Female Genital Cutting in Somaliland: Baseline Assessment

Female genital cutting in Somaliland: Baseline assessment

Somaliland Family Health Associaton (SOFHA) Katy Newell-Jones, Orchid Project | January 2017 The female genital mutlaton/cutng (FGM/C) Research Capacity Building project’s main purpose is to provide high-quality research-based evidence to support Norway’s 2014–2017 strategy for intensifying internatonal eforts to eliminate FGM/C.

The project is led by Populaton Council, Nairobi and funded by the Norwegian Agency for Development Cooperaton (Norad) providing support and building capacity to generate and use research evidence amongst Norad partners - Somaliland Family Health Associaton (SOFHA) based in Somaliland, Norwegian Church Aid and Save the Children in Ethiopia and Norwegian Church Aid and Save the Children in South-Central and Puntland Somalia.

SOFHA works in the feld of reproductve health in Somaliland as well as all of its cross- cutng issues. In Somaliland, there is no issue more interwoven into women’s health than FGM/C. SOFHA is determined to see the end of FGM/C in one generaton and is working with local and internatonal partners to develop and implement evidenced based interventons.

Orchid Project has a vision of a world free from female genital cutng (FGC). Orchid Project was set up in 2011 to pursue this vision and works as a catalyst for change to foster and accelerate the abandonment of FGC. As a UK charity with global reach Orchid Project works through partnering, sharing and advocacy to end FGC worldwide. www.orchidproject.org

Populaton Council confronts critcal health and development issues—from stopping the spread of HIV to improving reproductve health and ensuring that young people lead full and productve lives. Through biomedical, social science, and public health research in 50 countries, we work with our partners to deliver solutons that lead to more efectve policies, programs, and technologies that improve lives around the world. Established in 1952 and headquartered in New York, the Council is a nongovernmental, non-proft organisaton governed by an internatonal board of trustees. www.popcouncil.org

To cite this report: Newell-Jones, K. 2017. ‘Female genital cutng in Somaliland: Baseline assessment’, January 2017

Please address any inquiries about the FGM/C Research Capacity Building project to: Dr. Jacinta Muteshi, Project Director, [email protected]

Funded by: The views and interpretatons in this report are those of the author and do not necessarily represent those of the Norwegian Agency for Development Cooperaton (Norad).

2 Aknowledgements

This research was carried out by Somaliland Family Health Associaton (SOFHA) with technical support from Dr. Katy Newell-Jones, Orchid Project, and in close collaboraton with Populaton Council. The research team wish to thank all eight community researchers who carried out the data collecton, the community mobilisers in each community and the various community members who partcipated in the research, sharing their experiences and opinions so openly.

The report was writen by Dr. Katy Newell-Jones, Independent Consultant at Orchid Project. The author of this report is grateful for insightul review and comments by Amal Ahmed, Executve Director, SOFHA, Lucy Walker, Programmes Manager, Orchid Project, Jacinta Muteshi, Project Director, FGM Research Capacity Building Project and Chantalle Okondo, Assistant Programme Ofcer, Populaton Council.

The FGM/C project is led by Populaton Council, Nairobi and funded by the Norwegian Agency for Development Cooperaton (Norad) providing support and building capacity to generate and use research evidence amongst Norad partners such as Somaliland Family Health Associaton based in Hargeisa, Somaliland.

SOFHA works in the feld of reproductve health in Somaliland as well as all of its cross cutng issues. In Somaliland there is no issue more interwoven into women’s health than FGM. SOFHA is determined to see the end of FGM in one generaton and is working with local and internatonal partners to develop and implement evidenced based interventons.

3 Contents

Executve Summary 5

1. Context of female genital cutng in Somaliland 6 1.1 Terminology 6 1.2 Existng knowledge 6 1.3 Gaps in existng knowledge 7

2. Methodology 8 2.1 Terms of Reference for the baseline research 8 2.2 Overall approach 8 2.3 Research tools 8 2.4 Data collecton 9 2.5 Analysis 9 2.6 Sample size 9 2.7 Limitatons 11

3. Research fndings 12 3.1 Prevalence of female genital cutng amongst women and girls in Somaliland (Goal 1) 12 3.2 Complicatons of female genital cutng and access to clinical and support services (Objectve 4a) 15 3.3 Knowledge of the types of cut and their efects on girls and women (Objectve 2b) 18 3.4 Messages heard on female genital cutng (Objectve 2c) 19 3.5 Support for abandonment of female genital cutng (Objectves 2a and 2d) 22 3.6 Attudes of young people 27 3.7 Attudes of teachers and the role of schools in abandoning female genital cutng 29

4. Key Themes 35 4.1 Change is happening and hoped for by over 90% of community members 35 4.2 Increased medicalisaton of cutng 35 4.3 Knowledge and awareness among communites is higher than antcipated 36 4.4 Opportunites to exchange experiences and opinions about female genital cutng are limited 36 4.5 People face decision-making dilemmas about female genital cutng 36 4.6 Schools require support to become environments for change 37 4.7 Youth (female and male) are an untapped resource for change 37 4.8 Promotng health seeking behaviour receives limited atenton 38

5. Implicatons for the project 39 5.1 Selectng and supportng change agents 39 5.2 Approaches to ‘sessions’ 39 5.3 Promotng health seeking behaviour 39 5.4 Supportng schools 39 5.5 Training manuals and handbooks 39

6. Recommendatons for monitoring, evaluaton and learning 40

7. Conclusions 43

Appendix A: Terms of Reference 44

Appendix B: SOFHA project performance monitoring plan 46

Appendix C: Community survey questons 55

Appendix D: Interviewees 57

4 Executive Summary

This report summarises research fndings into the prevalence and attudes around female genital cutng (FGC) in 20 communites across 5 regions of Somaliland (Awdal, Maroodi Jeex, Sanaag, Saaxil and Togdheer). A mixed method approach was adopted involving a community survey of 1847 individuals (53% female, 47% male). There was a specifc focus on young people, who accounted for 47% of the interviewees, and also on the role of schools in promotng abandonment of cutng. The community survey was supported by selected focus group discussions and key informant interviews. This research found that the prevalence of FGC in the 5 regions studied is 98.9% across all age groups, city, semi-city and village communites.

The type of cut young women and girls report as having undergone is changing from the pharaonic towards the In Somaliland, traditonally most girls and women have intermediate cut and sunna. Among 15-24 year olds, 38% undergone the pharaonic cut (WHO type III) with a underwent the pharaonic cut, 33% the intermediate cut, 27% very small number of girls undergoing the sunna, which the sunna and less than 1% remain uncut. This change is greatest involved no sttches (WHO type I). Recently, there has among young women who atend school. been an increase in the use of the intermediate cut, ofen referred to as sunna2 (WHO type II). This is seen as causing There is evidence of increasing pressure towards the less damage than the pharaonic cut, yet stll partally medicalisaton of cutng. 11% of young women (15-24 years) closes the vaginal orifce with two or three sttches. In interviewed were cut by a health professional (nurse, midwife, this research, the term ‘sunna’ is used to refer only to doctor), with 16% of women reportng that their own daughters WHO type I, which requires no sttches and the term were cut by a health professional. The trend is strongest in city ‘intermediate’ is used for WHO type II. The community and semi-city communites and among those who have atended researchers were trained to clarify the precise type of cut school. to which partcipants were referring, asking, in Somali, 90% of men and women want to see some kind of abandonment, whether or not sttches were involved and if so whether although desire for abandonment exists primarily in relaton to the vaginal orifce was partally or completely closed. the pharaonic. Only 5% want to see the abandonment of all types of cutng. Men appear to be more open to change than women, with only 2% of men wantng to retain the current situaton of individual teachers. Twice as many (84%) teachers felt that in regard to FGC, compared with 17% of women. Women schools had a role to play in relaton to FGC than had actually experience a greater pressure to conform to social norms on FGC spoken about it at school (42%). More awareness raising as well and a lack of communicaton between men and women suggest as capacity building is needed among teachers in order for them that women’s percepton of men’s preferences might not always to be efectve change agents. be accurate. Although 72% of people have heard messages about FGC there The level of awareness among community members about FGC is litle dialogue taking place among families. In community is higher than antcipated. Virtually all of those interviewed meetngs and workshops, community members are expected to (96%) knew that there were diferent types of cut used in their listen to ‘facts’ presented by ‘experts’. In most school sessions communites. The vast majority of women (94%) and men parents and girls are expected to be passive listeners, rather than (97%) were able to list complicatons resultng from cutng with being encouraged to discuss their experiences and opinions about sttches. These fndings suggest that decisions about cutng are FGC. In focus group discussions, partcipants reported that these being made despite people knowing about the types of cut and were the frst opportunites to exchange opinions and discuss FGC many of the complicatons involved. This suggests that lack of among themselves and many reported changing their opinions on knowledge is unlikely to be the primary reason for contnued the type of cut they would prefer their daughters to undergo. cutng in most instances. Decision-making in relaton to FGC involves complex decision- Over half of women said they had experienced severe pain as making dilemmas. Parents, for example, are balancing conforming a result of being cut, irrespectve of the type of cut they had to the social expectatons to verify their daughters’ purity and undergone. An even higher proporton (75%) of women said that virginity by cutng, whilst simultaneously not wantng their they have sufered long-term complicatons as a result of being daughters to sufer from complicatons as a result of being cut; 77% of women who had undergone the pharaonic cut and cut. Midwives and other health professionals are faced with 60% who had undergone the sunna. Two thirds of these have the contradicton between their personal preference, their sought support in dealing with complicatons arising from being understanding of their professional role and the pressure they cut, predominantly from a family member. Less than 5% sought feel under to minimise the harm done to an individual girl. support from a health professional or health provider. There was Teachers are faced with balancing their personal opinions on litle evidence of schools supportng health seeking behaviour cutng and their understanding of the role of their school. in relaton to FGC by ofering advice on managing complicatons It appears that decision-making in relaton to FGC is less to do arising from being cut or of encouraging girls to access health with having accurate knowledge, and more to do with making facilites. difcult decisions. This has implicatons for the kinds of actvites Most schools are not actvely involved in the movement towards and interactons which are most likely to successfully bring about the abandonment of cutng. Few schools have developed policies changing attudes and, in turn, abandonment of FGC. or whole school approaches to FGC. Advice ofered to girls and Further research is required to understand the factors infuencing their parents is limited and ofen based on the personal eforts decision-making at family and community levels in Somaliland.

5 1. Context of female genital cutting in Somaliland

1.1 Terminology

The terminology used in relaton to female genital cutng (FGC) in Somaliland is complex. Table 1.1A indicates the three broad categories of cut currently being used, how they relate to the WHO classifcaton and the terms used in this research.

Table 1.1A: Classifcaton of types of female genital cutng as used in SOFHA research (linked to WHO classifcaton)

Sunna Partal or complete removal of the clitoris (clitoridectomy), requiring no sttching. (no sttches) Ofen described as removing the tp of the clitoris in Somaliland. WHO type I

Intermediate cut Partal or total removal of the clitoris and the labia minora, with or without excision of the labia majora WHO type II (excision), requiring 2 or 3 sttches to partally close the vaginal orifce. Ofen referred to as sunna or sunna2 in Somaliland.

Pharaonic cut Narrowing of the vaginal orifce with creaton of a covering seal by cutng and re-sttching the labia minora WHO type III and/or the labia majora, with or without excision of the clitoris (infbulaton), requiring 4-7 sttches and resultng in only a very small vaginal orifce.

With Somaliland being predominantly Sunni Muslim, from the MICS (2011) found that 99.1% of women responding had been Shaf’i school of thought, FGC is considered by most not to be cut, with 85% of them having been sewn closed, therefore mandated by Islam in the Qur’an, but subject to guidance, called experiencing the most extreme form of FGC, infbulaton or a ‘Hadith’ (or ‘Sunna’) under Sharia law. pharaonic (WHO type III). EAUH found in its survey from 2002 – 2006 that 97% of women had been cut, and in the second Traditonally most girls and women in Somaliland have undergone survey from 2006 – 2013 that 98.4% of women partcipatng in the pharaonic cut, which equates to WHO type III, with a minority antenatal examinatons had undergone FGC, 82.2% of whom undergoing the sunna, which equates to WHO type I. In recent had experienced the pharaonic cut. The results of the ActonAid years, the intermediate cut (WHO type II) has risen in popularity research in Maroodi Jeex and Todgheer (Newell-Jones 2016) in Somaliland, as it is seen as causing less damage than the showed that: pharaonic, yet stll partally closing the vaginal orifce with two or three sttches. This intermediate cut is being called ‘sunna’ or ‘The overall prevalence rate among community women remains ‘sunna2’ in the community, which can lead to confusion. Senior high at 99.4%, with 80% having undergone the pharaonic cut. clerics and the Ministry of Religious Afairs (MoRA) are opposed There is evidence of a change, partcularly in urban communites, to the pharaonic cut and consider only the sunna, with no away from the pharaonic cut to the intermediate and sunna cuts. sttches, to be acceptable under Sharia Law. Only 34% of girls aged 12-14 years have undergone the pharaonic cut compared to 96% of women aged over 25 years. Just 5% of In this report, the term ‘sunna’ is used to refer only to WHO type girls and women are currently cut by health specialists. However, I, which requires no sttches and the term intermediate is used for there is widespread evidence of increased medicalisaton of WHO type II. The community researchers were trained to clarify cutng, with younger women more likely to have been cut by the precise type of cut to which partcipants were referring, midwives, nurses or doctors. Many religious leaders and some asking, in Somali, whether sttches were involved and if so community leaders are calling for midwives and nurses to be whether vaginal orifce was partally or completely closed. trained to perform the cut safely and hygienically.’ 1.2 Existing knowledge MICS, EAUH and Newell-Jones all show that women are not universally in favour of the contnuaton of FGC, yet almost all of them are cut themselves and many of them intend to cut Data from MICS (20061 & 20112), Crawford and Ali (2015), Edna their own daughters. Crawford and Ali (2015) interviewed some Adan University Hospital (EAUH) (20093 & in prep.), NAFIS men about their attudes, however, the numbers involved are Network (2015)4 and Newell-Jones (2016)5 all indicate that relatvely small and they identfy the need for more research Somaliland has an overall prevalence rate of around 99% of girls data from men and boys about their knowledge, attudes and women undergoing FGC. and beliefs around FGC in Somaliland. Further data has been provided by Newell-Jones (2016) indicatng that men are ofen 1. www.childinfo.org/fles/MICS3_Somalia_FinalReport_2006_eng.pdf not well-informed about the diferent types of cut being used 2. www.unicef.org/somalia/SOM_resources_somalilandmics4_fnalreport.pdf in Somaliland and therefore are open to misinformaton about 3. htp://ednahospitalfoundaton.org/wp-content/uploads/2014/10/female-genital- what is happening to their daughters or sisters. This study also mutlaton.pdf 4. NAFIS Network (2015) Assessment of prevalence, percepton and attude of highlighted the decision-making dilemmas which many parents female genital mutlaton face, ofen not wantng to harm their daughters but also wantng 5. Newell-Jones K (2016) Empowering communites to collectvely abandon FGM/C to conform in order to be able to demonstrate their daughter’s in Somaliland AAIS/ORCHID htps://orchidproject.org/resource/empowering- virginity. Given that FGC is identfed as a pre-requisite for communites-to-collectvely-abandon-fgmc-in-somaliland/

6 marriage, the attudes and expectatons of men and boys are an The role of schools in the abandonment of female genital cutng important factor in understanding the drivers in relaton to the contnuaton of the practce. Previous research (Newell-Jones 2016) indicated that schools do not currently play a strong role in actons to promote the There is clear evidence from the research in Maroodi Jeex and abandonment of FGC in Somaliland, however, they are infuental Togdheer of a desire for change in relaton to FGC among all places atractng respect from across the community. Those who stakeholder groups, including religious leaders, the MoRA and have atended school are less likely to have undergone the most senior clerics (Newell-Jones 2016). Only 18% of community severe forms of FGC, suggestng that there is a link between members would like to maintain the existng situaton in their access to educaton and decision-making in relaton to FGC. In community, leaving 82% in favour of change of some sort. The countries where the prevalence of FGC has decreased, schools preferred opton is a move towards the abandonment of the have played a signifcant role in the disseminaton of informaton pharaonic cut. However, less than 10% of community members and in providing forums for parents and children to talk. SOFHA supported the introducton of a law based on Zero Tolerance and already had strong connectons across the Ministry of Educaton, only around 5% aspired to an abandonment of all forms of cutng natonally and regionally, and also among schools, hence the in their community. inclusion of schools and teachers in this project and the baseline research. 1.3 Gaps in existing knowledge Access to health support services in relaton to female genital cutng This baseline research aims to shed light on the following specifc areas, as well as providing baseline data against which progress The government is working with health workers to curb the move can be monitored in the current SOFHA project (see Terms of towards medicalisaton and to support their role as providers of Reference 2.1 for the specifc goals and objectves). guidance for the abandonment of cutng and advice and support for girls and women who have been cut. However, there is litle Prevalence rates and types of cut of female genital cutng evidence of the kind of support which young girls seek or the among young girls skills among health workers for this role.

There is limited data on the prevalence of FGC among young girls, The potental role of young men towards the abandonment of although the research in Maroodi Jeex and Togdheer (Newell- female genital cutng Jones 2016) indicated that there was only a very small decrease in the overall prevalence but a shif away from the pharaonic There is general agreement that young men are key stakeholders towards the intermediate and sunna cuts. Further research in the abandonment of FGC in Somaliland, especially given that into the factors causing such shifs would be valuable, including marriage is seen as the source of social-economic status and perhaps the messages given by diferent schools and the level of stability for many women in Somaliland. However, relatvely litle educaton among parents. is known about the attudes of young men and how they see their role in the movement towards abandoning all forms of cutng.

