Introduction

Female genital cutting (FGC) is a global public health problem affecting women and communities in Africa, the Middle East, and some parts of Asia and South America, along with immigrants around the world.^1–3 FGC, also known as female genital mutilation (FGM) or female circumcision, includes any procedure intended to alter or injure female genitalia without a medically necessary reason.⁴ In Kenya, rates of FGC have declined over the past two decades, from 38% in 1998 to 21% in 2014.^3,5–7 Kenya shares its borders with Somalia and Ethiopia, with an estimated FGC prevalence of 98% and 74%, respectively. The difference in prevalence between these countries and Kenya, alongside Kenya’s declining rates, provides some hope and shows some progress in reducing the harmful practice in the region. Specific factors affect prevalence, and certain areas in Kenya continue to have incredibly high rates of FGC. For example, at a national level, 54% of women without any education have undergone FGC compared with 19% of women with at least some secondary education.⁸ Other situations that may lead to increased rates of FGC include poverty, the desirability of marriage, and residing in a rural location.⁵

Marsabit County, Kenya

While working at a Maternal and Child Health organization in Philadelphia, the author (KW) collaborated with Dahabo Abagaro, a Borana nurse-midwife and Mandela Scholar from the Sololo District of Marsabit County. Her work inspired the author to learn more about FGC in Marsabit County and about successful programs to reduce the practice in similar communities.

Marsabit County sits in the Eastern province of Kenya on the northern border, alongside Ethiopia, and stretches south towards the middle of the country. Various ethnic groups, like the Rendille, Gabra, Borana, Samburu, and Turkana, reside here.⁹ About 92% of females have experienced FGC in this county,¹⁰ a striking difference compared with the overall rate for the Eastern province of 35.8%.⁸ Dahabo Abagaro stated that “no woman from [her] tribe or ethnicity has not undergone FGM” (Abagaro D, Personal communication, September 23, 2017). She also explained that this county is more similar in culture, lifestyle, and beliefs to the Northeastern province of Kenya (Abagaro D, Personal communication, September 19, 2017), which has much higher FGC rates (reaching 97.5%).⁸ A study by Achia⁵ showed Marsabit County to be part of a high-risk cluster for both current and potential future prevalence of FGC.

When considering specific risk factors, females in Marsabit County fall into many high-risk categories. For example, girl child enrollment in school in the county is only 30%, and the overall ability to read and write within the community is 26.2%.^11–13 The county’s poverty rate is 91.9%,¹³ and nearly 78% of the population live in rural areas.¹⁴ In addition, the culture strongly supports FGC and considers it a necessary rite of passage, so much so that every woman wants her daughter to undergo the procedure to promote marriageability and save her from the stigma that occurs for girls without FGC. The stigma continues into adulthood, resulting in difficulty finding a husband and the potential for divorce when a husband realizes his wife has not been cut.¹¹ This kind of stigma and societal ostracism occurs in many cultures that support FGC.^12,15–19 Despite recent laws criminalizing the practice, people in Marsabit County continue to perform FGC, and there is little to no enforcement of the law.^10,15

Types of FGC

FGC occurs in different proportions and varies depending on culture and location: (i) Type I- clitoridectomy involves the partial or total removal of the clitoris and/or the prepuce; (ii) Type II- excision involves the partial or total removal of the clitoris, the labia minora, and potentially the labia majora; (iii) Type III- infibulation involves removal of the labia minora and the potential removal of the labia majora and the clitoris, and may also include stitching the labia together, leaving only a small opening for urine and menstrual blood to pass through; and (iv) Type IV involves all other forms of procedure harmful to female genitalia.^2–4 These four distinct types are, in practice, rather fluid and not exact, and each type includes variety.^12,20 In Marsabit County, the majority of FGC is type II, with some type III occurrence (Abagaro D, Personal communication, September 23, 2017).

Consequences of FGC

The practice of FGC harms women in myriad ways. In the short term, FGC is extremely painful and can cause excessive bleeding, infection, shock, and death. Women often suffer long-term from chronic pain, infections, scars, anemia, anxiety, post-traumatic stress disorder, and other emotional and psychological experiences that negatively impact their lives.^1,18,21–24 In addition, FGC may contribute to obstetrical problems, including increased risk for stillbirth, postpartum hemorrhage (a pivotal cause of maternal mortality throughout Kenya), and prolonged and obstructed labor.^{1,18,19,21,25} Prolonged and obstructed labor can result in obstetric fistula, leading to severe stigma and other difficulties physically, psychologically, and culturally.^2,24,26 FGC also increases the risk for vaginal prolapse, sepsis, STIs, and HIV infection.^18,19,24 The severity of these complications differs based on type; for example, type I does not increase risks surrounding childbirth, and infibulation creates the highest risk for most complications.^12,19

