Female Genital Mutilation Survey in Somaliland

Female Genital Mutilation Survey In Somaliland

At the The Edna Adan Maternity and Teaching Hospital, Hargeisa, Somaliland 2002 to 2009

By Mrs. Edna Adan Ismail, Nurse/Midwife Acknowledgements

The staff and Management of the Edna Adan Maternity and Teaching Hospital wish to express appreciation for the financial support received from Norwegian Peoples Aid that provided part of the funds to undertake this survey.

Sincere thanks and appreciation is expressed to the staff and students of the Edna Adan Maternity and Teaching Hospital who collected the data and recorded their findings on the Prenatal Charts following the physical examinations of the women attending the Prenatal Clinic. Sincere appreciation is expressed to the Midwives and Doctors who provided Prenatal Care to the women and who supervised the students during their rotation in the department. Sincere appreciation is expressed to the Administrative staff of the Hospital who undertook the tedious task of typing the data that had been collected by the midwives and student nurses and which had been recorded in the individual patient Edna Adan charts. Maternity HospitalHargeisa Sincere thanks goes also to Amal Ahmed Ali who provided much appreciated Somaliland support in editing the draft document. Tel: (00 252 828) 5999 The tabulation and analysis of the data collected could not have been carried out Tel: (0025221) 38014 without the valuable assistance of Dr. Emma Watkins of Kings College Hospital, Tel/fax (00 252 828) 5226 Denmark Hill, London, to whom sincere thanks is being expressed. www.EdnaHospital.org Contents Contents

What is Female Genital Mutilation? 6 The Study 26 Classification 7 Purpose of Survey 27 Global Prevalence 8 Methodology of the Data Collection 27 Studies of FGM Prevalence 8 Post-Natal Chart 28 World Wide Opinions about FGM 9 Post Natal Visit 28 Edna Adan Maternity Hospital, Pregnancy Record 29 The Procedure 11 Flow diagram of Sample 30

The Operation Itself 12 Recommendations 35 De–infibulation at the time of Marriage 14 Strategies for the eradication of FGM 35 The Dangers of FGM 15 Complications 16 Reasons Given for FGM 19

Campaign to Eradicate FGM 20 The International Campaign 20 UN involvement in the eradication of FGM 20 The Campaign in Somalia/Somaliland 21

Location of Study: The Edna Adan Maternity and Teaching Hospital 23 Health Profile of the People of Somaliland 23 Services Provided by the Hospital 24 UN involvement in the eradication of FGM 24 The Hospital and FGM 25 What is Female Genital Mutilation? Classification According to the definition of the World Health Organization Procedures vary throughout the world but 2 (WHO)1, Female Genital Mutilation FGM comprises all procedu- the WHO classifiesFGM into four types as follows: res involving partial or total removal of the external female ge- Type 1: Excision of the prepuce with nitalia or other injury to the female genital organs whether for or without excision of the clitoris. cultural, religious or other non-therapeutic reasons and does not include medically prescribed surgery or that which is performed for sex change reasons. It is practiced in more than 20 countries throughout Africa, the Middle East and Asia, and within immi- grant populations throughout the world with prevalence rates ranging from 5-99%. Its practice can be found among all religious, ethnic and cultural groups and across all socioeconomic classes. It is estimated that up to 130 million women and girls Type 2: Excision of the clitoris with have already been subjected to some form of FGM and 2 milli- partial or total excision of the labia on more are expected to experience it each year. minora.

Female Genital Mutilation (FGM), also known as Female Circumcision (FC), or Female Genital Cutting (FGC), is a universal practice that results in many health-related and life threatening complications. It also has other physical and psychological effects that do great Type 3: Excision of part or all of the ex- harm to the wellbeing of women and ternal genitalia and stitching together children who have had it performed of the exposed walls of the labia majo- on them. ra, leaving only a small hole (typically less than 5cm) to permit the passage Fig. 1 : Normal female genitalia of urine and vaginal secretions. This hole may need extending at the time of the menarche and often before first In the countries where most or a large number of women have been mutilated, the intercourse. medical complications that result from these practices place a heavy burden on the health services of these countries. Type 4: Unclassified, covers any other damage to the female genitalia including pricking, piercing, burning, cutting or introduction of corrosive substances.

