The role of men in abandonment of female genital mutilation: a systematic review

Background Men in their roles as fathers, husbands, community and religious leaders may play a pivotal part in the continuation of female genital mutilation (FGM). However, the research on their views of FGM and their potential role in its abandonment are not well described. Methods We undertook a systematic review of all publications between 2004 and 2014 that explored men’s attitudes, beliefs, and behaviours in regards to FGM, as well as their ideas about FGM prevention and abandonment. Results We included twenty peer-reviewed articles from 15 countries in the analysis. Analysis revealed ambiguity of men’s wishes in regards to the continuation of FGM. Many men wished to abandon this practice because of the physical and psychosexual complications to both women and men. Social obligation and the silent culture between the sexes were posited as major obstacles for change. Support for abandonment was influenced by notions of social obligation, religion, education, ethnicity, urban living, migration, and understanding of the negative sequelae of FGM. The strongest influence was education. Conclusion The level of education of men was one of the most important indicators for men’s support for abandonment of FGM. Social obligation and the lack of dialogue between men and women were two key issues that men acknowledged as barriers to abandonment. Advocacy by men and collaboration between men and women’s health and community programs may be important steps forward in the abandonment process.


Background
FGM is a transnational public health, human rights, and gender injustice issue, which more than 125 million girls and women in 29 countries of Africa and the Middle East have been subjected to [1]. It is also prevalent in some countries of Asia and migrant communities in Europe, the USA, Australia and New Zealand [1]. Even if the worldwide decline in FGM is maintained at current rates, population growth means that about 196 million girls would be cut by 2050 [2]. We therefore need a change in our approach to the prevention of this practice that can have a devastating impact not only on girls and women, but can adversely affect men [3] and communities as well.
FGM refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons [4]. It is usually performed on girls from birth to age 15. Girls may die at the time of cutting from haemorrhage or infection, or experience significant physical, psychological and sexual complications [5][6][7][8]. There is a discrepancy between the wishes of many men and women to stop FGM and the reality of it continuing due to the deeply entrenched sense of social obligation to cut one's daughter [1]. Moreover, this practice persists due to the lack of open dialogue between men and women, and reluctance to debate it in the public sphere. This precludes opportunities for culturally sensitive and critical introspection by communities [1].
Although women appear to be at the forefront of the perpetuation of FGM, there is some evidence that men may play a significant role in its continuation as fathers, husbands, and community and religious leaders [9,10]. Existing FGM research involving men in regards to their influence on the decision-making process is very limited. There is no data on the success of involving men in the abandonment process. Moreover, there is little knowledge regarding the implication and effect of FGM practice on men. Footbinding of girls in China, a practice with similar sociocultural underpinnings, was abandoned and advocacy by men had played a crucial role [11].
Our systemic review examines perceptions and attitudes of men towards FGM, and their perceived and actual role in the abandonment process. The results have implications for research and intervention programs to empower men, women and their communities to be able to make the decision to abandon FGM.

Methods
A textual narrative synthesis was undertaken involving the analysis of study characteristics, context, and findings [12]. A PICOS question was developed to guide this review [13]. We therefore sought to answer the question "For men who were born in countries, or claim ancestry from ethnic groups where FGM is practised, what are their attitudes, beliefs, and behaviours in regards to FGM, its prevention and abandonment?" Observational studies, quasi-experimental and non-experimental descriptive and qualitative studies were considered appropriate for inclusion in the review. If intervention studies were available, we sought to examine strategies that had led to change in knowledge, attitudes and behaviours. However, we also sought to identify the current views of men across different settings and contexts to gain insights that may provide opportunities to garner men's support for the prevention and abandonment of FGM.
A systematic search of the peer reviewed research literature published in English from 2005 to 2015 was undertaken by AD. The PRISMA guidelines were applied to the review process ( Fig. 1) [14].
We searched Academic Search Complete (EBSCO) that included the pertinent databases Medline and CINAHL. We also searched ProQuest Health & Medical Complete, SCOPUS, Web of Science and Science Direct. The following key words were used in the search: "female genital mutilation" OR "female circumcision" OR "female genital cutting", AND "men" AND "attitudes" OR "beliefs", OR "behaviour". In addition, we hand searched the reference lists of relevant papers to gain additional documents. Duplicate records were removed as well as papers that were not within the scope of the review, or older than 2005. AD and NV then screened  35 papers and removed those that did not disaggregate data by sex or gender or where male views did not provide a substantial contribution to the findings. For example two papers included only one reference to men's understandings of FGM [15,16]. In the paper by Shell-Duncan et al [15], it was difficult to extrapolate men's knowledge and views from women's. In another paper that was removed, women spoke about FGM and men did not contribute data on FGM in the study [17].
Twenty-one papers deemed eligible for inclusion were then appraised for quality using checklists to assess both qualitative and quantitative papers [18,19]. One paper was discarded, as it was not a research study [20]. The characteristics of all 20 papers were summarised (Table 1) to examine context, sample, study aims and findings. All findings were then analysed and the data pertaining to men only were extracted. These findings were then synthesised to answer the review question as described by Harden et al [21] and key categories developed concerning men's perceptions, issues and support. These findings were discussed by NV and AD and agreement was reached.
Three main themes in regards to men's attitudes, beliefs and behaviours to support continuation or abandonment of FGM and its prevention emerged. These were (1) men's perceptions of FGM, (2) FGM as an issue for men, and (3) influence of socio-demographic factors. A synthesis of the available data revealed ambiguity of men's wishes in regards to the continuation of FGM. Many men wished to abandon this practice because of the physical and psychosexual complications to both women and men. The silent culture between the sexes was posited as a major obstacle for change [32], as was the entrenched sense of social obligation [31,35,37].