7 2. Methodology

2.1 Terms of Reference for the survey as the primary data collecton was in line with a social norms approach as it gathered data on the opinions and attudes baseline research of a wide range of community members.

This baseline research was carried out across fve regions in The baseline research used a mixed method approach involving Somaliland (Awdal, Maroodi Jeex, Sanaag, Saaxil and Togdheer) a community survey supported by a series of focus group with the following four objectves: discussions and key informant interviews. Self-reportng was used as the means of gathering data on the prevalence and types of • To identfy the prevalence of FGC among women and school cut women and girls had undergone. aged girls An inital community mapping actvity across all regions • To understand the knowledge, attude and practce regarding of Somaliland informed the selecton of the regions and FGC among parents, adolescents and teachers communites in which the data collecton took place.

• To investgate young men’s future preferences and their role The primary data collecton was a community survey which in interventons to end FGC involved individual interviews using a survey questonnaire. This was supported by a series of focus group discussions and key • To gather relevant baseline data for key project indicators to informant interviews. enable changes in benefciaries’ lives to be measured over the course of the project. 2.3 Research tools Below are those key project indicators specifcally identfed for the baseline research. The questonnaire for the community survey was developed through collaboraton between the consultant and the SOFHA team. It used Open Data Kit sofware and smartphones for mobile Goal 1 Prevalence of FGC amongst women data collecton. The topics covered by the questons are listed and girls in Somaliland below. See appendix C for the full list of questons.

• Introducton - name, gender, age, community, educaton, Objectve 2a * Percentage of populaton supportng role (teacher, health professional, home-based, farmer etc.), abandonment of FGC married, parent, daughters in primary grades 1-3

• Knowledge of types of cut - sunna, sunna2/intermediate and Objectve 2b Percentage of people who know the pharaonic efects of FGC • Knowledge of complicatons of cutng with and without sttches Objectve 2c Percentage of people who report to have heard ant-FGC messages • Intentons for future daughters, preferences for daughters- in-law

Objectve 2d * Percentage of populaton NOT • Messages heard - where from, what types of messages supportng alternatve FGC • Ant-FGC actvites – current involvement, what type, future involvement, what type, barriers to involvement Objectve 4a Percentage of women and girls afected by FGC who have received FGC related • Aspiratons for abandonment – the pharaonic, the clinical and support services intermediate, all types of cutng

• Personal questons for women

* Objectves 2a and 2d are linked and have been combined for the purpose of the • Questons about their own experience - whether they baseline study. were cut, which type, age, who cut, complicatons, See appendix A for the full Terms of Reference and appendix B health seeking behaviour, whether they were re-cut in for the full list of project indicators from the project management preparaton for marriage plan (PMP). • Questons about their daughters – whether they were cut, which type, who cut, complicatons 2.2 Overall approach • Unmarried men’s preferences for future wife, does the cut SOFHA adopts a social norms approach to FGC, recognising that status of their future wife mater the decisions individual households make about whether or not • Teachers - role of school, whether they talk about cutng to cut their daughters and the type of cut to use are infuenced in school, who with, messages given, requests for advice, signifcantly by the expectatons, real or imagined, of those they actons before long holidays. interact with on a regular basis. The selecton of a community

8 Obtaining ongoing consent was built into the questonnaires, for 2.5 Analysis example before personal questons were asked of women about their own experience of being cut they were asked if they were willing to contnue with the questonnaire. The questons were The data analysis was a collaboratve process involving the available in both Somali and English. consultant and the SOFHA team through a rigorous process of review and refnement. The community survey data forms Most questons had a series of response optons (see appendix C). the basis of the fndings. Key themes were identfed from the The community researchers did not read the list out but allowed focus group discussions and key informant interviews which the interviewees to talk in response to the queston and then were verifed by the SOFHA team members responsible for the selected the appropriate response(s) from the optons, or tcked translaton during these actvites. other and inserted text for responses not listed. 2.6 Sample size The questonnaire was piloted frstly among the community researchers and the SOFHA team during the workshops on ethical research and secondly with community men and women. The Data collecton took place in 20 specifc communites in fve questonnaire was refned as a result of feedback from pilotng regions: Awdal, Maroodi Jeex, Saaxil, Sanaag, Togdheer. Of the actvites. 20 communites 13 were urban (10 city, 3 semi-city (large towns) and 7 were village communites (small rural communites)). The The focus group discussions and key informant interviews SOFHA team felt that the division into the 3 categories of city, followed a semi-structured approach, covering the same broad semi-city and village refected the diferent types of communites. themes as the questonnaires, although allowing for discussion This decision was supported by other civil society organisatons among partcipants and follow up questons. (CSOs) and representatves from the Ministries of Educaton, Health and Labour and Social Afairs.

2.4 Data collection A total of 1847 individuals were interviewed as part of the community survey with an average of 92 people per community. Data collecton was carried out by a team of eight trained (see table overleaf). In some communites, people were engaged community researchers, four female and four male. The in community meetngs which prevented the team reaching community researchers were supported by the senior SOFHA the target number of interviews. In other drought-afected team who coordinated the data collecton process, accompanying communites it was not possible to reach the target number of the community researchers to the communites, monitoring the interviews. process and ensuring the data was uploaded to the server daily. Overall, of the 1847 interviewees, 971 (53%) were female and The consultant facilitated a series of workshops on ethical 876 (47%) were male. 859 (47%) were 15-24 years of age and research prior to the data collecton for the SOFHA team and 988 (53%) were aged over 25 years. A total of 209 teachers were the community researchers. These workshops covered the key interviewed. principles of ethical research, diferences between research and project implementaton, informed consent, incentves, child protecton, confdentality, managing distress and minimising researcher bias as well as the practcalites of sampling, data collecton and security.

All interviews were carried out in Somali by a person of the same gender as the interviewee. The team of community researchers worked in two teams of two male and two female community researchers.

In each target community, the research team aimed to interview approximately 100 people, with a balance of community women and men from diferent backgrounds and specifcally including young men and women from school, university and the community. The sampling process was biased in favour of young women and men as these are an important target group which SOFHA considers to be partcularly important in relaton to female genital cutng.

Female community researchers visited schools and health clinics, selected randomly from community lists, and also undertook a household survey, again selectng households at random. Male community researchers visited schools, tea rooms and mosques where men were likely to gather. Specifc locatons were selected using random selecton techniques (dice and a pencil compass). Individual interviewees at each locaton were selected again using random selecton techniques.

9 Region Community City/semi-city/ No. female No. of male Total village interviewees interviewees interviewees

Sanaag Daallo (Cerigabo) City 23 42 65

Yufe Village 60 57 117

Gudmo Biyo Cas Village 59 61 120

October (Sanaag) (Cerigabo) City 8 19 27

Xaafadsoomaal (Cerigabo) City 40 31 71

Shacabka (Cerigabo) City 55 40 95

Other Sanaag * 10 5 15

Total 255 255 510

Awdal Sheeddheer (Borama) City 32 29 61

Sheekh Ali Jawhar (Borama) City 23 31 54

Dilla Semi City 52 45 97

Qulujeed Village 54 48 102

Gorayo Cawl Village 33 35 68

Total 194 188 382

Saaxil Moskow (Berbera) City 54 45 99

Barwaaqo (Berbera) City 62 42 104

Sheekh Semi City 53 56 109

Abdaal Village 48 38 86

Xamaas Village 50 29 79

Total 267 210 477

Togdheer Yaroowe Village 49 47 96

October (Burao) City 67 49 116

Total 116 96 212

Maroodi Jeex Baligubadle Semi City 55 47 102

Ahmed Dhagax (Hargeisa) City 84 80 164

Total 139 127 266

Grand total 971 876 1847

* People interviewed in Sanaag city communites but living in other city communites

10 An additonal 106 community members took part in 11 focus Timescale of the data collecton process group discussions with young women, young men, secondary school girls (aged 15 or over), community women and teachers. The data collecton process was relatvely short (15 days) due to the need for the SOFHA core team to balance coordinatng Key informant interviews took place with seven people: a the research process and also manage their programme Regional Educaton Ofcer, a Primary and Secondary School commitments. This resulted in only a small number of focus Principal, a gender focus person at a primary school, a traditonal group discussions and key informant interviews being included. cuter and two midwives in community health facilites. The tmescale also prevented the research team from returning to communites where fewer people were interviewed to 2.7 Limitations collect additonal data. However, the advantages of the capacity building of the SOFHA team by coordinatng the research process outweighed the alternatve opton of employing external people Prioritsing of target groups who would be able to dedicate a longer period of tme to the SOFHA had the difcult task of selectng the specifc target process. groups in order to gain baseline data and also to inform the Selecton of communites afected by local conditons natonal debate around FGC. The decision was taken to focus on young people and the role of schools. SOFHA had already There were changes in four of the communites in which the developed close links to schools and was aware that schools are survey took place as a result of local issues. Outbreaks of local not widely perceived as actve agents of change in relaton to violence in communites in Sanaag resulted in the research team FGC. Additonally, the Ministry of Educaton is commited to the having to change communites during the data collecton process. abandonment of FGC and sees schools as central to achieving In additon to this, one of the rural communites in Saaxil had a change. The research has strong data on these target groups, major community meetng taking place which meant that there however, less new informaton is available on other stakeholders, were very few people to interview so the team moved to the including religious leaders and health workers, which have nearest village about 5 km away. been explored in depth by other recent research including the ActonAid research (Newell-Jones 2016).

Reliability of self-reportng data

Many women report that their experience of being cut is etched in their memory with considerable clarity, far more so than other events in their childhood. However, self-reportng on FGC brings with it dangers and limitatons as highlighted in the technical briefng ‘Consideratons on the use and interpretaton of survey data on FGM/C (2016)’6. Care was taken to reduce reportng inaccuracies by a. briefng the community researchers by an experienced doctor and community development ofcer on the types of cut, the names they are called locally, b. ensuring all interviewing took place in Somali and did not use terms like FGM or circumcision but used local terminology, c. designing the questons to be as specifc as possible on the type of cut and not using euphemisms, like ‘purifed’, d. basing the diferentaton of types on the use of sttches as this is more likely to be known and remembered than whether fesh was or was not removed.

These measures reduced the inaccuracies in understanding between the partcipant and the researcher. However, as suggested by Shell-Duncan (2016) there are likely to be some errors through lack of memory and the passing of tme. Askew (2005:472-473)7 concluded that ‘if female genital cutng is widespread, socially acceptable and there is no well-publicised interventon causing people to queston its acceptability and legality….then self-reportng is likely to be valid’.

6. Shell-Duncan B (2016) Consideratons on the use and interpretaton of survey data on FGM/C. Populaton Council htp://www.popcouncil.org/uploads/ pdfs/2016RH_FGMC-HouseholdSurveyTechBrief.pdf 7. Askew I (2005) Methodological issues in measuring the impact of interventons against female genital cutng. Culture, health and sexuality 7(5) 463-477

11 3. Research fndings

3.1 Prevalence of female genital cutting The change in type of cut, from pharaonic to intermediate and sunna, among younger women is refected in the percentage amongst women and girls in Somaliland who have been cut and sewn almost completely closed and are (Goal 1) re-opened before being married. Almost all (97%) of women over 40 were cut open for marriage, as opposed to 71% of girls and women aged 15-24 (chart 3). A total of 881 women, across the 22 target communites in the 5 regions of Awdal, Maroodi Jeex, Saanag, Saaxil and Togdheer, agreed to answer personal questons about whether and how Chart 3: Percentage of married women cut open on their they were cut. Of these, 871 women reported that they had wedding night (by age) been cut, 7 reported being uncut and 3 were unsure, giving an overall prevalence rate of female genital cutng of 98.9%. The prevalence rate is the same for young women 15-24 years as it is for older women (chart 1). Over 60 years

41 - 59 years Chart 1: Overall prevalence of female genital cutng

25 - 40 years

Over 60 years 15 - 24 years

41 - 59 years % 0 10 20 30 40 50 60 70 80 90 100

25 - 40 years Key Cut open on wedding night Not cut on wedding night

15 - 24 years

The reasons given in focus group discussions for the change % 0 10 20 30 40 50 60 70 80 90 100 were mainly concerning the health of girls and women. The term hygiene used below refers to the whole range of complicatons Key experienced by girls and women afer undergoing the pharaonic Don’t know Uncut Cut cut.

There is strong evidence of a change in the type of cut which “We used to do the pharaonic cut on all younger women are undergoing (chart 2). Almost 90% of women girls but now this has reduced and most aged over 25 years underwent the pharaonic cut. This percentage has dropped dramatcally in recent years to 38%, with 33% young women are having a less severe cut. undergoing the intermediate cut and 27% undergoing the sunna We changed because we realised all of the only. problems of hygiene associated with being cut…Every month we used to get infections, Chart 2: Type of cut of women by age and swelling and many other things that women must live with for the rest of their lives

Over 60 years after they are cut.”

Community woman, Abdaal, village community, Saaxil 41 - 59 years The infuence of educaton on female genital cutng

25 - 40 years It is widely thought that there is a strong correlaton between whether a girl atends school and the severity of the type of cut which she has undergone. This is supported by evidence 15 - 24 years from this research. Of the young women (aged 15-24 years) interviewed, those who have not atended school at all were more likely to have undergone the pharaonic cut and less likely % 0 10 20 30 40 50 60 70 80 90 100 to have undergone only the sunna (chart 4) than those who Key have atended school where the patern of cutng is more equal Pharaonic Intermediate Sunna Uncut Don’t know/decline between the pharaonic cut, intermediate cut and sunna.

12 Chart 4: Relatonship between educaton and type of cut Chart 6: Percentage of girls and women cut by health undergone among young women aged 15-24 years professionals (by age)

School or Over 60 years university

41 - 59 years No school

25 - 40 years % 0 10 20 30 40 50 Key Pharaonic Intermediate Sunna Uncut 15 - 24 years

% 0 2 4 6 8 10 12 The age at which women were cut Key There has been a gradual reducton of the age at which girls are Nurse Midwife Doctor Total health professionals cut, with progressively fewer girls being cut aged over 12 years and more being cut aged under 8 years (chart 5). 79% of young women (aged 15-24) interviewed were cut before they were 11 For the 11% of families who chose to use a trained health years old. Few, if any, girls remain uncut untl such tme as they professional (nurse, midwife or doctor) to cut their daughters, could play a signifcant role in the decision-making process. 6% used a nurse, 3% a midwife and 2% said they used a doctor. Community members might not be sure of the distncton between a doctor, midwife and nurse, however, the community researchers were careful to ensure that all those recorded as Chart 5: Age at which girls are cut using health professionals were referring to a trained health worker and not using the term nurse or doctor to refer to a traditonal cuter or TBA. Over 60 years There are clear links between atendance at school and university and the type of person used to perform the cutng (chart 7). 41 - 59 years Families where the girls did not go to school tended to use TBAs, whereas those families where girls atended school and university were more likely to select a trained health professional. 25 - 40 years

Chart 7: Selecton of health professionals as cuters linked 15 - 24 years to educaton

% 0 10 20 30 40 50

Key University Cut aged Cut aged Cut aged Cut aged Cut aged under 8 9 or 10 11 or 12 13 or 14 over 14 Secondary

The people who are performing the cutng Primary The overwhelming majority (92%) of women were cut by traditonal cuters (89%) or Traditonal Birth Atendants (TBAs) (3%), who usually have strong links with health facilites and No school whose primary role is supportng women in child birth.

There are signs that this is changing with an increase in the % 0 2 4 6 8 10 12 14 percentage of cutng being performed by qualifed health Key professionals (nurses, midwives and doctors) among younger women (chart 6). Among young women aged 15-24 years, cutng Nurse Midwife Doctor Total health professionals by health professionals comprised 11% of the cutng. There is also evidence of an increase in the intentons of young women to use health professionals for their own daughters (see secton 3.6 There are signifcant diferences in the medicalisaton of cutng chart 42). between city, semi-city and village communites (chart 8). In rural villages, where health facilites are limited, only 5% of cutng is performed by health professionals, as opposed to 11% in city communites where there are more hospitals and Midwife, Maternal and Child Health centres (MCHs).

13 “For myself, my daughter would go to the Chart 8: Percentage of girls and women cut by health workers in city, semi-city and village communtes MCH for a hygienic and safe cut. It is free and safe at the MCH.”

Principal, Sheikh Secondary School City Decision-making dilemmas of health professionals

Health professionals, nurses, midwives and doctors sometmes Semi-City seem to have contradictory attudes towards FGC in their personal and professional lives. It is not unusual to meet someone who supports the abandonment of all types of cutng, Village yet in their professional role they perform the cut on young girls. When questoned, they usually explain this contradicton as a professional dilemma as demonstrated by the example below of

% 0 2 4 6 8 an experienced and commited midwife in a rural village maternal health centre. Her name has been changed to protect her identty Key and that of the MCH. Nurse Midwife Doctor Total health professionals

Midwife, Maternal and Child Health centre (MCH), Further evidence of changing practce comes from the reports village community from women who have cut their daughters. Overall, 8% of women interviewed reported that they were cut by a health worker, Zeinab has been a trained midwife for over 10 years. She whereas 16% reported that they had used a health worker to has been involved in campaigning for Zero Tolerance with a cut their daughter(s). Once again there is a marked diference local NGO and would prefer for all types of cutng to stop, between village, semi-city and city communites. Health including the sunna with no sttches. professionals (nurses, midwives and doctors) perform only 7% of cutng in village communites, as opposed to 18% and 24% of Usually in this community, mothers invite a traditonal cutng in semi-city and city communites (chart 9). cuter or TBA from Hargeisa or Berbera to perform the cutng on a group of girls. Many of the girls sufer infectons, severe pain, difcultes with menstruaton and Chart 9: Percentage of WOMEN’S DAUGHTERS cut by other severe complicatons. As a midwife, she sees young health workers in city, semi-city and village communites girls and women seriously damaged by being cut. Zeinab says, “I have to re-open girls for marriage, then cut them again for childbirth. I feel very bad about this painful process”. City Some mothers ask her or one of the other two midwives to cut their daughter hygienically with antseptc. “I always try to persuade the mothers not to cut their daughters by Semi-City telling them about the complicatons. Usually they are not persuaded and so I do the sunna, taking of the tp of the clitoris which usually needs 1 or more sttches to stop the Village bleeding”, she says.