1 WHO. Female Genital Mutilation, a teacher’s guide. Geneva: WHO, 2003. 2 WHO. Female Genital Mutilation, a teacher’s guide. Geneva: WHO, 2003. 6 7 Global Prevalence universal, with 91% undergoing the most severe form, Type 3. A Swedish study published in 1991 questioned 290 Somali women living in Sweden and found Female genital mutilation is a widespread practice that is carried out on young that 100% had FGM, with 88% being Type 3 despite a relatively high socio-e- girls between the ages of 5 and 10 years, and in some countries on grown women conomic level, and the majority was willing to perform FGM on their daughters as well. Unlike male circumcision, female circumcision is not a Religious obligation due to religious reasons9. A recent study by the WHO and UNICEF looking for the required by Islam, Christianity, or any of the other known religions; The practice is first time, into HIV prevalence also asked women about their FGM status. The nevertheless a cultural tradition. It is practiced mainly in Africa and in some Asian study included 769 women and found that 98% had undergone Type 3 circum- countries. At one time it is said to have even existed in Europe before it was abolis- cision10. hed in that continent some centuries ago. In recent years because of immigration and population movements, the practice World Wide Opinions about FGM is emerging among refugee populations in Europe and North America where the medical and obstetrical complications that mutilated women and girls are seeking The United Nations and other humanitarian organizations consider FGM 11, 12 treatment for is causing a lot of concern among health-care providers in Western a violation of human rights . As early as 1979 the WHO recommended, at an 13 countries. This concern is expressed through the constant attention FGM receives international conference, that the practice should be eradicated and in 1993 14, 15 from international health and human rights organizations as well as from the world the World Health Assembly called for abolition of the practice . Consequently, media. most countries have strict laws forbidding the practice. FGM In Asia Studies of FGM Prevalence Female Genital Mutilation is occasionally reported to be practiced by a limited few in Oman; Saudi Arabia; United Arab Emirates; Yemen; and by even fewer Prior to this present study that is being reported on, there had been very few stu- in certain communities in Indonesia; Malaysia; India and Pakistan. dies conducted in the past, or studies had been on a small number of women. FGM In Africa 3 Some of the most accurate early data on FGM comes from Fran Hosken who Female Genital Mutilation is reported to exist in many African countries, in some in 1982 compiled statistics from her many years of studying FGM in Africa. Between it is performed on all or most women while in others it may be performed only 1995 and 2002 the Demographics and Health Surveys published data compiled on some women belonging to certain ethnic groups. by questionnaire from 16 countries, but Somaliland and Somalia were not included. Countries that have had repeated data collected have shown small declines The countries where FGM is reported to be practiced with varying applications in prevalence and a trend to less severe forms of mutilation4. There are a number of Types and different prevalence rates are: of published studies from African countries, (not including Somaliland), in particu- Benin; Burkina Faso; Cameroon; Central African Republic; Chad, Democratic Re- lar Nigeria, which have estimated FGM prevalence, but most have involved small public of the Congo, Djibouti, Egypt, Eritrea, Gambia, Ghana, Guinea, Guinea-Bis- numbers and have only been carried out over short periods 5 6 7 8 . sau, Ivory Coast, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra In 1998 a national survey by the Ministry of Health in Somalia stated a 96% pre- Leone, Somalia, Somaliland, Sudan, Tanzania, Togo, Uganda valence rate. In 1999 Care International studied Somaliland and stated that it was