FGC may also have some positive social consequences. Many societies that practice FGC believe that removing the clitoris removes the masculine part of a female, showing an affirmation of her femininity and of matriarchal power.^12,21,27,28 As a rite of passage, women celebrate FGC, as it publicly transforms them from girls into women and gives them a separate identity from not only men but also animals.^12,21,27,28 Alongside gender identity, FGC embraces a woman’s ethnic identity^21,29 and can improve her own and her family’s social status.^14,19,30 Finally, FGC can provide the opportunity for women to fulfill what many females in this context consider to be their central role in life, that of wife and mother.^12,21,27,28

Marriageability may easily be considered a positive consequence and the main driver behind FGC. Sometimes the practice occurs earlier in life, sometimes as part of the traditional marriage ceremony itself, and sometimes after a marriage takes place.^12,27 Cross-culturally, though, it symbolizes a woman’s status as worthy of marriage and motherhood, ready to take on the pain of labor and the difficulty of marriage.^12,20,30 Following the procedure, women become available and acceptable as wives; without it, women are considered undesirable. In some cultures, even children born to women who have not been cut are ostracized.^12,28 The complex interaction at play involves women believing that men will not marry them (or their daughters) without FGC, and men believing that women who have not been cut have already been sexually active or will be unfaithful to them in marriage.^16,20 Even when women understand the risks associated with FGC, they often choose to continue the practice because the risk of not being cut is greater.^2,12 In addition, FGC legitimizes the man’s role in reproduction. If his wife has undergone FGC, there is no doubt the child is his.²

Kenyan law

Some of the overall declines in Kenya’s FGC rates may be attributable to recent laws. Part two of the Children’s Act of 2001 prohibits FGC, alongside early marriage, under the protection from harmful cultural rites section.³¹ In 2011, a more specific act was put in place. Within the Prohibition of Female Genital Mutilation Act, performing FGC, aiding and abetting FGC, taking someone to another country for FGC, and even possession of tools used for FGC are all considered offenses and have legal consequences.³² These laws have provided much-needed support for people who oppose the practice but feel social pressure to affirm it.²

With the successes that Kenya has realized because of the passing of these laws, there are also unexpected consequences. Legislation may result in people hiding acts of FGC to maneuver around the law,^{2,22,23,28,33–35} resulting in increased health risks.² Legislation forbidding FGC can also make criminals out of women and girls and takes away their right to choose. Increases in incidence have followed the implementation of new legislation, which may be rebellion against political repression and the potential disempowerment of women.^28–30,36

Current Programs

Programs working to reduce harmful FGC practices currently exist around the world. The following programs exhibited the greatest long-term successes and were implemented in communities similar to Marsabit County and are therefore more applicable to the context.

Tostan

One of the most effective and well-known programs is Tostan, based in Senegal and stretching through parts of West Africa. Tostan began with the intention of introducing problem-solving skills to women in rural areas whose husbands worked outside of the village much of the time.³⁰ The program expanded to include women’s health and human rights and has shown over 8000 West African communities openly abandoning FGC. Their Community Empowerment Program includes three parts: human rights-based classes, the formation of Community Management Committees, and social mobilization.^26,37,38

Classes use traditional African methods, such as theater and dance, to encourage dialogue about societal issues, often leading to discussions surrounding positive change. Classes also incorporate skill-building, such as literacy and project management. Community Management Committees comprise 17 people from the area, including at least nine women, and are responsible for implementing projects designed by the community.³⁸ Locals make all the decisions and implement their plans, showing empowered people and healthier communities.^26,30 Finally, social mobilization or organized diffusion spreads new ideas and information to other connected groups, increasing opportunities for positive change.^34,38,39

Sponsored Arts for Education (S.A.F.E.)

S.A.F.E., another program successfully reducing rates of FGC, works in Maasai communities of Loita Hills in Southwest Kenya. Through in-depth conversations with the community, it recognized that the most appropriate method in reducing the practice of FGC would involve an alternative rite of passage to publicly recognize and celebrate the necessary change from a girl to a woman.³⁷ S.A.F.E. prepares the community’s trained birth attendants, who perform FGC, to assist in the alternative rite of passage, which involves pouring milk onto a girl’s thigh to represent her transition to womanhood.^18,37 Additionally, the program challenges cultural norms surrounding FGC through public performances, community workshops and meetings, health clubs in schools, and interventions with individual families.⁴⁰

The S.A.F.E. outreach team has collected detailed information from families through individual-level communication (Reding N, Personal communication, 8 November 2017). Since the program began, the Maasai of Loita Hills have seen a 30% reduction in FGC incidence, and only 10% of the girls in the community received FGC of any other than type I. Before program implementation, 99% of the girls experienced type II or III.^18,39 Program advocates include women and men, young and old, and cutters and traditional birth attendants, several of whom take on leadership roles within the community. The variety of local commitments contributes to the long-term success of their goals.^37,39

Ethical Considerations

Marsabit County, Kenya, would benefit from the development and implementation of programs such as the above. At first glance, a program intended to reduce FGC seems to have little to no ethical risks. But indeed alternative views and understandings must be considered when creating and designing any program. Upon closer examination, there are important ethical considerations that cannot be ignored. From an international human rights perspective, FGC violates children and discriminates against women. Yet in many cultures, as a rite of passage, FGC provides the chance for a girl to become a fully actualized woman, to step into her rightful place in society as a wife and a mother, and is embraced and celebrated by women.^12,27,28,30 We must take care not to impose Western ideals onto other cultures, using our power to unnecessarily alter tradition and identity.