Zeinab would prefer to leave the girls untouched but fears that if she refuses they will be harmed much more by % 0 5 10 15 20 25 going to the TBA. “I always try to persuade them, but if Key they won’t change their minds I do it to stop them being Nurse Midwife Doctor Total health professionals cut somewhere else”.

She says there is no payment for cutng girls at the government facility. There are also no records of the In the focus group discussions, people talked openly and proudly procedure being carried out. Every other procedure would of using health professionals to perform the cutng. be recorded but there is no form for doing female genital cutng, so it goes unrecorded. “the move was initially from the pharaonic to the intermediate with 2 or 3 stitches but now She recognises the contradicton between cutng girls and campaigning for Zero Tolerance. “One is what I have to do women take their daughters to the hospital as a midwife, the other is what I hope for in my community where they have the sunna with no stitches.” in the future”.

Prominent woman campaigner for Zero Tolerance, Shaabka, Berbera

14 The midwife above clearly blamed the mothers for insistng that be strongest in the semi-city communites and weakest in city she perform the sunna2, a cut with stches. In the focus group communites. The city communites selected included some with discussions, there were also examples of mothers blaming health high concentratons of internally displaced people where access professionals for using sttches when they had asked for the to educaton is low, which might explain why the move towards sunna with no sttches, the sunna is weaker in the city than the semi—city communites. Further research would be required to clarify this. “For myself, my daughter would go to the School atendance is linked to the type of cut a young woman Midwife, Maternal and Child Health centre undergoes, with those atending school more likely to undergo (MCH) for a hygienic and safe cut. It is free the intermediate or sunna cuts. and safe at the MCH.” The age at which girls are being cut appears to be reducing with 79% of young women being cut aged 8 years or under. Community woman, Abdaal, Saaxil Although the majority of young women are stll being cut by a Conclusion traditonal cuter, there is evidence of increased medicalisaton of cutng with 14% of young women (aged 15-24 years) being The overall prevalence rate of FGC is 98.9% among the 881 cut by a health worker, 10.5% of whom were cut by a trained women interviewed. This rate is consistent across the age ranges health professional (nurse, midwife or doctor). The use of trained of the women, whether they live in city, semi-city of village health professionals is higher among families where the girls communites or whether or not they atended school. atend school and university. The medicalisaton of cutng is also more marked in city and semi-city locatons where access to There is strong evidence of a change in the type of cut which health professionals is higher. 21% of women have used a health younger women are undergoing and the type of people professional to cut their own daughters, which confrms the move performing the cut. Almost 90% of women aged over 25 years towards medicalisaton. underwent the pharaonic cut, as opposed to just 38% of young women aged 15-24 years. 27% of young women underwent the Some health professionals who are cutng young girls have sunna, which is refected in 29% of married young women not explained that they do so in order to avoid more damage being being re-cut open on their wedding night, as opposed to 9% over done by the girls being cut by non-health care workers. There is 25 years old. evidence of blame between health professionals and mothers as to who is responsible for the contnuaton of the use of sttches The change towards the sunna among young women appears to with both claiming it is the wish of the other.

3.2 Complications of female genital cutting and access to clinical and support services (Objective 4a)

98.9% of women interviewed had been cut and of these, 59% had experienced complicatons shortly afer being cut. The percentage of women sufering complicatons is considerably less (43%) among young women aged 15-24 years, than among those aged 25-40 years (70%) or over 40 years (85%).

Chart 10 shows the most commonly reported complicatons experienced. Although there was a higher incidence of long-term complicatons among those who had undergone the more severe forms of cutng, over half of women said they had experienced severe pain as a result of being cut, irrespectve of the type of cut they had undergone.

Chart 10: Most commonly reported complicatons linked with undergoing female genital cutng

Fistula

Swelling

Shock

Psychological trauma

Problems conceiving/infertility

Diffculties with marriage relationships

Infection/fever

Problems in childbirth

Severe bleeding/slow healing

Diffculties passing urine/incontinence problems

Problems with menstruation

Severe pain

% 0 10 20 30 40 50 60

15 An even higher proporton (75%) of women interviewed said that Two thirds (64%) of girls and women who sufered complicatons they have sufered long-term complicatons as a result of being afer being cut sought support. This proporton is consistent cut. This was highest (77%) among women who had undergone across the age range and also across city, semi-city and village the pharaonic cut, however, 60% of those who said they had locatons (chart 12 and chart 13). undergone the sunna said they had long-term complicatons. These complicatons tended to be problems with menstruaton and infectons. Chart 12: Percentage of women who were cut, who Women who had undergone the pharaonic cut reported having a sufered complicaton and sought support (by age) higher incidence of severe bleeding/delayed healing, difcultes in passing urine/incontnence problems, problems conceiving/ infertlity, difcultes with marriage relatonships and problems in Over 40 childbirth (chart 11). 25-40

Chart 11: Diferences in the complicatons experienced by 15-24 women who had undergone the pharaonic, intermediate and sunna cuts % 0 20 40 60 80 100

Key Cut Complications Sought support Pharaonic

Chart 13: Percentage of cut women who were cut, sufered complicatons and sought support (city, semi- Intermediate city, village)

City

Sunna Semi-city

Village % 0 10 20 30 40 50

Key No long term effect Severe bleeding/slow healing % 0 20 40 60 80 100

Diffculties passing urine/incontinence Problems concieving/infertility

Diffculties with marriage relationships Problems in childbirth Cut Complications Sought support

16 Chart 14: People and services where women sought support afer being cut

Traditional healer

Hospital

Pharmacy

MCH

TBA

Traditional cutter

Religious leader

Teacher

Friend

Sister

Grandmother

Mother

% 0 10 20 30 40 50 60 70 80 90

Key 15-24 years 25-40 years Over 40

Although two thirds sought support, fewer than 5% of these, sought professional support from a MCH, pharmacy or hospital (chart 14). Advice and guidance tends to be sought from within the family, from the mother, grandmother and sisters.

Conclusion

Over half (59%) of women who had been cut had experienced complicatons shortly afer being cut. This proporton is lower among young women (43%) than among those aged 25-40 years (70%) or over 40 years (85%). The decrease in the incidence of complicatons among younger women is likely to be a combinaton of undergoing a less severe cut and also changes in the conditons in which cutng is carried out, in partcular the use of antseptc, sterilised cutng tools and antbiotcs.

Overall, 75% of women who were cut reported sufering long term complicatons. Problems with menstruaton were reported among women who had undergone all types of cut. The four complicatons which were reported more frequently by those who had undergone the pharaonic cut were; severe bleeding/delayed healing, difcultes in passing urine/incontnence problems, problems conceiving/infertlity, difcultes with marriage relatonships and problems in childbirth.

Two thirds of those experiencing complicatons sought support. However, this was primarily from within their family. Fewer than 5% have sought advice and support from health facilites.

17 3.3 Knowledge of the types of cut and their effects on girls and women (Objective 2b)

Overall, 96% of women and men interviewed knew that there were diferent types of cut, with almost all being able to describe the pharaonic and sunna cuts.

There were diferences in the knowledge of the types between men and women with men being less aware of the intermediate/sunna2 (chart 15). However, 36% of young men (aged 15-24 years) were aware of the intermediate cut. This increased knowledge among young men is most marked in city and semi-city communites where the awareness of the intermediate type cut is approaching that of young women (chart 16).

Chart 15: Knowledge of types of cut (by age and gender) Chart 16: Knowledge among young men of diferent types of cut (aged 15-24 years)

Pharaonic

Pharaonic Intermediate/ Sunna2 Intermediate/ Sunna2 Sunna (no stiches) Sunna (no stiches)

% 0 20 40 60 80 100 % 0 20 40 60 80 Key

Women all Young women (15-24) Key Men all Young men (15-24) Village Semi-city City

Knowledge of the efect of cutng with and without sttches on girls and Chart 17: Knowledge of the efect of cutng with sttches women

The efects on girls and women of Fistula cutng with and without sttches are seen as markedly diferent. The Infertility overwhelming majority of women (80%) and men (68%) consider that Problems in childbirth girls and women sufer no harmful Diffculties with efects from the sunna (without marriage relationships sttches). The most frequently Problems conceiving reported efects reported by women were severe pain (7%), problems with Psychological trauma menstruaton (6%) and difcultes Diffculties passing urine passing urine (3%). Swelling There was general agreement between men and women that cutng with Infection/fever sttches (intermediate or pharaonic Problems with menstruation cuts) has a far greater efect than the sunna, with only 4% suggestng Diffculties healing there are no harmful efects (chart Severe bleeding 17). Twice as many women as men recognise that girls and women sufer Severe pain from problems with menstruaton (women 62%, men 33%), severe pain Shock

(women 41%, men 22%), difcultes None passing urine (women 45%, men 23%) and infectons/fever (women 29%, men 14%). Men report a higher % 0 10 20 30 40 50 60 70 incidence of difcultes with marriage relatonships than women (men 25%, Key Women (all) Men (all) women 15%).

18 There were no signifcant diferences in the awareness of the harmful health efects of cutng between people from diferent backgrounds (teachers, health workers, government workers, home-based people, farmers and traders), from people from city, semi-city and village communites, or between young and older women and men. Health workers used more technical language when describing the efects than, for example, farmers or traders. Men were more general in their descriptons than women. However, all groups were aware from their personal experience of the wide range of complicatons and the general types of health risks brought about by cutng.

Conclusion

Overall, 96% of women and men knew that there were diferent types of cut used in Somaliland. Most described the pharaonic and sunna cuts. The intermediate/sunna2 cut was less well known with 55% of women and only 8% of men being aware of it, although this was higher among young men in city and semi-city communites (35% and 48% respectvely).

The majority of women (80%) and men (68%) considered that girls and women sufer no harmful efects from the sunna (without sttches), whereas only 4% suggested that there are no efects of cutng with sttches (intermediate and pharaonic). Twice as many women as men recognise that girls and women sufer from problems with menstruaton, severe pain, difcultes passing urine and infectons/fever from cutng with stches. Men report higher incidence of difcultes with marriage relatonships as a result of cutng with sttches.

3.4 Messages heard on female genital cutting (Objective 2c)

Overall, 72% of people interviewed had heard messages about FGC, with a signifcantly higher percentage (80%) of men than women (65%) (chart 21). This diference is consistent across all the age ranges (chart 18). Older women and men were more likely to have heard messages than younger ones. This fnding is interestng given that FGC is considered to be the responsibility of women and not to involve men.

Chart 18: Percentage of women and men who have heard messages about female genital cutng

All

Women all

Women over 40

Women 25-40

Women 15-24

Men all

Men over 40

Men 25-40

Men 15-24

% 0 10 20 30 40 50 60 70 80 90 100

Chart 19 shows the percentage of people who have heard messages about FGC according to their role. Those least likely to hear about FGC are women, especially those at home. Farmers, fshermen and traders are also less likely to be involved in actvites where people are exposed to messages about FGC than those working in educaton, health or government positons.

Chart 19: Percentage of people who have heard messages about female genital cutng (by role)

Health workers

Teachers

Students Fathers width daughters grades 1- 3 Fathers

Government workers

Traders Mothers width daughters grades 1- 3 Farmers and fshermen

Mothers

Women at home

% 0 10 20 30 40 50 60 70 80 90 100

19 A higher percentage of people in city (77%) and semi-city The most commonly heard messages are “the pharaonic cut is communites (74%) have heard messages about FGC than in a crime against girls”, heard by 61% of men and 49% of women village communites (64%) (chart 20). (chart 22). Women are more likely than men to hear messages to abandon all types of cutng (22% for women as opposed to 1% for men). Interestngly, 21% of men reported having heard Chart 20: Percentage of people who have heard messages messages apparently from the media and NGOs “opposing the about female genital cutng (city, semi-city and village campaign against FGM”, i.e. telling people to contnue to cut communites) their daughters despite the campaigning for Zero Tolerance. There were no reports of such messages being heard in the focus group City discussion.

Semi-city Chart 22: Types of messages women and men are hearing Village about female genital cutng

% 0 20 40 60 80 Opposing the campaign against FGM Pharaonic cut is a crime against girls Chart 21 shows from where women and men are hearing Health consequences messages about FGC. The most commonly reported source is the of cutting radio with 61% of men and 40% of women getng informaton on Abandon all except the FGC from the radio. The next most common sources are TV, CSOs Sunna (no stiches) and health workers, especially for women, and public meetngs for both genders. However, public meetngs are only reaching Abandon ALL 13% currently. Schools and the family are places where FGC is types of cutting clearly not being talked about very much at all, with only 3% reportng hearing messages about FGC in their family and 5% (7% % 0 10 20 30 40 50 60 70 women and 3% men) in schools. Key Women (all) Men (all) Chart 21: Source of messages on female genital cutng for men and women (overall)

CSOs/NGOs

Government workers

Family

Health workers

Public meetings

Mosque

School

Posters

Internet

Radio

% 0 10 20 30 40 50 60 70

Key Women (all) Men (all)

20 The diferences between the sources from which teachers, health workers, Chart 23: Source of messages on female genital cutng for employees and government workers and religious home-based/traders/farmers leaders hear messages about FGC and those who are home-based, traders and farmers are relatvely minor (chart 23). CSOs/NGOs It was clear in most of the focus group discussions, that although people have heard messages Government about FGC, most have not had workers opportunites to actually discuss how they feel about it with others. Family “This was never mentioned in school, Health workers never. In fact, this is the frst time we have ever Public meetings talked about it with each other…. We have even been to some community Mosque meetings but we listened and that was all”. School

Community woman, Abdaal, Saaxil TV “there are some workshops where we go Posters and get information but this [focus group] is the Internet frst time we have talked about what we believe and been able to hear Radio different people’s views and opinions.” % 0 10 20 30 40 50 60 70 80

Young man, city, Berbera Key Employees - teachers, health workers, Home based, traders, farmers (female) When people spoke in focus group government workers (female) discussions about moving away Employees - teachers, health workers, Home based, traders, farmers (male) government workers (male) from the pharaonic, they said it was because they could see the efect the cutng was having on the girls and women in their community.

Conclusion

Almost three quarters of people have heard messages about FGC, with higher proportons of men than women being exposed to them and higher proportons in city and semi-city communites than in village communites. Those in professional roles (teachers, health workers, government positons) and students are more exposed to messages about FGC than women at home, traders, farmers and fshermen. Age is less important than gender or role.

The message most commonly heard is that the pharaonic cut is a crime against girls and women. Women are more likely to hear messages about abandoning all types of cutng than men.

Radio, NGOs/CSOs and TV are the most common sources of messages about FGC. Health workers and public meetngs are the next most common source, although they reach less than 20%. Family and schools are not places where messages about FGC are heard, although the family is where the decisions are made.

21 3.5 Support for abandonment of female Despite more young women (aged 15-24 years) undergoing only the sunna cut, this age group does not appear to aspire to greater genital cutting (Objectives 2a and 2d) change in their community than older people (chart 26). In focus group discussions, young women were not very optmistc for The support for abandonment was assessed by asking about change as they felt that cutng was deeply embedded in their partcipants’ aspiratons and intentons. All partcipants were culture. asked what their intentons were for cutng any daughters they might have in the future and also whether they would prefer “It is the older women who keep the pressure, their future daughters-in-law to be cut and if so what type of cut. Unmarried men were asked what their preference would be for so although I want to not do the pharaonic their future wife. and maybe only do the sunna, but we also

In additon, everyone was asked about their aspiratons for the have to listen to the community. We cannot abandonment of cutng in their communites in the future. just decide on our own.”

Aspiratons for future abandonment Community woman, village community, Saaxil

Overall, only 10% of those interviewed said they did not want to see any abandonment of FGC and would prefer to see the current Female teachers and health workers seem to be more range of types of cutng contnue. This leaves 90% aspiring to see conservatve about abandonment than their male counterparts abandonment in some form. Most (73%) would like to see the (charts 27 and 28), refectng the overall patern (chart 24). abandonment of only the pharaonic type, 12% would like to see abandonment of both the intermediate and the pharaonic and Chart 25: Aspiratons men (by age) just 5% would like to see the abandonment of all forms of cutng (chart 24).