Men's perception of FGM
A study of fathers in Egypt showed that they believed uncut women to be promiscuous [31]. FGM was deemed important for good marriage opportunities and to ensure fidelity in marriage [31]. In this respect, FGM helped men maintain polygamy in some communities [39]. Men in Guinea considered FGM to reduce the likelihood of premarital sex [24]. In a study of Somali men, however, they were divided on whether FGM prevented premarital sex, marital infidelity and preserved the dignity of girls [25].
Men acknowledged and complained about the negative impact of FGM on marital sexual relationships, and found the lack of sexual response of their wives disturbing or inconvenient [31,33]. Almost all 99 men and religious leaders, Muslims and Christians, in a study in rural communities in Egypt acknowledged women's equal right to enjoy sex [33]. Nevertheless, for some men these concerns and beliefs were overridden by their wish to ensure their wives' fidelity in marriage [31] or their fear of loss of control over the sexual relationship [33].

FGM as an issue for men
Interviews with men in Northern Sudan revealed that men did not accurately understand FGM, as it was not until they were newly married that they experienced the irrevocable consequences of their wives' FGM [32]. Men felt they, too, were victims of the consequences of FGM. Almost all men stated they did not want their daughters to undergo FGM and believed it would become less common as men had started to prefer women who had not been cut [32]. Men described their own complications, including male sexual dissatisfaction, compassion for female suffering and perceived challenges to their masculinity [32,33].
Factors that influence men's support for continuation or abandonment of FGM Social obligation Somali men in Oslo acknowledged that men in Somalia disliked the practice but that it continued due to social obligation [35]. Men agreed to it so as not to upset their mothers [37]. Somali men in Norway no longer felt social pressure to perform FGM. In fact, they maintained that it was prestigious for a woman not to have been cut [35].
Fathers in Egypt acknowledged the wish to abandon FGM and a longing for change [31]. They cited social pressure and fear of rejection from the community as significant barriers to the abandonment process. The entrenched sense of social obligation was stronger than the belief that FGM was against their religion [31].

Education, urban living, religion and ethnicity
The level of education of men, urban living and wealth are associated with disapproval of FGM [24,26,29,30]. Evaluation of DHS data in Guinea from 1999 revealed that 51 % of men wanted FGM to continue, whilst 38 % were against it [24]. Each additional year of schooling substantially increased the odds of favouring the discontinuation of the practice [24].  Men expressed concern about lack of knowledge on FC by doctors. They felt responsible to advocate on her behalf of their wives and be cultural educators to healthcare providers. Men acknowledged strong matriarchal support of FGC. All but one man disagreed with the practice. They were aware of FGC-related morbidity. Men maintained they just agreed to the practice because they did not want to upset the mothers. To explore knowledge and attitudes of Gambian men towards FGM/C, as well as practices in their family and household; to promote knowledge on FGM/C and empower communities 72 % of men did not know FGM/C had negative impact on health.
Awareness of health problems was higher among younger men who were less supportive of practice. These men also had lower intention of cutting their daughters and highest willingness of seeing men intervening in  To determine factors associated with men's preference for circumcised women 18.8 % of men preferred women who had FGC. Men who preferred women with FGC were significantly more likely to be illiterate or have only primary or middle school education as compared to secondary and higher education. Men who preferred women to have FGC were significantly more likely to be Nankana compared to Kassesa ethnicity and more likely to report their religion as traditional compared to Christianity.
*female genital cutting **female genital mutilation/cutting *** female circumcision ****ablation/female genital mutilation A school-based study of adolescent boys in Oman revealed that they were more likely to support FGM if they lived in rural areas and their parents had lower level of education [26]. Eighty percent of the boys considered FGM to be important and necessary.
The analysis of the DHS of Guinea showed that if FGM was considered to be accepted by religion, men were more likely to be supportive of the practice [24]. In two studies in Somalia, almost all men supported the continuation of FGM and 96 % preferred to marry women who had been cut, even though 90 % were aware of its complications [25,34]. Men supported the "lesser" Sunna type, i.e. types I and II, because they believed it not to have any negative health effects, unlike the Pharaonic type, i.e. type III or infibulation [8]. Ninety-six percent of men believed FGM to be a religious requirement.
Prevalence of FGM varied amongst Muslims with different ethnic backgrounds from 12 % to 98 % in a study of 993 men in Gambia [38]. The Serer and Wolof communities that were Muslim but traditionally nonpractising, had the lowest prevalence. Wolof men also had the highest awareness of complications of FGM [38]. Similarly, male healthcare workers in Gambia belonging to traditionally practising communities were more likely to support the continuation and medicalisation of FGM, and intended to cut their daughters [38].

