Shift from type III to type, FGM/C and perceived drivers
Reduction in Type III FGM/C is being driven forward by religious teaching, awareness raising sessions in mosques and hospitals, the increasing recognition of complications and recovery time so a safer procedure is needed, and the Oath taken by midwives to stop FGM/C which helps them justify stopping the practice and is also helping communities to stop the practice of Type III. Women pressurized into FGM/C will choose Type 1 if they can. Reduction in Type III FGM/C in Sudan is still being held back by strong cultural commitment to the practice of FGM/C, social networks and reference groups forcing continuation of Type III, and the practice of community social ostracism of trained midwives who refuse to do FGM/C.
Both men and women described Type I as Sunna-a practice approved by religion. Many people, believe erroneously type I is religiously required and approved. Explaining the religious basis for Type I FGM/C, a 30–35 years old respondent who had completed secondary school explained:
“We do Sunna, which is the Sunna (teaching) of Prophet Mohamed (PBUH) he told UmiAtia [a woman in Prophet Mohamed’s time] not to cut much and leave parts as they are. This is the Sunna. We should do it.”
Focus group discussion, Fathers, Umbadda
Educational and awareness-raising interventions, especially in urban areas are having an influence on the shift in the Type of FGM/C. Awadia, a 42-year-old, secondary school educated respondent living in Khartoum, explained: “People used to circumcise (the) Pharaonic (way) (Type III), but nowadays [we have] shifted to Sunna because of the education and awareness sessions in the mosques and hospitals”.
The perception that Type I has no complications and is safer was also reported to drive the shift from Type III. Explaining why people in her community prefer the Type I cut, a 40–45 years old, secondary school educated respondent living in Khartoum State explained that: “When a girl is circumcised (in the) ‘Pharaonic’ (way) (Type III), she may suffer from bleeding, obstructed labor, and difficult sexual intercourse with the husband.” Other health-related complications mentioned associated with Type III FGM/C included severe infections, and abscess.
Women and girls who had undergone Type III FGM/C were also noted to need a lengthy recovery period. For some men, such as one father from rural Khartoum State, this lengthy period was disadvantageous to them because it meant that they had to take over tasks normally performed by women. As he explained:
“The ‘pharaonic’ (Type III FGM/C) causes women great problems. They (have to) stay in bed for 40 days. I have suffered in this situation as I had to do the household chores and also the cooking. I told her (the woman who did the FGM/C) (she should) do Type I only. Women with Type I FGM stay in bed for a week and then move around. The future for women is in Type I.”
Women who are against FGM/C themselves, but who were pressurised to undergo it by older women relatives reported they would want to have Type 1 as it is less severe.
Importantly the midwifery oath to abandon FGM, now taken by all 3 year trained is seen as the basis for many midwives to say they are now against Type III FGM/C. These midwives may have created an understanding in communities that Type III is illegal. Women in both rural and urban areas noted that many midwives now refused to perform FGM/C, particularly type III, based on the oath.
Reduction in Type III FGM/C in Sudan is still being held back by strong cultural commitment to the practice of FGM/C and social networks and reference groups forcing continuation of Type III.While most mothers noted that they had shifted to practicing less severe FGM/C due to health and religious reasons, a very small number of mothers were insistent about performing Type III FGM/C. These mothers noted that Type III FGM/C has long been a strong cultural practice. As noted by a 25–30 years old respondent who was living in Khartoum noted:
“Pharaonic circumcision (Type III FGM/C) is very deep in our culture and we will not give it up. We have inherited it from our grandmothers. We will ensure it is done if a mother died, then an aunt or the grandmother will get it done”.
Social Networks and reference groups are perpetuating severe Type III FGM/C. Mothers often stated that they are forced to do the type of FGM/C that is acceptable to others in their community even when their personal preference is different. As noted by a 35-40 years old, a secondary school educated respondent living in Khartoum State:
“I really do feel guilty; my four daughters were circumcised (in the Pharaonic (way) (Type III) by my in-laws. I wanted them to have (the) Sunna (Type 1), but my in-laws refused.”
Increased use of traditional providers of FGM/C who are more likely to continue Type III also occurs because trained midwives refusal to participate in FGM/C means they will become socially excluded. For these midwives, when they refuse to perform FGM/C it can result in ostracism by their community and peers. Negative sanctions against midwives who refused to perform FGM/C were reported by both midwives themselves and community members. As one woman explained:
“We have to bring the traditional midwife from far away when our local one refuses to do FGM. We bring the dayat aljabal [traditional midwife] to conduct the FGM (‘to cut our daughters’) and when we want help to deliver their babies we bring a relative from Omdurman. The midwife we have here does not cut the girls (she refuses to do the FGM/C) and so we do not talk to her or invite her to anything. She has lived here with us for twenty years but she does not want to do things for us.” 35-40 years old, primary school educated respondent, rural Khartoum
Despite clear drivers to reduce Type III FGM/C there is a problematic issue with focus on reduction in Type III FGM/C, since some midwives and families reported they believe that Type I is not FGM/C which justifies the practice of FGM/C Type 1 continuing. Even when people claimed to have stopped practicing FGM/C, they were likely to practice Type I.