Abandon all Chart 24: Aspiratons men and women Abandon intermediate

All Abandon pharaonic

Women Abandon none

% 0 20 40 60 80 100 Men Key 15-24 25-40 Over 40 % 0 20 40 60 80 100

Key Abandon pharaonic Abandon intermediate Chart 26: Aspiratons women (by age) Abandon all Abandon none

Abandon all There is some diference between the aspiratons of men and women. The overwhelming majority of men (98%) want to Abandon see some abandonment and 89% want to abandon only the intermediate pharaonic. Women varied more in their responses with 17% wantng to see no change, 59% wantng to abandon just the Abandon pharaonic pharaonic and 20% wantng to abandon the pharaonic and the intermediate, leaving 4% wantng to abandon all types of cutng. Abandon none The overall patern of responses was similar across the age ranges, in village, semi-city and city contexts, among teachers, health workers, parents and among university students with some % 0 20 40 60 80 100 small variatons (charts 25-30). Key 15-24 25-40 Over 40

22 Chart 27: Aspiratons health workers Chart 30: Aspiratons all (by city, semi-city, village)

Abandon all Abandon all

Abandon Abandon intermediate intermediate

Abandon Abandon pharaonic pharaonic

Abandon none Abandon none

% 0 20 40 60 80 100 % 0 20 40 60 80 100

Key Key Female Male All Village Semi-city City

Intentons for future daughters Chart 28: Aspiratons teachers The majority of people (84%) intend to cut their daughters in the future, with 62% intending to use only the sunna cut (chart 31). Men favour the sunna more than women, although this is likely to Abandon all be due, in part, to men not being familiar with the intermediate cut and viewing the choice as between the pharaonic and the Abandon intermediate sunna. Overall, 17% favour not cutng their daughters at all, with this being highest (24%) among unmarried men. Abandon pharaonic Chart 31: Intentons of cutng of daughters Abandon none (men and women)

% 0 20 40 60 80 100 All Key Female Male All Women

Chart 29: Aspiratons university students Men

Abandon all Unmarried men

Abandon intermediate % 0 20 40 60 80 100

Abandon Key pharaonic Pharaonic Intermediate Sunna Uncut

Abandon none Young men favour not cutng their daughters more than older men and also more than young women, with 29% preferring their % 0 20 40 60 80 100 future daughters not to be cut (chart 32). Young women seem Key more traditonal with a third (31%) favouring a cut with sttches Female Male All (the pharaonic or intermediate cuts).

23 decrease in the proporton who intend their daughters to Chart 32: Intentons of cutng of daughters undergo the pharaonic cut and an increase in those who intend (by age and gender) to leave their daughters uncut or for them to only undergo the sunna with no sttches. Surprisingly, none of the university students interviewed wanted to see the abandonment of all types of cutng. Over 25 male

Chart 34: Young women’s intentons for their daughters Over 25 female

University 15-24 male

Secondary 15-24 female

Primary % 0 20 40 60 80

Key Pharaonic Intermediate Sunna Uncut No school

There is a similar patern of intentons among people with % 0 20 40 60 80 100 diferent roles in the community (chart 33), although teachers and government workers are less likely to favour a cut which Key requires sttches than people who are home-based, farmers or Pharaonic Intermediate Sunna Uncut traders (teachers 6%, government workers 8%, home-based, farmers and traders 24%). 17% of health workers interviewed intend on using the intermediate cut for their daughters, although the sample size was small. Chart 35: Young women’s aspiratons for abandonment

Chart 33: Intentons of cutng of daughters (by role) University

Home based, farmers Secondary and traders

Government workers Primary

Health workers No school

Teachers % 0 20 40 60 80 100

Key Abandon pharaonic Abandon intermediate % 0 20 40 60 80 100 Abandon all Abandon none Key Pharaonic Intermediate Sunna Uncut In focus group discussions, there was talk among men and women of the role of sttches to protect young women from There is a link between partcipaton in educaton and the future the sexual atentons of men. Many felt that girls who had only intentons of young women (15-24 years) in relaton to FGC undergone the sunna were more ‘fighty’, although others (charts 34 and 35). Young women who had not atended school expressed the change more positvely, for example, “life is life were divided between wantng to retain all types of cutng (32%) and it is good that young women can feel more and have sexual and wantng to abandon the pharaonic cut (68%), whereas about feelings and be satsfed”. a third of those who had atended school and university wanted to abandon the intermediate cut with some wantng to abandon all types of cutng. A similar patern is seen when asked about their intentons for their own daughters; there is a progressive

24 “Previously, after cutting girls were shy, they “I want to know that my daughter in law had no feeling, no conversation, they could has not been with another man and so the not be persuaded into relationships easily. situation is not clear if she does not have the Nowadays with not so many girls undergoing stitches.” the pharaonic cut, girls are not shy, they are Young woman, village community, Saaxil easily persuaded and there are illegal children coming out all of the time.” However, it appears that the importance of proving virginity might be decreasing, at least in the city and semi-city communites, with Young man, city community, Saaxil the high proporton of those preferring their daughters-in-law undergoing the sunna only. When asked whose responsibility it is to deal with this change, Attudes of parents there was an inital recogniton that both young men and young girls should take responsibility. However, this quickly turned to SOFHA is partcularly interested in the attudes of parents, listng the ways that mothers should support their daughters. especially those with daughters in grades 1-3 at school. Chart 37 There were no suggestons of any actons on the part of young shows the aspiratons of all parents interviewed and just those men. with daughters in school grades 1-3. The patern is similar to the whole sample and other sub-groups with 73%/69% respectvely “Mothers should educate their daughters not aspiring to the abandoment of just the pharaonic cut and 5%/4% to have sex, girls should learn about sexual aspiring to abandonment of all types of cutng respectvely. and reproductive health, religious leaders should educate the girls about the dangers of Chart 37: Aspiratons of parents sexual relations before getting married, girls should be found a husband and married early Abandon all enough to avoid ‘illegal pregnancies’.” Abandon intermediate Young man, city community, Saaxil Abandon pharaonic Abandon Intentons for future daughters-in-law none When asked about whether or not they would prefer their future daughters-in-law to be cut, the majority of men (71%) % 0 20 40 60 80 and women (48%) said they preferred them to have undergone Key the sunna only (chart 36), with women again showing a stronger All With daughters grades 1-3 preference for the intermediate cut. Only 13% of people said they would prefer a daughter-in-law who had undergone the pharaonic cut. No-one responded that their daughters-in-law When parents were asked about their intentons in relaton to should be completely uncut. However, an additonal category the cutng of their daughters a complex picture emerges. Chart ‘son decides’ was included. This was selected by the remainder of 38 shows the intentons for all mothers and all fathers and also partcipants (22% of women and 12% of men). for those mothers and fathers who currently have daughters in primary grades 1-3 who are as yet uncut. The patern with fathers difers relatvely litle as to whether or not they have daughters Chart 36: Preferences for the type of cut of their future at the age at which girls are usually cut. However, mothers whose daughters-in-law (women and men) daughters are at the age at which most girls are being cut, difer in their intentons from mothers in general. None of those making decisions currently intend for their daughters to remain uncut. 12% 13% 13% 4% 22% Half (51%) will undergo the sunna, a third (32%) the intermediate and 17% the pharaonic. 16% Men (all) Women (all) These fndings suggest that a quarter of mothers would like to see their daughters uncut, but when faced with the actual decision, they move to a more cautous positon and decide to have their daughters undergo the sunna. 71% 48% However, if the intentons of mothers with daughters in grades 1-3 (chart 38) are carried through to acton, this will stll represent Key a further move away from the pharaonic towards the sunna, in Pharaonic Intermediate Sunna Uncut Son decides (none) comparison with the young women (15-24 years) interviewed where approximately equal numbers of young women have undergone the pharaonic, intermediate and sunna cuts (chart 2). The following statement expresses the opinions of those who prefer the pharaonic or intermediate for their daughters-in-law.

25 Chart 38: Parents intentons of cutng their daughters Chart 39: Parent preferences for the cutng status of their daughter-in-law

8% 17% 11% 12% 27% 22% 10% Mothers with 14% 20% 15% All mothers 51% daughters Mothers with grades 1-3 All mothers daughters 32% grades 1-3

42% 39% 45%

8% 11% 15% 14% 3% 4% 12% 15% 9% 15% 5% 3% Fathers with All fathers daughters Fathers with grades 1-3 All fathers daughters grades 1-3

65% 78% 63% 65%

Key Pharaonic Intermediate Sunna Uncut Key Pharaonic Intermediate Sunna Uncut

In one of the focus group discussions, in Berbera city, a similar patern was seen. An older, well-educated woman had been Conclusion involved in Zero Tolerance campaigns and declared that, “in 3 years we can reach Zero Tolerance when everyone will stop all Overall, 90% of those interviewed would like to see some types of cutng, even the sunna”. The younger women in the abandonment of cutng in their communites, although only 5% group did not openly disagree with her. However, when the young would like to see the abandonment of all types of cutng. Men mothers with daughters in grades 1-3 were asked about their are less familiar with the intermediate cut than women and see intentons for their daughters they said they would be using the the choice between the pharaonic and sunna, with 89% wantng sunna as they wanted their daughters to be “pure to be able to to abandon only the pharaonic. Women are varied more in their marry freely”. responses with 17% wantng to see no change, 59% wantng to abandon just the pharaonic, 20% to abandon the pharaonic and When asked about their preferences for their daughters-in- the intermediate, leaving 4% wantng to abandon all types of law, none of the parents wanted them to be completely uncut, cutng. however, 20% of mothers and 12% of fathers would allow their sons to decide (chart 39). In the focus group discussions, there The majority of people (84%) intend to cut their daughters in was a tendency among those community women who wanted to the future, with 62% intending to use only the sunna cut. This see the greatest change to allow their sons to make the decision represents a stronger move from the pharaonic cut to the sunna about who they marry, as opposed to those who favoured in people’s personal intentons than their overall aspiratons for the pharaonic who expressed that as a preference for their their community. Young men were the group who favoured not daughters-in-law. cutng their daughters most with 29% saying they would prefer their future daughters not to be cut at all. This was in contrast to During focus group discussions, women in several communites young women where only 6% said they did not intend to cut their felt that their husbands were resistng change as illustrated in the future daughters. statement below.

“Fathers want the more traditional cut, the pharaonic cut, it is us mothers who want to change but sometimes we are forced into the pharaonic cut. It is causing serious disagreements between mothers and fathers.”

Community woman, Abdaal, village community, Saaxil

This statement appears contrary to the fndings about the attudes of men (chart 25), however, it likely to be more a result of the lack of communicaton about FGC and misunderstandings about the attudes of others.

26 3.6 Attitudes of young people “would prefer to marry a girl who could feel”. However, when asked if they would marry a girl who had not undergone the sunna, they were clear and unanimous: Young men (aged 15-24 years) have a greater understanding of the types of cuts which young women are undergoing in their communites than older men (chart 40). This is likely to be a result “Defnitely not. This is not part of our religion, of greater use of the media to disseminate informaton about no-one is not sunna in Somaliland. Girls must FGC (see secton 3.4). They were also aware of a wide range of have sunna, it’s religious.” harmful efects of cutng (see secton 3.3), even though they were not usually involved in conversatons about these in their Young man, city community, Booroma families. This suggests that young men are more likely to be able to engage in meaningful conversatons with their future wives The reacton was equally strong when young men were asked if about the cutng of their own daughters than their fathers. they knew of any young women in their community who were uncut: Chart 40: Knowledge of types of cut (by age and gender) “Absolutely no-one, this would not be acceptable and would bring shame. There Pharaonic is no-one in our community who has not Intermediate/ even undergone the sunna. This would be Sunna2 completely against Islam.” Sunna (no stitches) Young man, city community, Berbera

% 0 20 40 60 80 100 However, in the survey when young men were asked confdentally about their intentons in relaton to their own Key daughters 29% said they would prefer their own daughters not Young women (15-24) All men Young men (15-24) to be cut at all with a further 63% preferring their daughters to only undergo the sunna cut (chart 42). This difers from the opinions of young women where 11% would prefer them to The majority (96%) of the young men interviewed were undergo the pharaonic and 20% the intermediate, giving a total unmarried. When asked about their preferences for their future of 31% intending their daughters to undergo a cut which requires wives, 89% said they would prefer to marry a young woman who sttches. had only undergone the sunna, with just 3% saying they would prefer a young woman who had not been cut at all. Overall, 84% of young men said that the type of cut their prospectve wife Chart 42 Intentons of cutng of daughters had undergone matered in their choice of wife. This was most (young men and young women) pronounced in the semi-city communites (chart 41). 81% said they would ask their prospectve wife directly themselves about this very sensitve issue. Male (15-24)

Chart 41: Young men’s opinions on the importance of the type of cut their future wife has undergone Female (15-24)

City % 0 10 20 30 40 50 60 70

Semi-city Key Pharaonic Intermediate Sunna Uncut Village

% 0 20 40 60 80 100 Young men and young women have similar aspiratons for their Key communites to older men and women. The overwhelming Does not matter Does matter majority would like to see some change, although 16% of young women interviewed oppose any change. 93% of young men would like to see just the pharaonic cut abandoned and 4% In focus group discussions, young men drew a strong distncton want to see all types of cutng abandoned. Young women are between women who had only undergone the sunna and those showing a more stepwise movement from the pharaonic to the who had not been cut at all. Many of the young men said they intermediate to the sunna (chart 43).

27 Involvement in actvites to reduce female genital cutng Chart 43: Apsiratons for the future of cutng in communites Currently 40% of young men and 23% of young women say they are involved in actvites to reduce FGC in their communites with 87% and 75% respectvely saying they would like to get involved in the future (chart 44). Only 18% of these young people came Abandon all from villages, with over half coming from city communites. Abandon intermediate

Abandon Chart 44: Young people’s current involvement in actvites pharaonic to reduce female genital cutng and future intentons

Abandon none

Young men

% 0 20 40 60 80 100 Young women Key Young women (15-24) Young men (15-24) % 0 20 40 60 80 100

Key Overall, young people were inclined towards change, however, Future involvement Current involvement in the focus group discussions, there were young women and men who contnue to support the cutng and were confdent and artculate in their views. Chart 45 shows the sorts of actvites young people reported “It is necessary and the pain is a good thing, if to be involved in. 17% of young men reported being involved in community health outreach actvites. Young men were also it was only the sunna with 2 stitches and not more likely to have been involved in workshops. The next most the pharaonic cut.” common actvity against FGC that they partcipated in was public meetngs. Community woman, Abdaal village, Saaxil

Chart 45: Types of actvites to reduce female genital “The process of going through the pain cutng that young people are currently involved in develops stronger women able to be mature and cope with the pain of being a mother.”

Young woman in secondary school, age 16, Booroma Young men

“It is part of our culture and we should not just stop it because of pressure from the West… Young women I seem to be the odd one out here. I am actually thinking of starting up a group for the % 0 5 10 15 20 frst type of cut [pharaonic]” Key Community health outreach Girls empowerment programmes Young man, aged 18, Booroma Poster/leafets Workshops

Campaigns Public meetings

28 The most common barriers to becoming involved were not knowing what to do, Chart 46: Types of actvites that young people want to get involved with in the fear of being ridiculed, fear of not being future to reduce female genital cutng listened to and not understanding the culture around FGC as they were not involved in conversatons in the family. Media Chart 46 shows the kinds of actvites Peer to peer education which young people said they would like to get involved with in the future. The Poster and leafets high proporton of young people wantng Girls empowerment to advise parents refects the weight of programmes decision-making power held by parents. Public meetings A third of young people want to speak in Being a role model schools, which is a forum where there are for change currently relatvely few opportunites for young people to talk about FGC. Helping cut girls Advising young girls Conclusions Advising parents With young men being more informed than previous generatons and also expressing a Talking in the Mosque distnct preference towards cuts which do Talking in schools not require any sttching, or no cut at all, young men would appear to be potentally Campaigning important stakeholders in the campaign towards abandonment. % 0 5 10 15 20 25 30 35 40 45 There appears to be a contradicton in Key the opinions expressed by young men in Young women Young men focus group discussions and in confdental interviews. When interviewed individually, 29% of young men said they would prefer their daughters not to be cut at all. However, in focus group Chart 47: Number of teachers, male and female, discussions the overwhelming opinion was that not being cut interviewed per region was completely unacceptable in their community. This diference could be due to the group pressure to agree with the accepted social norm, that FGC is expected among all women in the Maroodi Jeex community. Togdheer Young women and men are more than twice as likely to be involved in actvites against FGC in city and semi-city Saaxil communites than in village communites. Sanaag 3.7 Attitudes of teachers and the role of schools in abandoning female genital cutting Awdal

This secton includes the fndings from the interviews with % 0 20 40 60 80 teachers and educaton ofcers, followed by an example of a Key school which has adopted a whole school approach to FGC. Female Male A total of 209 teachers were interviewed in 22 communites in the 5 regions of Awdal, Maroodi Jeex, Sanaag, Saaxil, Togdheer. Chart 47 shows the number interviewed per region. In village communites, only 10% of teachers were female as opposed to Chart 48: Rato of male and female teachers interviewed 36% and 28% in semi-city and city communites (chart 48). Two in city, semi-city and village communites thirds (65%) of teachers interviewed work in primary schools, 10% 27% work in secondary school and the remainder teach in Koranic 28% and non-formal schools. The overwhelming majority of teachers 36% interviewed (89%) work in government schools with 11% working Village Semi-city City in private schools. 64% 72% 90%

Key Female Male

29 Personal experience and attudes towards female genital cutng Chart 51: Married teachers’ preferences for their future daughters-in-law All of the female teachers had been cut, with 68% undergoing the pharaonic, 18% the intermediate cut and 14% the sunna. There is a trend away from the pharaonic towards the intermediate and Pharaonic sunna, with 100% of teachers over aged over 60 years and 82% of teachers aged 40-59 years undergoing the pharaonic cut as Intermediate/ Sunna2 opposed to just 50% of teachers aged 15-24 years (chart 49). Sunna (no stitches) 30% of male teachers interviewed were unmarried and of these 91% would prefer to marry a girl who has only undergone the Uncut sunna (without sttches). The majority were prepared to directly ask a girl they would like to marry whether or not she was Son decides cut. % 0 20 40 60 80 100

Chart 49: Types of cut undergone by teachers of Teachers’ opinions on the abandonment of FGC are broadly in diferent ages line with those of the communites in which they work. Almost all (98%) of male teachers would prefer to see the pharaonic cut abandoned in their community. The views of female teachers Pharaonic vary more with 28% wantng all types of cutng to contnue, 50% wantng to see the abandonment of the pharaonic cut, 20% wantng to see the abandonment of both the pharaonic and Intermediate/ intermediate cuts and 2% supportng the abandonment of all Sunna2 types of cutng including the sunna (chart 52).