Knowledge of complications of FGM
Intervention studies involving men had an important positive effect on men's attitudes towards abandonment of this practice. In a study of men (n = 4488) and women (n = 5041) in Nigeria [41], a greater proportion of men (54 %) than women (44 %) did not want FGM stopped prior to the intervention of health education on FGM and its complications over ten days. There was a statistically significant decrease in this attitude to 25 % amongst men in the post-intervention stage.
A six months Village Empowerment Program was conducted by TOSTAN in Senegal on human rights, problem-solving process, basic hygiene, and women's health [23]. The change in the intention to cut their daughters amongst men was greatest among program participants (66 to 13 %) and least in the control group (78 to 56 %). Twenty percent of men as participants and 63 % in the comparison groups preferred a women who had been cut. Most participant men (75 %) indicated their support for the abandonment of FGM. Only 30 % in the comparison group expressed the same.
In a study of 993 men in Gambia, 72 % did not know FGM had a negative impact on health [38]. As compared to older men, younger men had a better understanding of the health problems and were less supportive of the practice, had lower intention to cut their daughters, and had higher willingness for men to participate in prevention programs [38].

Migration
There are three studies that examined the attitudes of men from Somalia in Norway [35] and the USA [37], and from Ethiopia and Eritrea in Sweden [36]. In contrast to findings from countries where FGM is prevalent, almost all men strongly rejected this practice [35][36][37]. Men had very good knowledge of the complications of FGM [35][36][37] and understood that it reduced female sexual pleasure [35,36]. They considered it devoid of meaning within the context of a cultural practice and that it had no religious mandate [35,36]. One man had believed it was done to girls to prevent sexual violence [35].
Even living in another African country had a positive effect on attitudes of men. Eighty-nine percent of Somali male refugees in Ethiopia positively viewed the usefulness of anti-FGM interventions [28].