Increased medicalization of FGM/C and perceived drivers
Our results in both States confirmed a shift from using traditional midwives to perform FGM/C to using health care providers including trained midwives.
Increase in the Medicalization of FGM/C is being driven by families’ belief it may be safer and more hygienic; the health campaigns that promote the dangers of FGM/C; and strong views that surely a doctor conducting FGM/C would not want to cause harm. In addition, families pressurised socially into having FGM/C may prefer a health care provider to do it. Further drivers of medicalization are health care providers justifying their involvement in FGM/C as response to demand; the widespread availability of health care professionals prepared to do FGM/C; some 3 year trained Midwives and 1 year trained Village midwives thinking Type 1 FGM/C is not FGM/C so it is not against the oath to do it;. Nonetheless there are drivers to reduce medicalization too, with 3-year Midwives who have taken the professional oath to cease FGM/C sticking to their word.
Families reported they choose health care providers because they perform FGM/C under safer and more hygienic conditions.
Health care providers also noted the growing awareness of health hazards of FGM/C. As a midwife from Khartoum State described;
“In the past people performed this [FGM/C] and they did not know its danger. They used to bring a grandmother who might use a non-sterile razor to do the FGM. She did not know that bleeding might occur, and the girl could have problems. But when people learned (about these risks and complications) they started to go the health centers because they might save their daughter’s life if something went wrong”
Health campaigns (emphasizing risks of FGM/C) were identified as playing a part in increasing medicalization as people believe that the risks with FGM/C are lower if health care providers perform it.
Mothers said they preferred having doctors perform FGM/C, since they believe doctors are more knowledgeable and will not cause harm to their daughters. A 30–35 years old respondent in the Kriab (urban) area of Khartoum state said;
“Doctors are knowledgeable and (they) do the right thing. If a doctor says to us, “Do circumcise,” then we will do it because if circumcision (FGM/C) causes harm they surely would not perform it.”
Perception that doctors are ‘safe performers’ was reported to be driving a new “social norm” that ‘a doctor will do it’.
Some participants’ narratives, suggested that medicalization would increase even more if more female doctors performed FGM/C. A 30–35 years old respondent in rural Khartoum who had completed primary schooling and had two daughters with FGM/C explained;
“We, Arabs, do not take our girls to male doctors but to the midwives. (We take ) the boys to the male doctors” Similarly, a 25-30 years old, secondary school educated respondent in Umbadda who had two daughters (one with FGM/C one intact), noted “We will only let our daughters be seen by a female doctor.”
Some health care providers explained their practice of FGM/C by being merely responsive to demands for FGM/C by the families, believing that if they did not meet these families’ demands for FGM/C, they will resort to traditional practitioners and end up with more severe FGM/C Type III.
Other factors for the increase in medicalization include changes in people’s reference groups and social networks due to migration, as well as the availability of practicing health care providers. Some participants also noted that women who were against FGM/C, but who were forced to undergo the procedure, would resort to medicalization.
As such, there was a general belief that if health care providers abandon FGM/C, many people would abandon the practice, resulting in less demand.
Shift in age of FGM/C and perceived drivers
Older age change drivers found included increasing awareness of raised health risks of FGM/C to a younger girl. Yet an opposing belief was that early age FGM/C could cure illness.
Fewer participants referred to a change in the age of cutting. The direction of the shift was not consistent. In Gedaref State, it was noted that there was an increase in age of performing FGM/C from five years to 11 or 12 years, probably driven by the belief it will lead to quicker healing, and show of maturity so that they could get husbands. Whereas, some mothers mentioned they prefer younger age of cutting, such as three years, as a ‘treatment’ of illness. Illustrating this view, a 26-year-old respondent explained:
“We do not normally circumcise (do FGM/C) at a young age, but I did my elder daughter at the age of 3 years because she was sick. The people told me FGM/C would make her well … … and she got better.
The age of FGM/C varies by ethnicity in Sudan. Among the Meloha in Gedaref State, daughters have FGM/C immediately after birth, or a week later during the “Semaia” celebration party or “Seboo” (the naming ceremony). Often, the FGM/C cutter is the same provider who delivered the baby. In Gamoeia, in Khartoum State, on the other hand, FGM/C is performed at the age of six to ten years reportedly because girls this age heal faster and face fewer risks. A 25–30 year-old, primary school educated respondent in urban Gederaf stated in the focus group discussion: “I prefer to circumcise my daughters at an older age to prevent her having more pain and more problems”.