Sunna (no stitches) Chart 52: Teachers’ preferences on abandoning types of cut

% 0 20 40 60 80 100

Key Abandon all 15-24 years 25-40 years 41-59 years Over 60 years Abandon pharaonic and intermediate Abandon 62% of teachers were married. When asked about their pharaonic preferences for their future daughters and daughters-in-law Abandon the majority would prefer them to have undergone the sunna none with no sttches (charts 50 & 51). Interestngly none said they would prefer their daughters-in-law to be completely untouched, % 0 20 40 60 80 100 however, 23% would prefer their own daughters to be untouched. There were no signifcant diferences in the preferences of Key teachers in city, semi-city or village communites. Female teachers Male teachers

Chart 50: Married teachers’ intentons for their In focus group discussions, teachers expressed a wide range of future daughters views on FGC, refectng the range of views across women and men in the community.

Pharaonic “The move towards the sunna only has led to Intermediate/ an increase in C-sections which is not good at Sunna2 Sunna all. Women no longer know how to deal with (no stitches) pain and instead go for costly C-sections… Uncut when she marries the price of the girl is higher

% 0 20 40 60 80 if she has been cut and closed properly - an open girl has a less good price.”

Male primary school teacher, Berbera city

30 “The other type [intermediate/sunna2] where Chart 53: Teachers’ understanding of the role of schools in they are closed only a little is ok. With the relaton to female genital cutng totally closed girls this is problematic when they get married and then they need to be To provide awareness open.” raising for parents To speak out against female genital cutting Principal, secondary school, Sheikh, Saaxil To enable boys to learn about cutting “We do not need to touch our daughters at To enable girls to learn all, not even the sunna. I will marry whoever I about cutting marry but she does not need to be touched. If To promote the tradition of cutting girls I have daughters they will not be touched, not at all. I cannot be persuaded from this.” No role at all

Male primary school teacher, Saaxil % 0 5 10 15 20 25 30 35

Key “The pharaonic is dangerous and brings so Female Male many health complications. We must stop this cut totally. But it is our tradition to do the cut In focus group discussions, opinions were divided about the role that schools should play in awareness raising about FGC. Most and so we can still do the small cut with just were of the opinion that “schools must raise awareness, it is their 1 or 2 stitches and the girls will not suffer the role to support the community not just to teach”, however a few bad health for their lives.” felt that “schools should teach only, that is their role and they should stck to this”. Female primary school teacher, Saaxil Teachers talking about female genital cutng in schools

With teachers holding such a wide range of views, it is inevitable Despite 84% of teachers feeling that schools have a role to play that they will be giving contradictory messages to girls and in relaton to FGC, only 42% have actually talked about it in parents when they do speak about FGC in schools. schools (chart 54). Perhaps surprisingly, a higher proporton of male teachers (55%) report that they have spoken about FGC Teachers’ understanding of the role of schools in relaton to compared to female teachers (45%). Teachers in schools in cites female genital cutng are less likely to talk about cutng, with only 33% doing so, than those in semi-city or village communites (55%) (chart 55). Teachers held a range of views about the role of schools in relaton to FGC (chart 53). There were no signifcant diferences between the views of teachers in city, semi-city or village Chart 54: Teachers who have talked about female genital communites, however, male and female teachers did have cutng in school (male/female teachers) diferent priorites. The overwhelming majority (84%) of teachers felt that schools should have a role in relaton to FGC. Only 2% of teachers felt that the role of schools was to promote cutng No with 29% seeing their role as speaking out against cutng. Male teachers are more likely to see their role as raising awareness Yes among parents (28%), whereas female teachers place a higher emphasis on providing opportunites for girls to learn about % 0 20 40 60 80 cutng (32%). Key Female teachers Male teachers

Chart 55: Teachers who have talked about female genital cutng in school (city/semi-city/village)

Yes

% 0 20 40 60 80

Key Village Semi-city City

31 Chart 56 shows the types of people that teachers are talking to about FGC. The cutng of the girls at school is not something Chart 57: Percentage of teachers being asked for advice which teachers talk to each other about with only 2% talking to on female genital cutng other teachers. Male teachers are more likely to talk to groups of girls (22%) and in classroom tme (14%). Female teachers tend to talk to both individual girls (18%) and groups of girls (16%). Only No 9% of teachers have talked to parents about FGC, despite, 22% of teachers (7% female and 28% male) seeing this as being the role Yes of schools. % 0 20 40 60 80 100 In focus group discussions, teachers who would like to see reductons in FGC were reluctant to speak out. Key Female teachers Male teachers “I do not speak about FGM in my school as it is a primary school. If it was a secondary school I would speak to the girls and parents Chart 58: Types of advice given by teachers about female but it is inappropriate to speak about this in genital cutng primary schools.” I tell girls not to be unkind Female primary school teacher, semi-city community, Awdal to other girls

Offer to talk to parents Chart 56: Types of people teachers have talked to about Explain parents are female genital cutng doing the best for them

Explain that not all girls are cut Whole school activities Advice about medical complications In classroom time None, it is not my role to give advice With other teachers

% 0 2 4 6 8 10 12 14 16 18 With parents Key With mixed groups of Female teachers Male teachers girls and boys

With groups of boys Teachers taking acton at school before holidays when cutng With groups of girls will take place Approximately a quarter of teachers (27% of female teachers and With individual girls 23% of male teachers) say that they take some kind of acton in relaton to FGC prior to the long school holidays when girls are % 0 5 10 15 20 25 most likely to be cut (chart 59).

Key Female teachers Male teachers Chart 59: Percentage of teachers who take acton on female genital cutng before school holidays

Requests to teachers for advice No Female teachers are more likely to be asked for advice about FGC, however, only 43% have been asked as opposed to just 17% Yes of male teachers (chart 57). There are no signifcant diferences between teachers in city, semi-city and village communites. % 0 20 40 60 80 100 Where teachers do give advice the most common is explaining Key that not all girls are cut, giving advice on managing medical Female teachers Male teachers complicatons of being cut and ofering to talk to parents (chart 58).

The main actvites which take place are talking to parents and girls, with no teachers talking to boys and few invitng religious leaders or health workers into schools (chart 60). Only 3 teachers appear to have interactve sessions, making plays or songs with pupils about the dangers of being cut.

32 Similar views were expressed in focus group discussions about Chart 60: Types of actons teachers take before a school teachers not currently being equipped to act as change school holiday agents on FGC:

Make a play or song “the teachers need awareness raising frst, they with the pupils do not understand the issues at the moment Invite a religious leader to the school so it would be wrong for them to start without

Invite a health some training” worker to the school Community woman, Sheikh, semi-city, Saaxil. Talk to the whole school Whole school approaches to female genital cutng Talk to the parents Most schools, both primary and secondary, do not have a policy Talk to the girls on FGC or provide training for teachers on handling requests for support from girls or responding to parents. In some Talk to the boys schools, some female teachers in partcular have partcipated in workshops with Candlelight or the Adventst Development and Relief Agency (ADRA). % 0 2 4 6 8 10 12 14 Where primary schools include FGC in sessions for girls on Key personal health and hygiene, it appears to be a relatvely short Female teachers Male teachers session provided for girls usually in grades 5 - 6. The main emphasis of the session is on explaining the complicatons of cutng to girls and persuading them to avoid being cut. However, Readiness of schools and teachers to play a signifcant role in by grades 5 - 6, many, if not most, of the girls will have already the abandonment of female genital cutng been cut so the teachers will be talking to mixed groups of cut and uncut girls. The Ministry of Educaton is commited to schools and teachers playing a strong role in the abandonment of FGC. However, School nurses are not provided in government schools, although with teachers holding a wide range of views, including some some individual schools have private arrangements. This means which strongly support the pharaonic cut, they are not yet in a that girls cannot approach their school nurse for advice on cutng positon to provide a consistent and reliable message towards or on managing the efects of being cut. abandonment. None of the schools visited provided sessions on FGC for boys. The Regional Educaton Ofcer in Berbera city explained the approach being taken by his department and the challenges the Several schools ofer sessions for parents of girls on health and department face. hygiene which include menton of FGC. The focus is on providing informaton on the complicatons of cutng and trying to “We already have a gender focal person at persuade parents not to make their daughters undergo the cut. regional and district level with a focus against One school in Hargeisa, reports a decrease in the number of all forms of violence and abuse against parents requestng to take their daughters out of school to be cut, although they know that some of these girls are stll cut, but children. In future, they should also consider in the school holidays. One of the teachers was given the ttle of FGM but we are not there now.” Gender Focal Person with responsibility to support girl students to contnue with their educaton and to resist early marriage and “Most of our teachers have had no training FGC. When parents request permission to take their daughters out of school, they are referred to the Gender Focal Person who at all on FGM and so are not ready to play a explained: role. However, I think FGM should be part of the teaching training curriculum. It is not now, “I tell them about the complications of FGM but in the future, it could be one of our cross- and try to persuade them not to cut their girls. cutting themes.” And tell them the school does not make up any of the school work if they miss. It is the “Teachers in primary, secondary and tertiary responsibility of the parents that they are level education should be trained on how to missing their lessons.” deal with FGM, they need awareness raising Gender Focal Person, Hargeisa Primary School before they are able to take on this role. Both male and female teachers should become involved as this is an important issue for men as well as for women.”

33 One school visited, Muse Ma’alesh Primary School, Sheikh, has The key features of the approach to cutng by Muse Ma’alesh developed a whole school approach to FGC. Primary School include:

• a cross-school policy which is agreed by all staf (even though Muse Ma’alesh Primary School, Sheikh, Saaxil this is limited to not promotng the pharaonic cut)

Muse Ma’alesh Primary School, established in 2015, under • awareness raising for teachers and opportunites for them to the UNESCO SOS Children’s Villages initatve, with funding talk to each other about the cutng of their female students from UK aid. There are 391 girls in 6 classes, 10 teachers • collectve responsibility across the school among male and (5 male, 5 female) and a female principal. female teachers that FGC is something they should all engage The school has a strong focus on the rights of the child, with and provide support for the girls with partcular emphasis on domestc violence and • actve consultaton with parents (actually listening to parents the rights of the child in the family. It has an outreach as well as providing informaton) programme which ofers places to 90 girls from the most hard-to-reach communites in partnership with the • involvement of local CSOs/NGOs Adventst Development and Relief Agency (ADRA). • a school nurse available to girls Girls tend to be cut over the summer break (June- September). Traditonally all girls underwent the pharaonic • sessions where boys have an opportunity to learn about and cut, however, there has been a change in the last 5 years discuss FGC away from the pharaonic towards the intermediate (sunna2), with a few girls undergoing only the sunna • a combinaton of (a) persuading girls not to undergo the (no sttches). There is currently a strong preference pharaonic cut and (b) to actvely support girls to manage their (80%) among parents for the sunna2, identfed through own complicatons afer being cut. consultaton meetngs with parents. Cutng is performed in the girls’ homes by a traditonal cuter who is highly Conclusion respected and performs the type of cut the parents Teachers’ opinions on the abandonment of FGC are broadly in request. Few girls, if any, are taken to the hospital to line with those of the communites in which they work. There is a be cut. discrepancy between what teachers feel is the role of schools in The Principal says, “Girls who undergo the pharaonic cut relaton to FGC and the percentage of teachers taking acton. The tend to return late to school and have difcultes in setling majority (84%) of teachers feel that schools have a role to play back in. Previous high achievers ofen become shy, lack in relaton to FGC. However, only 42% have actually talked about confdence and have trouble concentratng at frst. They it in schools. Teachers in schools in cites are less likely to talk don’t tend to drop out but are ofen changed permanently, about cutng, with only 33% doing so, than those in semi-city or behaviourally. The girls ofen feel bad about having been village communites (55%). Male teachers are more likely to see cut and the school’s focus is on trying to support them in their role as raising awareness among parents, whereas female managing the difcultes and to avoid infectons which teachers place a higher emphasis on providing opportunites for might lead to more severe complicatons in the future.” girls to learn about cutng.

The school brings parents in for meetngs and discussions 43% of female teachers and 17% of male teachers have been about the cutng of their daughters. These conversatons asked for advice about FGC. The most common given advice is on are usually led by the Candlelight team, a CSO with (a) managing the efects of being cut, (b) telling girls not all are expertse on FGC who promote abandonment of all cut and suggestng that they can therefore resist being cut and types of cutng. Teachers also talk to the students about (c) ofering to talk to parents about the dangers of cutng their the health and hygiene aspects of being cut and how daughters. to deal with the complicatons and difcultes they are A quarter of teachers take some kind of acton in relaton to FGC experiencing. These conversatons also extend to the prior to the long school holidays when girls are likely to be cut. parents. The main actvites are talking to parents and girls, although the The Principal’s personal preference is for the sunna only. girls are unlikely to have the agency to prevent themselves being The opinions of teachers range from supportng the cut, given the age at which most are cut. sunna2 to abandoning all forms of cutng. The school There is evidence that the educaton authorites recognise that has a ‘policy’ that no staf member should promote the teachers need some capacity building before they can play a pharaonic cut to parents or students, which has been strong role in the movement towards abandonment. Currently it agreed by the staf and is well understood. Staf have is likely that teachers are giving very diferent messages based on partcipated in awareness raising sessions, however, they their own widely difering beliefs about the cutng of girls. are not yet in a positon where they can extend this policy to not promotng the sunna2. One school provided an example of a whole school approach. The policy adopted permits the promoton of the sunna and the intermediate cuts but prohibits the promoton of the pharaonic cut. The support provided combines preventatve measures with girls and parents as well as providing advice and guidance on managing the complicatons (i.e. promotng health seeking behaviour among survivors).

34 4. Key Themes

The research fndings confrm that the overall prevalence rate of FGC in Somaliland remains high at 98.9% in line with other recent studies (MICS 2006 & 2011, EAUH 2009 & 2016, Crawford and Ali 2015, NAFIS 2016 and Newell-Jones 2016). The prevalence rate is consistent across the age ranges, including among young women (15-24 years), whether girls atended school and whether they come from city, semi- city or village communites.

These results indicate that FGC contnues to be practced almost universally among girls and women in Somaliland.

The SOFHA team identfed the following themes arising from the research which are relevant to the natonal debate around FGC and the SOFHA project implementaton.

4.1 Change is happening and hoped for by currently taking place in Somaliland in relaton to FGC. There is evidence from this research and Newell-Jones (2016) that men over 90% of community members and women in Somaliland do not tend to talk about how each feel in relaton to FGC and that the assumptons they make are not There is evidence of change in the type of cut being used in necessarily correct. In this study, for example, it is clear that men Somaliland with a decrease in the use of the pharaonic cut and are more open to change than women perceive them to be. an increase in the intermediate and sunna types. Approximately a third of young women (aged 15-24 years) underwent the If a mother is concerned that her daughter will not be able to pharaonic, intermediate and sunna cuts as opposed to almost marry unless she is cut and sewn with sttches as ‘proof’ of 90% of women aged over 25 years. This change is most prominent virginity, then knowing that there are young men who would among young women who have atended school. prefer to marry an uncut girl and that some in her community would prefer to stop cutng altogether, might help her with The research suggests that change in type of cut in Somaliland is her decision-making dilemma about her daughter. It may be through a stepwise process (pharaonic → intermediate → sunna). possible therefore, to use the evidence that 90% would like to There is no evidence currently of an increase in the proporton of see change of some sort as a trigger for positve dialogue among girls who remain completely uncut. diferent stakeholder groups. In this way, communites could be encouraged to be bold and to be a community which does The change in type is refected in people’s attudes towards not just follow, but leads, substantal change towards complete abandonment. Only 5% of those interviewed wanted to see abandonment of all types of cutng. the abandonment of all types of cutng in their communites, however, over 90% of people surveyed wanted to see some kind 4.2 Increased medicalisation of cutting of abandonment, albeit mainly only the abandonment of the pharaonic cut (73%). Strong evidence was found of an increase in the medicalisaton Men appeared to be more open to change than women, with of cutng, which is in line with the fndings from the ActonAid 89% of them wantng to abandon the pharaonic cut. This fnding research (Newell-Jones 2016) and also evident in a range of other is in line with ‘Populaton Council’s 2016 report A State-of-the-art countries, including Egypt, Sudan and Djibout, that practce FGC synthesis on female genital mutlaton/cutng: What do we know (Populaton Council State-of-the-Art report, Shell-Duncan et al.). now?’8 which indicates that in Eritrea, Guinea, Niger, Senegal, Although the majority of girls and women (92%) are currently Sierra Leone and Sudan a smaller proporton of men than women being cut by traditonal cuters and TBAs, young women (15-24 support the contnuaton of FGC. The Somaliland data in this years) are twice as likely to have been cut by a health professional study also suggests that female teachers and health workers (11%) as women over 25 years old. The rate of change appears to also seem to be more conservatve about abandonment than be increasing as the daughters of women interviewed are more their male counterparts. Overall, the fndings suggest that men than twice as likely to have been cut by a health professional as might be more open to change than is ofen portrayed, making their mothers (16% as opposed to 8%). These changes are more their involvement in dialogue and decision-making an essental prominent among young women who have atended school and element in bringing about change. those from city or semi-city communites where there are more health facilites. Social norms theory suggests that individuals are more likely to change their behaviour if they think that the community as a Further evidence of medicalisaton comes from the focus group whole is changing, as this means they need to change to comply discussions and key informant interviews. Community members, with the changing social norms. Bicchieri9 (2013) uses the term including a school principal openly and proudly report that they ‘pluralistc ignorance’ to describe the state where some, or intend to have their daughters cut by a health professional. many, individuals incorrectly assume that others in their social Health professionals interviewed in community hospitals and group support a partcular social norm. She stresses the need MCH centres also explain that they perform cutng of young girls, for transparent communicaton and open dialogue, which is not although they all report trying to persuade the mother not to use the most severe forms of cutng.