Discussion
Our systematic review supports the two main factors perpetuating the continuation of FGM, namely social obligation and marriageability [1]. The former relates to social pressure to adhere to norms, which vary among different communities and countries. The norms may pertain to perceived religious requirement, family honour through premarital virginity of daughters and marital fidelity of wives, aesthetics, and rite of passage [42][43][44]. Fear of exclusion from resources and opportunities as a young woman, including a good marriage, are other important reasons [42,43]. Men may play a passive role in approving FGM by refusing to marry uncut women or an active one by initiating the practice [9]. In a study of about 400 Nigerian men and women, 71 % of them stated that it was paternal grandfathers and fathers who were the decision makers responsible for requesting FGM [45].
On the other hand, many men wish the practice to end but are unable to voice their concerns. In Guinea, Sierra Leone and Chad, for example, more men than women want FGM to end [1]. There is evidence from DHS data that there may be limited dialogue on FGM between the genders [1]. In some surveys, women and girls tended to consistently underestimate the proportion of men and boys who wanted FGM to end. Similarly, in some surveys many women and men did not know the opinion of the opposite sex in regards to FGM [1]. Enabling communication between men and women, as well as among men, and opening up this practice to a debate of its validity in a culturally sensitive way warrants further research and may facilitate the abandonment process. In a family planning study, teaching communication skills to men to facilitate conversations on contraception with their partners, not only increased contraception uptake but also improved spousal relationships [46].
Our review suggests that FGM affects men as well as women and that it can no longer be considered an issue pertaining only to women's health [3]. Men married to women with FGM have health complications as well and feel they, too, are victims of this practice [32]. Indeed, the adverse effects of FGM on men have been well documented in a Sudanese study of married men (n = 59), most of whom expressed difficulty with vaginal penetration, wounds or infections on the penis and psychosexual problems [3]. Most notable was the finding that men perceived their wives' suffering as their own problem. Most of the young men stated they would have preferred to be married to uncut women [3].
Our results reveal that education, age, knowledge of the health complications of FGM, religion, urban living, ethnicity, and migration influence men's stated support for the abandonment of this practice. These findings are in keeping with the UNICEF 2013 report of analysis of DHS data over 20 years from 29 countries of Africa and the Middle East [1]. The common thread that binds these factors is education. Involvement of men in sexual and reproductive health promotion, for example, has been a successful strategy to help women with family planning, HIV/STI prevention, violence against women, and maternity care [46][47][48][49][50]. Studies have shown that men do want to be involved, and respond positively to efforts to involve them in these programs, as they care about the welfare of their families [51,52]. A study in Nepal, for instance, showed that educating pregnant women and their male partners had a greater impact on maternal health behaviours compared with educating women alone [47]. The relationship between education level and support for the abandonment of FGM, however, is presented through bivariate analysis and further research through multivariate analysis would help to determine causality.
Involvement of men in reproductive health services to date has been with the sole purpose of benefit to women [48]. In a study of male involvement in maternity health care in Malawi, men felt they were not the beneficiaries and were merely used as a means to get women to the health service [53]. Moreover, due to gender dynamics, men attending women's clinics with their wives were vulnerable and ridiculed by other men [54]. A more positive and successful involvement of men in the abandonment of FGM hence may be achieved by the provision of reproductive health services specific for men. A man-to-man strategy would allow open discussion of private and sensitive health and other personal men's issues. Men also, like women, need to be empowered through health literacy to be able to make informed and healthy decisions for themselves and their families. Interviews of Kenyan men suggested men-only community groups for creating awareness and conducting male reproductive health education [54]. Education has also been achieved through schools, social media, mobile phone technology, sporting events, musicians, radio, theatre and puppet shows [54,55]. Male musicians or sportsmen themselves could be key advocates for the abandonment of FGM. Using videos depicting graphic images of the practice has been particularly effective with men who became aware of the suffering involved for the first time [55].
It may be beneficial for the abandonment process if men's intervention and education programs worked with those of women's. Our study shows that some men distinctly wish the harmful practice of FGM to continue even if they believed their religion did not condone it. Their self-interest is to support polygamy in some communities and control the sexuality of their wives. This requires opposition and a voice from women. It requires their financial empowerment through education and independence from men.
In our review, some men highlighted that change should come from within their own community rather than governments or nongovernment organisations [34]. Communities in Sub-Saharan Africa endure many human rights abuses in addition to FGM, such as lack of access to clean water, food security, health services and education, child marriage, and sexual violence [56]. Addressing communities' priorities would be an important gateway to earning their trust and working with men and women towards the abandonment of FGM. This is borne out by our review that migration is a positive influence to the abandonment of FGM. We may speculate on the reasons for this phenomenon. When people are granted their basic human rights with stable and improved social and economic living options, the need to cut their daughter for marriageability and economic survival is removed. Moreover, social pressure is relieved, as FGM is counter-normative in the new country. Instead of FGM accruing positive outcomes like a good marriage, it causes prejudice and disadvantage, and becomes a liability. As borne out by the study of Somali migrants in Norway [35], uncut Somali girls were more likely to attract boyfriends and get married as compared to girls who had been subjected to FGM.

Strengths and limitations
This study is the first in the literature to present a systematic review of the role of men in FGM. It provides evidence on the importance of and need for directing research and intervention programs to involve men in the abandonment process. The limitations pertain mainly to measurement, interviewer, and response biases in the studies. In FGD especially, men may be reluctant to give socially unacceptable answers for a topic that has such high social pressure for conformity.
In particular, in the intervention studies, subjects may have acknowledged to the interviewer that they did not support the continuation of FGM at endline because they believed this to be the answer they wanted to hear. In some studies, money was given to subjects for participation, which introduced selection and response bias. FGM is a prosecutable offence in most of the countries where it is performed. Hence, in the studies cited, men may not have felt they could freely disclose their beliefs. The overall findings of the review cannot be generalised to all men in regards to FGM, as prevalence, views and behaviours are specific to countries and communities. Moreover, even though men's opinions are stated and they may support abandonment, we do not know their influence on the decision making process to subject girls to FGM.

Conclusion
Men have conflicting views on FGM. Many would like it to end but are unable to voice their support for its abandonment due to social pressure and obligation within the community. Change needs to come from within communities, supported by the creation of opportunities for men and women to debate the practice amongst themselves. Advocacy by men, as well as research, prevention programs and health services targeted at men could be explored to assess their success within the abandonment process. These programs may work together with those for women to empower men and women to decide to abandon this harmful practice to protect their daughters, men and communities from the devastating effects of this harmful practice.