In addition, the international stance condemning FGC is not equal across continents. For example, the famous female cosmetic genital surgeries (FCGS), even among teenagers, in Europe and the United States are very similar to what is considered mutilation in Africa (e.g., clitoral unhooding, labial trimming, or vaginal tightening). As these procedures alter female genitalia without a medically necessary reason, they would likely fall under the WHO definition of FGC,⁴ yet they are not considered illegal or a violation of rights in this setting because the individual (and her parents when necessary) has requested and consented to the process.²⁷ Of course, women and girls in many global communities strongly support the practice of FGC as well.^2,27,28 In some cases, girls have taken the initiative to undergo FGC themselves, clearly consenting to the procedure, when authority figures have tried to condemn the practice through legislation and punishment.^27,28 In addition, male circumcision, regardless of type and level of harm, is considered acceptable, perhaps because it is a common practice in the West. These contradicting views suggest racism and ethnocentrism.^2,27,29 It is not ethical to condemn a practice and attempt to eradicate it simply because it is unfamiliar or does not feel comfortable in one specified setting. Programs in Europe and the United States intending to alter the cultural practices of immigrants or ethnically diverse women must also address the conflict of FGC versus FCGS. The international community should consider males and females in all settings to promote a thorough and equitable stance of what is and is not acceptable.

We must also take care not to ignore women by negating their thoughts about FGC or to minimize African voices because international agendas overwhelm the conversation.^27,34 African women have expressed wonder at the realization that certain international agendas prioritize FGC above other concerns that feel more pressing in their reality.^2,40 For example, fewer women die from FGC-related causes than from malaria, diarrhea, or starvation.²⁹

Emphasizing the idea that women in other cultures need help and protection from outside sources may also turn them into helpless victims in our minds, unable to make their own decisions. Yet, women are not powerless, and coercive attempts to curb FGC may increase the practice underground.^{2,22,23,28,33–36} Program designs can and should encourage voluntary abandonment of FGC, intentionally respecting the self-determination and strength of women.^26,30,34,35

Balancing physical health and cultural risk, alongside cultural freedom, proves difficult when considering FGC and its consequences. Programs intended to reduce the incidence of FGC should involve local women through all phases of development and implementation and should intentionally avoid disrespecting women and culture and instead reinforce the beauty and strength within both. Working alongside grassroots organizations within the community can provide insight into the acceptability of ideas and increase accountability to the local culture. Indeed, culture is not static. It swings and shifts through time, and peering through the lens of different cultures presents new ideas and possibilities for positive change.^{12,29,35,41,42} Programs must be community-led, focusing on a community-wide shift in social norms. Along with women’s empowerment, these aspects can encourage healthy change within Marsabit County as well as other communities with high FGC rates worldwide.³⁰

Future Research

Future research is needed to gain a more in-depth understanding of the current context of FGC and what will encourage the reduction of the practice. Using a gender-transformative perspective, the thoughts, opinions, and ideas of women, girls, birth attendants, and female leaders in communities with high FGC rates can provide clarity about this issue while also instigating ideas that will reduce FGC and improve other aspects in the community, as Tostan and S.A.F.E. have shown. Male voices can also add to a critical cultural understanding by providing more ideas about creating gender-transformative programs that will reach entire communities.

In addition, research is needed to pick apart the varied ethical considerations related to FGC. Specifically, an exploration of differences between what has been deemed acceptable Western practices and unacceptable foreign practices (i.e., FGC vs. FCGS and FGC vs. male circumcision) can provide an evidence base for programmatic equity and scope.

Conclusion

The practice of FGC heavily affects women and communities in Marsabit County, Kenya. Programs focusing on human rights, community engagement, and women’s empowerment and self-sufficiency can encourage a shift in cultural norms surrounding FGC and ultimately reduce the practice. Programs can move toward community-wide voluntary abandonment of FGC by promoting cultural movement through mobilizing the community to critically engage with previous experiences, communicate as a group, and work together to find their best approach to respecting and celebrating the lives of all community members.

Such interventions can significantly impact the lives of girls, women, and all community members in Marsabit County by influencing the immediate issues surrounding human rights and women’s health, long-term reproductive outcomes, and overall community wellness and sustainability. By shifting community norms surrounding the desirability and acceptability of FGC, girls will discover greater opportunities for achievement through fewer health risks and increased equality.