8. Shell-Duncan B, Naik R and Feldman-Jacobs C (2016) A State-of-the-Art synthesis The current trend in medicalisaton suggests that cutng is on female genital mutlaton/cutng: What do we know now. Populaton Council increasingly going to be carried out by health workers. This is htp://www.popcouncil.org/uploads/pdfs/SOTA_Synthesis_2016_FINAL.pdf likely to result in decreased income for traditonal cuters who 9. Bicchieri C (2016) Norms in the wild: how to diagnose, measure and change social perform cutng. However, approaches which focus exclusively norms. Cambridge University Press

35 on fnding alternatve sources of income for traditonal cuters 4.4 Opportunities to exchange experiences are unlikely to bring about a reducton in the actual prevalence, as cutng is driven more by expectaton and demand than the and opinions about female genital cutting are supply of cuters. Reducing the number of traditonal cuters limited could lead to a further increase in the medicalisaton of cutng. Strategies need to be developed which tackle the move towards Most informaton comes from the media (radio, TV, social medicalisaton, which take into account the pressures on health media), NGOs/CSOs, health workers and public meetngs, with professionals, highlighted in the case of the midwife (secton 3.1), litle sharing of messages about cutng taking place in either the and address both the demands placed on health professionals schools or families. and their motvatons to perform the cut. Although 72% of people have heard messages about FGC, few 4.3 Knowledge and awareness among people have had opportunites to actually exchange experience communities is higher than anticipated and opinions. Where sessions are taking place in schools they tend to be providing informaton on the complicatons of cutng and trying to persuade parents not to use the most severe This research suggests that the level of awareness among forms of cut or to persuade girls that they do not need to be community members about FGC is higher than antcipated. cut. Equally, those who have atended community meetngs Virtually all of those interviewed (96%) knew that there were or workshops say the focus was on providing informaton to diferent types of cut used in their communites. Men were less them, rather than enabling them to discuss their intentons or familiar with the intermediate cut, although younger men were the challenges they faced in relaton to their daughters with much more informed with a third of them knowing about the each other. In most of these situatons community members intermediate cut. are passive partcipants, primarily expected to listen to ‘facts’ There is a substantal diference in the perceptons of the harm of presented by ‘experts’. cutng with and without sttches. 80% of women and 68% of men The focus group discussions have provided several examples of consider there to be no harmful efects of the sunna, but only how people change their minds as they exchange experiences and 6% of women and 3% of men consider there to be no harmful opinions with others. There were occasions where young men efects of cutng with sttches. This suggests that an approach became aware of the contradicton between wantng girls not to based on potental medical complicatons might be successful in be harmed and wantng proof of virginity; where women realised reducing the prevalence of cutng with sttches (pharaonic and that they difered on their interpretaton of the opinions of intermediate) but not in reducing the use of the sunna. religious leaders; and where young women recognised that more The vast majority of women (94%) and men (97%) were able of their peers felt like they did about FGC than they thought. to list complicatons resultng from cutng with sttches. The Interventons to date have tended to focus on providing complicatons most commonly listed were problems with informaton to community members, assuming they know litle menstruaton, severe pain, difcultes passing urine, problems and also assuming that the provision of informaton itself will in childbirth, infectons and marriage difcultes. Health result in a change in behaviour. Whilst recognising that accurate professionals were able to explain these using medical terms, informaton is important, this research suggests increasing the however, community women and men were also aware of opportunites for genuine dialogue is more likely to bring about them and able to describe them using everyday language. changes in behaviour. There were some diferences in the types of complicatons which men and women identfed, with men being more likely to identfy marriage problems and women more likely to talk 4.5 People face decision-making dilemmas about problems with menstruaton, severe pain and difcultes about female genital cutting passing urine. However, the key point is that people from both genders, all ages, all backgrounds and city, semi-city and village A key fnding, which is not widely discussed, is that decision- communites were all aware of a range of complicatons and able making in relaton to FGC is not straightorward but involves to describe many of these. complex decision-making dilemmas. Parents are balancing conforming with the social expectatons to verify their daughters’ These fndings suggest that decisions about cutng are being purity and virginity by cutng, with wantng their daughters not made despite people knowing about the types of cut and many to sufer from complicatons as a result of being cut. Mothers, of the complicatons i.e. lack of knowledge is unlikely to be the the key decision-makers, are balancing wantng not to harm their primary reason for contnued cutng in most instances. daughters with their perceived expectatons of religious leaders, With the current level of knowledge about FGC, tme spent telling the father and the wider community. Midwives and other health people about the complicatons is unlikely to change attudes. professionals are faced with the contradicton between their Approaches which provide opportunites for people to share their personal preference, their understanding of their professional existng knowledge about types of cut, complicatons and the role and the pressure they feel under to minimise the harm done opton faced by decision-makers in relaton to FGC is more likely to an individual girl. Teachers are faced with balancing their to result in people making decisions to change. personal opinions on cutng, their understanding of the role of their school and their personal role as a teacher or principal.

36 These decision-making dilemmas arose frequently in focus group staf felt that as the girls are cut when at primary school, it was discussions and key informant interviews and were also implied not therefore necessary to talk to them at secondary school. in the survey data. There was, for example, a diference in the Whereas, primary school staf felt that the girls would only be intentons of all mothers and those who have uncut daughters in able to understand fully about FGC when in secondary school. grades 1-3. 17% of all mothers said they intended leaving their The Regional Educaton Ofcer in Berbera sums up the situaton future daughters uncut (chart 38), however, none of the mothers as follows; who have uncut daughters in grades 1-3 intended to leave their daughters uncut. In discussion groups, mothers who were in “Most of our teachers have had no training at all on FGM and so the process of making these difcult decisions (i.e. had uncut are not ready to play a role. However, I think FGM should be part daughters in grades 1-3) were cautous about breaking the social of the teaching training curriculum”. norms, whereas others felt more able to say that they hoped One school visited had introduced a policy on FGC and had a that community attudes will have changed by the tme they are series of measures in place to promote dialogue and exchange making these decisions and so felt more comfortable saying they both in relaton to reducing the severity of the cut being used intended to leave them uncut. So, there is a diference between and also promotng health seeking behaviour. Male and female the opinions of the women when talking about the cutng of staf, parents and students were encouraged to be involved in daughters in general and that when it relates to a decision they discussions about FGC. A local CSO, with a commitment to the are currently making. abandonment of all types of cutng, was invited to provide Decision-making dilemmas relatng to FGC have also been training for staf and the school actually consulted with parents as identfed in Somaliland in other recent research (Crawford & well as providing informaton to them. Ali 2015 and Newell-Jones 2016) and are experienced across The fndings from this research, combined with the practce of most, if not all, stakeholder groups and in other countries. If schools where the prevalence of FGC has reduced substantally, changing attudes in relaton to FGC are perceived as less to do could form the basis for drawing up good practce guidelines and with following on from having accurate knowledge and more to policies on FGC for schools, as well as teacher training, in the do with making difcult decisions this will have implicatons for future. the kinds of actvites and interactons which are most likely to successfully bring about change. 4.7 Youth (female and male) are an untapped 4.6 Schools require support to become resource for change environments for change The fndings of this research indicated that young people (aged 15-24 years) are more informed than older people and also are SOFHA has a specifc interest in the role of schools in bringing keen to become more involved in actvites to reduce FGC. about change in relaton to FGC based on the strong role which schools have played in countries where the prevalence of FGC has The change in the type of cut among young women means that been reduced substantally. they are the frst generaton where a substantal proporton of them have undergone a cut less severe than their mothers. This In Somaliland, most government schools have not developed represents a signifcant change in attudes, which if brought whole school approaches to FGC. The support ofered to girls and more into public debate, could infuence further change. The their parents is limited and ofen based on the personal eforts of majority of young women said they would like to intervene to individual teachers. prevent younger girls from undergoing the most severe forms of The majority (84%) of teachers felt that schools had a role to play cutng. in relaton to FGC. Male teachers are more likely to describe the Young men are more informed than older men about the three school’s role as talking to parents, whereas female teachers are diferent types of cut being used in Somaliland and consequently more likely to see it as providing opportunites for girls to learn more able to engage in meaningful discussion with their about the potental complicatons of cutng. However, only half future wives about the cutng of their future daughters or the as many teachers (42%) had actually spoken about FGC at school, requirements of their future daughters-in-law. The overwhelming suggestng that many felt the school had a role to play, but that majority (89%) of young men said they would prefer to marry a they did not necessarily consider it to be their responsibility. young woman who had only undergone the sunna type of cut, Teachers’ experiences and opinions in relaton to FGC are broadly with 84% of them saying this was a signifcant factor in their in line with those of the communites in which they work. selecton of a future wife. Additonally, although only 3% of young Only 2% of teachers want to see the abandonment of all types men prefer to marry a girl who is uncut, 29% said they would of cutng. Without substantal support to change their own prefer their own daughters not to be cut at all. This suggests that attudes towards the cutng of girls and women, teachers are involving men more in discussions about the cutng of young girls unlikely to be equipped to be efectve agents of change. would increase the pressure to move away from the pharaonic and intermediate cuts and would be likely to promote the case for There is some confusion and contradicton about the most a complete abandonment of all types of cutng. appropriate tme and way in which schools can infuence attudes in relaton to FGC. Girls tend to be cut in primary grades 3-5, The majority of young women (75%) and young men (87%) whereas sessions for girls on health and hygiene tend to be given would like to be involved in actvites to reduce cutng in the to girls older than this on the basis that younger girls will not future, with only half of these currently being involved. The most understand. Both primary and secondary school staf said that common barriers were (a) not knowing what to do to support FGC should not be discussed in their schools. Secondary school change in relaton to FGC, (b) fear of being ridiculed and (c) not understanding enough about FGC.

37 4.8 Promoting health seeking behaviour This raises questons of both supply of, and demand for, clinical support. receives limited attention Even in cites and semi-cites, where there are more health The United Natons Populaton Fund (UNFPA) are in the process of facilites than in villages, only 5% of girls and women seek support developing a common approach to FGC based on a commitment from health facilites, suggestng that the social norm is to seek to Zero Tolerance with an overall goal to reduce FGM/C support from within the family only and that health seeking prevalence by 40% in 5 years. The Ministry of Labour and Social behaviour needs to be actvely developed. There have been Afairs (MoLSA) in Somaliland and UNFPA have led the process successful campaigns to promote accessing health facilites during of developing Natonal Indicators on FGC, with capacity building pregnancy, childbirth and post-natal care for mothers and infants, support from Populaton Council. This process will feed into however, this has not yet been extended to seeking support for the development of regional and global indicators. The UNFPA cutng related complicatons including diferent optons for young framework has three components: Policy Framework, Community women being re-opened before marriage. Engagement and Service Provision. Organisatons involved in the Where schools are actve in relaton to FGC, the focus tends to work to promote the abandonment of FGC are encouraged to be on providing informaton about the complicatons of cutng include actvites which address these three components. Service in order to persuade families not to use the most severe forms delivery includes improving the availability and quality of clinical of cutng. School nurses are not provided by the Somaliland support services in relaton to FGC, as well as promotng positve Government. Most girls and young women are not able to seek health seeking behaviour among girls and women. advice at school about health issues or concerns from a nurse and Currently less than 5% of women and girls sufering complicatons consequently do not develop positve health seeking behaviours. as a result of being cut actually seek support from health Where a school nurse is available, there tends to be a stronger facilites. Instead they approach family members for advice on focus on managing complicatons arising from being cut. how to manage their complicatons, partcularly their mother or grandmother. Consequently, girls and women are likely to be sufering more severely from medical complicatons arising from being cut than if they had sought support and advice from health professionals.

38 the diferent optons for young women who have undergone the 5. Implications for the project intermediate or pharaonic cuts prior to being married, identfying and seeking medical support for long term complicatons of being cut. This is one of the three themes in the natonal 5.1 Selecting and supporting change agents indicators being developed on FGC which are being promoted and supported by Populaton Council, UNFPA and the Ministry of Community members actng as change agents are key to Labour and Social Afairs (MoLSA), with funding from Norad. maximising the impact of the interventons and to promotng sustainable change. In order to be efectve, change agents need The impact of the SOFHA project might be enhanced by an to have attudes which refect the goal of the project, rather than increased focus on promotng health seeking behaviour. the current situaton within the community. This could substantally reduce the severity of the health complicatons sufered by young girls and women, as well as SOFHA is commited to the complete abandonment of all types provide further pressure in the change away from the pharaonic of cutng. This research suggests that it will be difcult to fnd and intermediate cuts, in partcular. sufcient numbers of change agents who are commited to the abandonment of all types of cutng in schools, health facilites Additonally, if more health professionals were involved in and mosques within the lifetme of this partcular project. providing advice to girls and women on the health complicatons, Teachers and health professionals in Somaliland hold a wide this might assist them in opposing the medicalisaton of cutng. range of opinions in relaton to FGC and therefore SOFHA will need to consider carefully the selecton of change agents from 5.4 Supporting schools among these groups, their inital training and on-going support. Schools are a core element of the SOFHA project with sessions SOFHA are using young people as volunteer facilitators in being ofered to large numbers of teachers, parents and students. schools. The research suggests that young people have many Key staf from each school are partcipatng in workshops the aim of the attudes required to be efectve change agents and that of which is to develop strategies to implement in their schools there could be advantages to using them in a wider variety of on FGC. These sessions could be used to introduce the good roles throughout the project, for example, in advocacy roles practces identfed in secton 3.7 including: communicatng with policy makers as well as in awareness raising sessions for health professionals and teachers. • developing a cross-school policy which is agreed by all staf which combines measures to reduce the prevalence of cutng 5.2 Approaches to ‘sessions’ of students and also provides supports for those girls who have undergone the cut Currently, most SOFHA workshops focus primarily on providing • training for teachers and opportunites for them to talk to informaton on the types of cut and the potental health each other about the cutng of their female students complicatons. The assumptons are that people do not know of the complicatons and that once they do know they will change • developing collectve responsibility across the school among their minds and abandon cutng. male and female teachers that FGC is something they should all engage with and provide support The research suggests that the level of knowledge about cutng and the potental health risks is higher than antcipated and that • actve consultaton with parents (actually listening to parents many people are involved in complex decision-making dilemmas as well as providing informaton) in relaton to FGC. • linking with local CSOs/NGOs working on FGC Providing opportunites for young women and young men, parents, health workers, teachers and others to exchange • providing sessions where girls and boys have an opportunity opinions and discuss the dilemmas they face would seem to to learn about and discuss FGC be a more efectve approach when planning sessions with stakeholders. This would require revising the tming as well • promotng positve health seeking behaviour among girls and as the content of the sessions in order to allow tme for these their parents in relaton to FGC. discussions to take place. Facilitators will also need to adopt a diferent approach to the sessions; one of facilitatng discussion 5.5 Training manuals and handbooks and encouraging listening to diferent perspectves, rather than just providing informaton. Drama, theatre and role play could Currently, training manuals and handbooks focus primarily on be valuable approaches to help partcipants explore diferent providing informaton on types of cut and health risks of cutng. optons. The fndings from this research suggest that the following might enhance these resources: 5.3 Promoting health seeking behaviour • actvites to promote the exchange of experiences and Many of the groups which SOFHA convenes on FGC include girls discussions on the decisions people face in relaton to FGC (or parents of girls) who have been cut as well as those who • including actvites which promote health seeking behaviour have not been cut. Currently the primary focus of the sessions among girls and women who have been cut. is on reducing the likelihood of the uncut girls being cut. Less emphasis is placed on promotng health seeking behaviour A move towards creatng forums for discussion rather than among those who are sufering from complicatons arising from providing informaton in mini-lectures also requires a change in being cut. This includes minimising and managing short term the type of training required for facilitators. health complicatons resultng from being cut, being aware of

39 6. Recommendations for monitoring, evaluation and learning

The fgures in the table below are selected from the baseline research as indicatve of the current situaton in relaton to FGC and against which progress could be measured. Some, for example overall prevalence, is unlikely to change within the lifetme of the project. Others, for example the percentage of young women seeking support from clinical services, could increase substantally following interventon.

