role models, for example sports stars, fashion models and famous singers who have not been circumcised to become ambassadors for non-circumcised females could also break the shame and stigma. Moreover, there should be enforcement and implementation of the law to stop the health care workers from their collaboration with FGM.