PMP no. Project management Evidence from baseline research and comments plan (PMP) indicator and secton in report

Goal 1 Prevalence of FGC Overall prevalence: 98.9% amongst women and Prevalence is constant across all ages, educaton level and city, semi-city, village. girls in Somaliland (disaggregated by Type of cut: age, type of cut, 15-24 years: 38% pharaonic cut, 35% intermediate, 27% sunna educaton, rural/ over 25 years: 89% underwent the pharaonic cut urban, type of cuter) Impact of educaton: 15-24 years No school: pharaonic cut (50%), intermediate cut (36%), sunna (14%), uncut (3%) Secton 3.1 School/university: pharaonic cut (38%), intermediate cut (33%), sunna (28%), uncut (0%) (note the uncut diference is not signifcant) Type of cuter: overall 92% cut by traditonal cuters or TBAs Percentage cut by health professionals: 15-24 years (11%), over 25 years (5%), no school (0%), primary (10%), secondary (11%), university (12%), city (11%) semi-city (5%), village (5%) Percentage of daughters of interviewees cut by health professionals: Overall (16%), city (24%), semi-city (18%), village (7%)

Objectve 2a Percentage Aspiratons of populaton All: abandon all (5%), abandon intermediate (12%), abandon pharaonic (73%), supportng Objectve 2d abandon none (10%) abandonment of Men (all): abandon all (6%), abandon intermediate (3%), abandon pharaonic (89%), FGC (disaggregated abandon none (2%) by gender, age, benefciary type) Women (all): abandon all (4%), abandon intermediate (20%), abandon pharaonic (59%), abandon none (17%) Teachers (female): abandon all (3%), abandon intermediate (20%), abandon pharaonic Percentage (50%), abandon none (28%) of populaton NOT supportng Teachers (male): abandon all (1%), abandon intermediate (0%), abandon pharaonic (98%), alternatve FGC abandon none (1%) (disaggregated Intentons for daughters by gender, age, All: uncut (17%), sunna (62%), intermediate (12%), pharaonic (9%) stakeholder group and type of FGC Men (all): uncut (21%), sunna (69%), intermediate (2%), pharaonic (9%) practce) Unmarried men: uncut (24%), sunna (67%), intermediate (1%), pharaonic (8%) Women (all): uncut (14%), sunna (55%), intermediate (21%), pharaonic (10%) Secton 3.5 Intentons for daughters-in-law Men (all): uncut (0%), sunna (71%), intermediate (4%), pharaonic (13%), son decides (12%) Women (all): uncut (0%), sunna (48%), intermediate (16%), pharaonic (13%), son decides (22%) Parents intentons for their daughters Mothers (all): uncut (27%), sunna (42%), intermediate (22%), pharaonic (8%) Mother with daughters in grades 1-3: uncut (0%), sunna (51%), intermediate (32%), pharaonic (17%) Fathers (all): uncut (15%), sunna (65%), intermediate (4%), pharaonic (14%)

40 Fathers with daughters in grades 1-3: uncut (8%), sunna (78%), intermediate (3%), pharaonic (11%) Qualitatve data SOFHA could select a sample of diferent stakeholders and interview them afer they have been involved in project actvites asking them: • What do they feel about the abandonment of FGC? • How, if at all, they have changed their attude as a result of being involved in the SOFHA programme? • What actons, if any, have they taken as a result of their change of attude? • What do they think would need to happen for them to support the abandonment of all types of cutng, if they do not support it already? A selecton of these could be writen up as brief case studies demonstratng the kinds of changes which have been triggered as a result of being involved in the programme.

Objectve 2b Percentage of people Knowledge of types of cut who know the efects Overall 96% of people interviewed knew there were diferent types of cut of FGC (disaggregated by gender, age, By age stakeholder group) Women (all): sunna (94%), intermediate (55%), pharaonic (69%) Young women (15-24 years): sunna (94%), intermediate (50%), Secton 3.3 pharaonic (66%) Men (all): sunna (66%), intermediate (8%), pharaonic (80%) Young men (15-24 years): sunna (51%), intermediate (36%), pharaonic (77%) By community type Young men (city): sunna (72%), intermediate (35%), pharaonic (48%) Young men (semi-city): sunna (66%), intermediate (48%), pharaonic (34%) Young men (village): sunna (65%), intermediate (13%), pharaonic (57%) Knowledge of complicatons Percentage considering girls and women sufer NO harmful efects of the sunna (no stches): women (80%), men (68%) Knowledge of types of complicatons from cutng WITH sttches (no signifcant diferences by age, community type or role) None: women (6%), men (3%) Problems with menstruaton: women (62%), men (33%) Severe pain: women (41%), men (22%) Difcultes passing urine: women (45%), men (23%) Problems in childbirth: women (30%), men (39%) Infecton/fever: women (29%), men (14%) Severe bleeding: women (26%), men (20%) Difcultes with marriage: women (15%), men (25%) Swelling: women (5%), men (1%) Problems conceiving: women (5%), men (3%) Infertlity: women (1%), men (3%) * Fistula: women (2%), men (3%) * Psychological trauma/shock: women (6%), men (3%) * Further research is required on the links between FGC and infertlity or fstula.

Qualitatve data The project includes workshops and forums for a large number of diferent stakeholder groups including teachers, parents, health workers, young men, young women which will include informaton on the types of cut and complicatons. Partcipants could be invited to identfy (a) what they have learned and (b) what they are going to do as a result. The SOFHA team could select a sample of the partcipants to interview 6 months aferwards to fnd out what actons, if any, they have carried out and with what result.

41 Objectve 2c Percentage of Overall: 72% of people interviewed have heard messages about FGC people who report Men (80%), women (65%) to have heard In cites (77%), in semi-cites (74%), in villages (63%) ant-FGC messages (disaggregated by Source of messages (female/male) gender, age, source of Radio (40%/61%), NGOs/CSOs (28%/19%), health workers (20%/10%), schools (7%/3%), message) families (3%/2%), TV (22%/15%), posters (3%/3%), Mosques (5%/5%), public meetngs (13%/13%) Secton 3.4 Qualitatve data Gathering a collecton of informaton on the types of messages which members of the community are hearing. This could involve: • collectng examples or taking photographs of leafets, posters and other writen materials • listening to diferent radio and TV messages • partcipatng in public meetngs and actvites at the Mosques when FGC is being mentoned • partcipatng in any workshops, school meetngs etc. where FGC is being covered. The team should note the nature of the messages being given, in order to be able to categorise them and analyse them. The results can be used to improve the quanttatve data gathered on the messages being given on FGC. Partcipants can also be asked which messages they feel have the greatest impact, and why.

Objectve 4a Percentage of Overall: < 5% seek help from health professionals (aged 15-24) women and girls Percentage of women who were cut who sufered complicatons and sought support afected by FGC who have received FGC 15-24 years: cut (99%), complicatons (43%), sought support from health related clinical and professionals (4%) support services 25-40 years: cut (99%), complicatons (70%), sought support from health (disaggregated by age professionals (4%) and type of service) Over 40 years: cut (98%), complicatons (84%), sought support from health professionals (1%) Secton 3.2 These fgures were not disaggregated by type of service (MCH, pharmacy, hospital) as the numbers were so small that diferences would not be signifcant. At mid-term and end of project it might be possible to measure: • the number of women seeking support from SOFHA clinics for complicatons • the number of schools providing clinical support for complicatons Qualitatve data The baseline has established where women go when they need support, however, further exploraton is necessary to know how to increase the percentage accessing health facilites. It would be useful to consider the perspectve of both the young women and the health professionals. This could be done through: (a) focus group discussions with young women (15-24 years) exploring: • How would they go about seeking help from a health professional? • What kinds of symptoms would result in them seeking support of a health professional? • What response have any young women had when they have approached a health professional? • Are there any barriers to a young girl visitng an MCH or hospital? • Would they be able to go on their own or would they need to be accompanied by their mother or an older female relatve? • What are the costs of medicaton and treatment? Who would pay? (b) interviews with a selecton of health professionals exploring: • What types of issues/complicatons relatng to undergoing FGC do women present with? • What kind of support they are able to give? What are the costs? • What training have they had to provide this support? • What, if any, suggestons do they have for improving the service they can provide?

42 7. Conclusions

This research confrms the current prevalence rates and provides baseline data for SOFHA’s current interventon on FGC against which progress can be measured.

Change is happening in relaton to FGC in Somaliland in terms of the type of cut and the person who is cutng. There is evidence of a move from the pharaonic to the intermediate and sunna cuts. However, the overall prevalence rate remains high at 98.9% for all age ranges.

The change in the type of cut presents SOFHA with a signifcant challenge of how to maximise the rate of change, yet also maintain the goal of complete abandonment of all types of cut. Over 90% of community members would like to see the pharaonic cut abandoned, yet less than 4% of support the abandonment of the sunna cut. Focusing on supportng the abandonment of the pharaonic and the intermediate cuts might result in the greatest reducton in physical harm to girls and women over the lifetme of the project, however, it also risks of being seen as condoning the sunna cut.

SOFHA is well-placed to contribute to opposing the medicalisaton of cutng, which is confrmed in this report, as they work closely with the Edna Adan University Hospital (EAUH) and facilitate sessions on midwifery training courses as part of this project. The evidence from this research, highlightng the decision-making dilemmas faced by health professionals could support the development of new approaches to training health professionals on FGC.

SOFHA are commited to working through schools to promote the abandonment of FGC. This research provides insight into the attudes of teachers, the need for training and also to the possibility of developing whole school approaches on FGC.

This research provides insight into the knowledge, attudes and behaviours of young people (15-24 years) which can support SOFHA and other organisatons in involving young people as change agents in relaton to FGC.

Perhaps most importantly, a key fnding of this research is that community members, male and female, young and old, know more about FGC than is ofen thought, yet they stll decide to cut their daughters. People from diferent backgrounds talk about the decision-making dilemmas they face, rather than the knowledge they lack about FGC. They also talk about not having opportunites to engage with each other in discussion about the difcult decisions they face. They describe how in most workshops, community meetngs and awareness raising sessions, they are expected to be passive listeners, rather than actve partcipants discussing the challenges. When ofered opportunites to exchange experiences in focus group discussions, many began to change their opinions. This fnding has signifcant implicatons for how sessions with the full range of stakeholders are facilitated and suggests that a more interactve and partcipatory approach would increase the likelihood of attudinal and behaviour change in relaton to FGC.

43 The MICS surveys (2006 & 2011) for Somalia and the EAUH Appendix A: surveys for Somaliland are alike in having spoken only to ‘adult’ women above 15 years old. The EAUH surveys interviewed Terms of Reference women presentng at the maternity hospital in Hargeisa who come from throughout Somaliland, while the women surveyed Terms of Reference for FGM/C baseline survey in MICS came from across Somalia. Unlike various comparable DHS surveys in other practsing countries, men surveyed in among school girls the MICS (2006 & 2011) in Somalia were not asked about their knowledge and attude towards FGM/C or their expectatons for Introducton its contnuaton. Anecdotally it is known that Somali men have strong opinions about FGM/C, and this baseline survey represents SOFHA is currently implementng a 3 year Norad funded female an opportunity to gain some robust data about the attudes of genital mutlaton/cutng (FGM/C) project in Somaliland, which men in Maroodi Jeex and Togdheer. While there is ‘daughter data’ seeks to empower a frst generaton of Somalis to abandon based upon questons asked to mothers in the MICS (2006 & FGM/C. The project is designed to accelerate interventons 2011) data, there is no existng data direct from girls themselves, towards the abandonment of FGM/C practced in Somaliland by about their FGM/C status and attudes, or from boys about their developing a 5-year strategy toward the eradicaton of FGM/C knowledge and beliefs. in Somaliland. This will be done by targetng Sheikhs/religious leaders and the Ministry of Religious Afairs (MoRA) in order gain Baseline research objectves: their support and to produce a statement so that individuals can choose to abandon FGM/C. Other groups targeted with various • To identfy the prevalence of FGM/C among women and interventons include: students, nurses, government workers, school aged girls (disaggregated by ages of cutng, rural/ media persons, youths, teachers, and parents. These groups are urban, educatonal level of parents, type of school private/ targeted in the 6 major cites of Somaliland by reaching them government and including the type of access to clinical and in schools, universites, MCH clinics, youth clubs and general support services) community. This project consists of both clinical and community • To understand the knowledge, attude and practce regarding aspects that have been integrated into the other existng project FGM/C among parents, adolescents and teachers (including work that SOFHA implements. their knowledge of cutng, which types they support and the messages they have heard about FGM/C) The objectves of this project include: • To investgate young men’s future preferences and their role a. To strategise a FGM/C campaign in Somaliland in interventons to end FGM/C (including marriage intentons b. To increase the public commitment for the eradicaton of for themselves and their sons in future, role in campaigning FGM/C against cutng) c. To promote the criminalisaton of medicalisaton of FGM/C in • To gather relevant baseline data for key project indicators to Somaliland enable changes in benefciaries’ lives to be measured over the course of the project. d. To reduce the health and social complicatons resultng from Users of the baseline data and informaton: FGM/C procedures • The output of the survey will inform SOFHA along with the The project is implemented through a project Task Force line ministries and other stakeholders to measure the impacts including: SOFHA, MoRA, MOH, MoLSA, MOE that meet monthly of the eforts of abandonment of FGM/C in the country throughout the life of the project. The role of the taskforce is to provide technical guidance to the project, advocate for project • SOFHA as a direct benefciary of informaton will use it for issues in other natonal forums and members as a link between tracking key project indicators and to support the FGM/C SOFHA and their respectve organisaton. Note: MOH, MoRA, project focus and interventons. MOE & MoLSA are the government Ministries of Health, Religious Afairs, Educaton and Labour and Social Afairs. Methods and targets

Note: MOH, MORA, MOE & MoLSA are the government Ministries A community survey approach, supported by focus group of Health, Religious Afairs, Educaton and Labour and Social discussions (FGDs) and key informant interviews (KIIs) will be Afairs. used for the baseline research. Target groups will include women, men, secondary school students, university students, teachers, Country situatonal analysis parents in public and private schools, health workers, government workers and religious leaders. The assessment of prevalence, percepton and attudes of FGM/C in Somaliland (2014) carried out by the Network Against Regions FGM in Somaliland (NAFIS) used a descriptve cross-sectonal survey approach, supported by focus group discussions and key The research will be conducted primarily in 3 regions – Sanaag, informant interviews and took place across all six regions of Saahil and Awdal with supplementary data collecton for school Somaliland. The prevalence rate of FGM/C was found to be 99.8% aged girls in Maroodi Jeex and Toghdeer. An earlier baseline with 82.3% undergoing the pharaonic cut. The NAFIS report research was conducted in Maroodi Jeex and Togdheer regions also investgated the decision-making process around FGM/C during January-May 2016 for an ActonAid 4-year project reportng that women, partcularly mothers, are the principle ‘Empowering communites to collectvely abandon FGM/C in decision makers with the fathers being involved in less than 20% Somaliland’ and the majority of the data collected in the research of the households and taking responsibility for the decision less was similar to SOFHA’s needs with the excepton of prevalence than 2% of the tme. rates of FGM/C among school-aged girls.

44 Project indicators Undertake frst visit to Somaliland (2 weeks) The baseline research should produce data on the following Support SOFHA on planning the data collecton process – project indicators: fnalising the implementaton plan Facilitate workshops with the SOFHA team on ethical PMP Performance monitoring plan (PMP) indicator research and community data collecton (2 days) no. Support SOFHA in pilotng the data collecton tools and reviewing the inital data Revise the data collecton tools following feedback from G1 Prevalence of FGM/C amongst women and pilotng girls in Somaliland (disaggregated by age, type of cut, type of school, rural/urban, educaton Undertake focus group discussions (FGDs) and key level of parents) informant interviews (KIIs) with key stakeholders in selected communites Visit MoLSA, MoRA as appropriate OB2a Percentage of populaton supportng abandonment of FGM/C (disaggregated by Revise budget in the light of the frst visit (some inital costs gender, age, benefciary type – teachers, were estmates as indicated) government workers, nurses and students Data analysis etc.) Analyse community data collected by SOFHA team Write up and identfy key themes from FDGs and KIIS OB2b Percentage of people who know the efects of FGM/C (disaggregated by gender, age, Produce summary of inital fndings for review benefciary type) Undertake second visit to Somaliland

Undertake FDGs and KIIs with key stakeholders, as OB2c Percentage of people who report to have appropriate heard ant-FGM/C messages (disaggregated by gender, age, source of message) Facilitate disseminaton seminar/workshop (not included in budget)

OB2d Percentage of populaton NOT supportng Final report alternatve FGM/C (disaggregated by gender, Produce draf report on fndings and recommendatons age, benefciary type and type of FGM/C Revise report following feedback practce) Deliverables

OB4a Percentage of women and girls afected by Incepton plan for baseline research (explaining FGM/C who have received FGM/C related methodology, sample procedure and size, logistcs, quality clinical and support services (disaggregated by assurance) age and type of service) Data collecton tools and protocols (for baseline and readily adaptable for annual monitoring) OB4b Proporton of health workers with skills on • Questonnaires for use with mobile data devices treatng FGM/C complicatons • Guidelines and record forms for consent • Role descripton for community researchers • Target numbers per community Research consultant: tasks and outputs Summary report on the capacity building training for SOFHA staf on: • Ethical research/implementaton of research Tasks • Links between baseline research and on-going project M&E Pre-frst visit Database of baseline research clean and accessible for on- Support discussion on the nature and focus of the baseline going project monitoring research with SOFHA and Populaton Council Report on the fndings and recommendatons of the Design the data collecton tools baseline research including: Approach ActonAid Internatonal Somaliland (AAIS), • Executve summary with SOFHA, to provide access to their web server for the • Context of FGM/C in Somaliland uploading of the data (if AAIS are unwilling to provide this • Methodology then another host will need to be sourced immediately) • Research fndings Write the protocols and guidelines • Key themes Write draf implementaton plan • Implicatons for the project • M&E/Conclusions

45 Appendix B: SOFHA project performance monitoring plan

Indicator Project Indicator defnitons Baseline Targets Data sources Frequency of Responsible No. Indicators (2016) Year Year Year collecton 1 2 3 GOAL: Abandonment of FGM/C practce in Somaliland Indicator Prevalence of This refers to TBD Survey Annually Research G1 FGM/C amongst proporton of questonnaire Consultant women and girls women and in Somaliland girls who have (disaggregated undergone any form by age, type of of FGM/C FGM/C) Numerator: Number of women who have undergone FGM/C in the surveyed areas Denominator: Total number of women and girls surveyed OBJECTIVE 1: To strategise FGM/C campaign in Somaliland Indicator 5 year FGM/C This indicator tracks 0 1 FGM/C Once Project OB1a strategy in place the progress of strategy Manager FGM/C strategy Meetng development Minutes Output 1.1: Religious leaders sensitsaton Indicator Ant FGM/C This indicator 0 1 Religious Once Project O1.1a statement by tracks the standard leaders Manager religious leaders statement expected sensitsaton produced by religious meetng leaders to facilitate report implementaton of the project. The statement will be one, thus reported once, however if it’s reviewed then it should be reported on in subsequent years Indicator Number of This indicator will Atendance O1.1b religious leaders track the number list supportng the of religious leaders ant-FGM/C who support the statement statement once it’s produced out of those sensitsed Indicator Number of This refers to the 0 Atendance Monthly Youth O1.1c religious leaders number of religious list Coordinator sensitsed on leaders who are FGM/C sensitsed on FGM/C Output 1.2: Taskforce consultatve meetng Indicator Number of This refers to N/A Atendance Monthly Project O1.2a ministries the government list Manager represented ministries that will in the project be contnuously FGM/C taskforce represented in the project taskforce

46 Indicator Number of Refers to the N/A Minutes of Monthly O1.2b taskforce number of taskforce the taskforce meetngs held meetngs held to meetngs discuss project implementaton progress OBJECTIVE 2: To increase the public commitment to the eradicaton of FGM/C Indicator Percentage This refers to the TBD Survey Annually Research OB2a of populaton proporton of questonnaire Consultant supportng populaton that abandonment says they support of FGM/C abandonment of (disaggregated FGM/C by gender, age, Numerator: Number benefciary type) of people who say they support abandonment of FGM/C amongst those surveyed Denominator: Total number of people surveyed The indicator will be disaggregated by gender (male and female), age and the type of benefciaries as per the project (teachers, government workers, nurses, students etc.) Indicator Percentage of This refers to the TBD Survey Annually Research OB2b people who proporton of people questonnaire Consultant know the efects who say they know a of FGM/C minimum of certain (disaggregated efects of FGM/C by gender, age, as provided in the benefciary type) survey instrument Numerator: Number of people who state to know the efects of FGM/C as provided in the study Denominator: Total number of people surveyed The indicator will be disaggregated by gender (male and female), age group of the populaton and the type of benefciaries as per the project (teachers, government workers, nurses, students etc.)

47 Indicator Percentage This refers to the TBD Survey Annually Research OB2c of people proporton of people questonnaire Consultant who report who report to have to have heard heard ant-FGM/C ant-FGM/C messages messages Numerator: Number (disaggregated of people who by gender, report to have age, source of heard ant-FGM/C message) messages in the study Denominator: Total number of people surveyed The indicator will be disaggregated by gender (male and female), age and the type of benefciaries as per the project (teachers, government workers, nurses, students etc.) Indicator Percentage This refers to the TBD Survey Annually Research OB2d of populaton proporton of people questonnaire Consultant supportng who state to support alternatve other alternatve FGM/C FGM/C practces (disaggregated Numerator: Number by gender, age, of people who state benefciary type to support other and type of alternatve FGM/C FGM/C practce) practces in the study Denominator: Total number of people surveyed The indicator will be disaggregated by gender (male and female), age, type of benefciaries as per the project (teachers, government workers, nurses, students etc.) and the type of practce they support Output 2.1: Informaton, educaton and communicaton Indicator Number of This indicator tracks 0 IEC Records Monthly Project O2.1a ant-FGM/C the ant-FGM/C Manager messages messages produced produced during the life of the (specify type of project and the type message) of message

48 Indicator Number of ant- This refers to 0 Distributon Monthly Project O2.1b FGM/C materials the ant-FGM/C lists Manager disseminated materials (disaggregated disseminated to by type of the populaton material) during the project period. This will be disaggregated by the type of material (e.g. brochures, pamphlets, T-shirts etc.) Indicator Number of This indicator 0 Media records Monthly Project O2.1c ant-FGM/C will track the Manager messages number of ant- shared publicly FGM/C messages through media disseminated (disaggregated through public by type of media, and will be media) disaggregated by the type of media used to disseminate (TV, radio, print media, social media) Indicator Number This will count the 0 Media records Monthly Project O2.1d of FGM/C interactve questons Manager questons raised raised by listeners during media during the media talk shows talks shows. The host will keep a record of how many FGM/C related questons were raised to gauge the public partcipaton Output 2.2: School interventons Indicator Number of This will count 0 Atendance Monthly Youth O2.2a parents with number of parents list Volunteers primary school with primary school girls reached girl children who are with FGM/C reached with FGM/C messages messages through (disaggregated sensitsaton by gender) meetngs. The indicator will be disaggregated by the gender of the parent (male and female) Indicator Number of This will count 0 Atendance Monthly Youth O2.2b students number of students list Volunteers reached targeted with with FGM/C FGM/C messages messages through sensitsaton (disaggregated meetngs in by gender and secondary schools secondary/ and universites. higher The indicator will insttutons) be disaggregate by the gender of the students, and type of insttuton

49 Output 2.3 Trainings of diferent cadres of people Indicator Number This refers to the 0 Atendance Monthly Youth O2.3a of young number of project list coordinator volunteers youth volunteers trained as who are trained trainers of as trainers by trainers (TOTs) the project. This (disaggregated indicator should be by gender) disaggregated by gender (male and female) Indicator Number of This refers to the 0 Atendance Monthly Youth O2.3b youth volunteers number of youth list coordinator trained volunteer who are (disaggregated trained by the TOTs by gender and on various aspects. type of training; This indicator should comprehensive be disaggregated sexual educaton by gender of the (CSE), FGM/C, trainees, and the advocacy type of training partcipaton) atended Indicator Number of This refers to the 0 Atendance Monthly Youth O2.3c nurses and number of nurses list Volunteers midwives and midwives trained on who are trained medical on medical complicatons of complicatons FGM/C of FGM/C and related treatment disaggregated by gender of partcipants Indicator Number This refers to the 0 Atendance Monthly Youth O2.3d of student number of nurses list Volunteers nurses trained and midwives on medical who are trained complicatons of on medical FGM/C complicatons of FGM/C and related treatment disaggregated by gender of partcipants Indicator Number of This refers to the 0 Atendance Monthly Youth O2.3e staf and youth number of staf and list Volunteers volunteers youth volunteers trained on social who have been media use trained on using social media to infuence FGM/C practces and create awareness. This indicator should be disaggregated by gender of the trainees

50 Indicator Number of This refers to the 0 Atendance Monthly Youth O2.3f media persons number of media list Volunteers trained persons who have on sexual been trained on reproductve SRHR and FGM/C and health practces to create rights (SRHR) awareness. This and FGM/C indicator should (disaggregated be disaggregated by gender and by gender of the type of media) trainees and the type of media they represent (e.g. radio, print, TV etc.) Indicator Number of ant- This counts the 0 Dialogue Monthly Youth O2.3g FGM/C dialogue number of dialogue forum records Volunteers forums/ sessions held by sessions held various groups of (disaggregated people supported by religious by the project. This leaders, youth, indicator should be teachers, nurses disaggregated by and community) type of benefciaries reached through dialogue sessions Output 2.4: Sensitsaton of government workers Indicator Number of This refers to 0 Atendance Monthly Youth O2.4a government the number of list Volunteers workers government sensitsed workers who have on FGM/C been sensitsed (disaggregated on FGM/C during by gender) the project period disaggregated by gender of the partcipant Indicator Number of This refers to the 0 Atendance Monthly Youth O2.4b TBAs and older number of TBAs and list Volunteers women reached older women who with FGM/C have been reached awareness through FGM/C sessions awareness sessions during the project period Output 2.5: Volunteer appreciaton day Indicator Number of This will count 0 Success Annually Youth O2.5a youths who the number of stories Volunteers share FGM/C youth who atend related the volunteer success stories appreciaton day and (disaggregated share FGM/C related by gender) success stories Indicator Number This will count the 0 Atendance Annually Youth O2.5b of youths number of youths list Volunteers atending the who atend the appreciaton day appreciaton day (disaggregated disaggregated by by gender) gender

51 OBJECTIVE 3: To promote the criminalisaton of medicalisaton of FGM/C in Somaliland Indicator Criminalisaton This indicator 0 OB 3.1 of medicalisaton tracks the progress of FGM/C policy on lobbying and approved advocatng for approval of FGM/C policy Output 3.1: Advocacy for approval of criminalisaton policy Indicator Number of This indicator 0 Atendance Monthly Project O3.1a stakeholders will count the list/Minutes Manager involved in diferent types of of the advocatng for stakeholders who meetngs approval of are involved in the criminalisaton meetng with key laws government enttes (disaggregated to advocate for by stakeholder approval of FGM/C type) policy Indicator Number of This indicator will 0 Atendance Monthly Project O3.1b taskforce count the number of list/Minutes Manager meetngs taskforce meetngs of the discussing that deliberately meetngs adopton of discuss the adopton criminalisaton of criminalisaton of of medicalisaton medicalisaton policy policy Indicator Number of This indicator will 0 Minutes of Monthly Project O3.1c meetngs count the number the meetngs Manager held with key of meetngs with government key government enttes to enttes that push for deliberately discuss approval of the and advocate for criminalisaton adopton of the policy criminalisaton of medicalisaton policy OBJECTIVE 4: To reduce the health and social complicatons resultng from FGM/C procedures Indicator Percentage of This refers to the TBD Survey Annually Research OB4a women and proporton of questonnaire Consultant girls afected women and girls by FGM/C who afected by FGM/C have received who report to have FGM/C related been reached with clinical and FGM/C support support services services and clinical (disaggregated services by age and type Numerator: Number of service) of women and girls afected by FGM/C reportng to have received support services Denominator: Number of women and girls surveyed This indicator will be disaggregated by age of the benefciary and type of service provided (clinical/support)

52 Indicator Proporton of This refers to the TBD Survey Annually Research OB4b health workers rato of health questonnaire Consultant with skills in workers who have treatng FGM/C skills to treat FGM/C complicatons complicatons. The skills will be established using criteria as proposed in the survey Numerator: Number of health workers who have the required skills to treat FGM/C complicatons in the sites surveyed Denominator: Total number of health workers in the surveyed sites Output 4.1: Provision of clinical services, referral services and social support Indicator Number of girls This refers to 0 Clinical Monthly Clinical staf/ O4.1a and women number of girls service Health care afected by and women who registers workers FGM/C receiving are afected by clinical services FGM/C and have (disaggregate by received clinical age and type of services at project service) interventon sites. This indicator should be disaggregated by age of client and type of service ofered Indicator Number of This refers to 0 Clinical Monthly Clinical staf/ O4.1b women and women and girls service Health care girls referred who have been registers/ workers for FGM/C referred from Referral cards clinical services interventon sites (referred to and those who and from, have been referred disaggregated by from other areas type of service) to the project interventon sites. This indicator should be disaggregated by referral from and to, and the type of service the person has been referred for

53 Indicator Number of This refers to Support Monthly Youth O4.1c vulnerable girls number of girls and services volunteers and women women who are records afected by afected by FGM/C FGM/C receiving and have been social support ofered project (disaggregated support services. by age and type This indicator should of service) be disaggregated by age of client and type of service ofered Output 4.2: Women and girls’ sports empowerment centre Indicator Women This indicator tracks 0 1 Youth center Once Project O4.2a and girls’ the establishment record/ Manager empowerment of the women and pictures centre girls’ sports centre. established The indicator will be reported on once the centre has been established and is in use by the women and girls Indicator Number of This refers to 0 Youth center Monthly Youth O4.2b women and women and girls atendance volunteers girls accessing utlising the sports registers the sports empowerment empowerment centres services centre once it’s established. (disaggregated It envisioned by type this would be of service established at the accessed) end of the project however should it be established earlier, this indicator should be reported on.

Text highlighted in orange identfes which project indicators the research focused on.

54 Appendix C: Community 4. Does the cutng of girls take place in your community? Is it by all, by most, by just a few? survey questions 5a. What problems does cutng WITH sttches cause among girls and women?

SOFHA baseline questionnaire If other, please explain

Date of interview 5b. What problems does cutng WITHOUT sttches cause among girls and women? Name of community researcher If other, please explain Consent questons Questons for women only Has the purpose of the interview been explained to you? Are you willing to answer some more personal questons about Are you willing to contnue with the questons? female genital cutng?

Background informaton 6. Have you been cut?

Which region do you live in? If not, do you expect to be cut in the future?

Community name 7. What age were you when you were cut?

Is this a CITY, SEMI-CITY or VILLAGE community? 8. What type of cut did you have?

Male or female If other, please explain

Age 9. Who carried out your cutng?

Are you atending school or university now? If other, please explain

If yes, what type of school? 10. Did you have any complicatons soon afer you were cut?

If yes, what class are you in? 11. What kind of complicatons did you have?

Have you atended school in the past? If other, please explain

If yes, what type of school? 12. Did you ask anyone for help?

If yes, how far did you progress? If yes, who did you ask?

Are you married? If other, please explain

Are you a parent? 13. Have you had any long term complicatons as a result of being cut? If yes, do you have GIRLS at primary school now? If other, please explain What type of school do your daughters atend? 14. Were you cut on your wedding night? If other, please explain 15. Do you have any daughters? If yes, are any in grades 1-3? Consent queston - Are you willing to answer some questons What do you do? about your daughters?

If other, please explain 16. How many?

If government worker, what is your job? 17. Have any been cut? (including the sunna)

If a health worker, where do you work? How many?

If other please state where? 18. At what age were they cut?

This survey is about female genital cutng 19. Who carried out the cutng of your daughters?

1. Have you heard about girls being cut? If other, please explain

2. Do you know that girls can be cut in diferent ways? 20. Which type of cut was carried out on your daughters?

3. Can you explain the diferent types? If other, please explain If other, please explain

55 21. Have any of your daughters had complicatons when they Questons for ALL teachers were cut? 36. What do you see as the role of SCHOOLS and COLLEGES in 22. If yes, what kind of complicatons did they have? relaton to female genital cutng?

If other, please explain If other, please explain

23. Do you have any uncut daughters? 37. Do you talk about female genital cutng in your school or college? 24. Will they be cut when they are older? If yes, when 25a. If yes, at what age will they be cut? If other, please explain 25b. If no, why will they not be cut? 38. Do girls ever come to you as a teacher for advice or support If other, please explain on female genital cutng?

26. Which type of cut will be carried out on your uncut 39. If yes, what advice are you able to ofer? daughters? If other, please explain Questons to ALL interviewees 40. Before the school holidays when girls are cut, do you take any 27. Do you intend to cut any daughters you have in the future? acton to protect girls?

28a. If yes, which type of cut? 41. If yes, which of these?

If other, please explain If other, please explain

28b. If no, why will they not be cut? Questons for ALL interviewees

Questons to young women only 42. Have you heard any messages about female genital cutng in your community? 29. As a young woman would you intervene to protect young girls from being cut? 43. If yes what kind of messages are being given?

If other, please explain If other, please explain

30a. If yes, how? 44. If yes, from whom?

If other, please explain If other, please explain

30b. If not, why not? 45. Are you involved in any actvites against female genital cutng in your community? If other, please explain 46. If yes, what kind of actvity? Questons to married men only If other, please state 32. Do you discuss the cutng of your daughters with your wife? 47. Would you like to be involved in actvites against female If not, why not? genital cutng in the future? Questons for ALL interviewees 48. If yes, which kinds of actvites? 33. Would you prefer a son of yours to marry a girl who is cut or If other, please explain uncut? 49. What has stopped you getng involved already? If cut, which type? If other, please explain Questons for unmarried men 50. Which types of cutng do you think should be abandoned in 34. As an unmarried man which kind of girl would you prefer to your community? marry?

If other, please explain

35a. How much does it mater whether the girl you marry has been cut?

If other, please explain

35b. How would you fnd out if a young woman you intend to marry was cut?

56 Appendix D: Interviewees

Region Community City/semi-city/ No. female No. of male Total village interviewees interviewees interviewees

Sanaag Daallo (Cerigabo) City 23 42 65

Yufe Village 60 57 117

Gudmo Biyo Cas Village 59 61 120

October (Sanaag) (Cerigabo) City 8 19 27

Xaafadsoomaal (Cerigabo) City 40 31 71

Shacabka (Cerigabo) City 55 40 95

Other Sanaag * 10 5 15

Total 255 255 510

Awdal Sheeddheer (Borama) City 32 29 61

Sheekh Ali Jawhar (Borama) City 23 31 54

Dilla Semi City 52 45 97

Qulujeed Village 54 48 102

Gorayo Cawl Village 33 35 68

Total 194 188 382

Saaxil Moskow (Berbera) City 54 45 99

Barwaaqo (Berbera) City 62 42 104

Sheekh Semi City 53 56 109

Abdaal Village 48 38 86

Xamaas Village 50 29 79

Total 267 210 477

Togdheer Yaroowe Village 49 47 96

October (Burao) City 67 49 116

Total 116 96 212

Maroodi Jeex Baligubadle Semi City 55 47 102

Ahmed Dhagax (Hargeisa) City 84 80 164

Total 139 127 266

Grand total 971 876 1847