3 Hosken, F. The Hosken report: Genital and sexual mutilation of females. Lexington, Massachusetts: 9 Dirie MA, Lindmark G. Femal Circumcision in Somalia and women’s motives. Acta Obstet Gynecol Scand. 1991;70(7-8):581-5. women’s International Network news. 1982. 10 HIV/AIDS ASSESSMENT: sero-prevalence survey. Dr Adan Yusuf Abokor. ICD WHO UNICER. 2000. 4 Carr, D. Female Genital cutting. Findings from the demographic and health surveys program. 11 Sullivan D, Toubia NF. Female genital mutilation and human rights. Calverton, Maryland 1997: Marco International Inc. Presented at the World Conference on Human Rights, Vienna, Austria, June 1993. 5 Ugboma HA, Akani CI, Babatunde S. Prevalence and medicalization of female genital mutilation. 12 World Conference on Human Rights: the Vienna Declaration and Programme of Action, June 1993. New York: United Nations. Niger J Med. 2004. Jul – Sep;13(3):250-3. 13 WHO. Traditional practices affecting the health of woman and children; 6 Dare FO, Oboro VO, Fadiora SO, Orji EO, Sule-Odu AO, Olabode TO. Female circumcision, childhood marriage, nutritional taboos etc. WHO/EMRO Tech Publ 1982;2:1-360. Female Genital Mutilation: an analysis of 522 cases in South-Western Nigeria. J Obstetric Gynaecology. 2004 Apr;24(3):281-3.) (325) 14 Female circumcision: female genital mutilation. Int J Gynaecol Obstet 1992;37:149. 7 Egbuonu AO. The Prevalence and practice of female genital mutilation in Nnewi Nigeria: 15 Female genital mutilation -- World Health Assembly calls for the elimination of harmful traditional practices. the impact of female education. J Obstet Gynascol. 200;20(5):520-2) (500) Press release of the 46th World Health Assembly, Geneva, World Health Organization, May 12, 1993. 8 Mandara MU. Female genital Mutilation in Nigeria. Int J Gynaecol Obstet. 2004 mar;84(3):291-8. 8 9 FGM in Somaliland The Procedure It has long been accepted that FGM is ubiquitous in Somaliland but accurate data has been lacking. Anecdotal evidence suggests that the procedure was The day of the FGM is considered an important event but it is commonly performed on girls between the ages of 4 and 11 and that 95–100% of women had undergone the procedure, the majority of whom having been kept secret from the pre-menarche child, and then sprung upon subjected to the most severe form of mutilation16, 17, 18. The study included in this her once the necessary preparations have been made. Senior present report shows that 97 % of the Somaliland women receiving antenatal female members of the community, relatives, traditional birth care at Edna Adan Hospital have undergone FGM. In Somaliland the women re- fer to their procedure by two names, the Sunna and the Pharaonic. The Sunna attendants (TBA’s) or occasionally healthcare workers may be correlates with Type 1 and 2 but also involves stitching of the anterior part of the called upon to carry out the procedure. genitalia to varying extent. The Pharaonic correlates with Type 3. No anesthesia is used while this very sensitive part of the female body is being Many successful awareness campaigns have been run in Somaliland since 1997 brutally cut and manipulated, except when the operation is being performed by and as a result more Somalilanders are willing to openly discuss the topic of FGM a health professional who has access to anesthetics and who the required and are becoming increasingly concerned about the health risks associated with knowledge in their use. the procedure. The age at which female genital mutilation is performed varies from country to country and according to the type of mutilation being done. The SUNNA is generally the type that is performed at a very young age and may be carried out soon after birth, during the first week of life or at any time before the Menarche. In the case of EXCICION and INFIBULATION when more tissues are to be removed which entail more manipulations, the child is allowed to grow older so that the tissues intended for excision are also given a chance to grow. This gives the operator a better pinch or grip. According to the findings of our survey, it was found that the usual age when Excision and Infibulations are performed is between seven and nine years of age.

Instruments and methods

The Instruments - Any sharp cutting instrument such as a knife, broken glass, razor blade will do, or the operator may have somehow acquired medical instruments like a scalpel, forceps or scissors. - The instruments may be new or may have already been used for other purposes and/or on other persons. - Sterilization is seldom known nor performed by these traditional operators.

The Sutures - Regular surgical Catgut, Silk or Cotton thread. - Domestic sewing thread. 16 WHO. Traditional practices affecting the health of woman and children; Female circumcision, childhood marriage, nutritional taboos etc. WHO/EMRO Tech Publ 1982;2:1-360. - Vegetable or nylon fiber pre-selected by the operator. 17 Female circumcision: female genital mutilation. Int J Gynaecol Obstet 1992;37:149. 18 Female genital mutilation -- World Health Assembly calls for the elimination of harmful traditional practices. Press release of the 46th World Health Assembly, Geneva, World Health Organization, May 12, 1993.

10 11 The Needles Understandably, it is vital for the child to be held as still as possible in order to – Regular surgical suturing needles avoid inflicting cuts other than those intentionally being carried out for the pur- (round bodied or sharp and any size) pose of Infibulation. For this, adult helpers grab and pull apart the legs of the – Domestic sewing needle. little girl. Usually, two persons grab one leg each and also hold down her hips; a third person holds back the head and torso. To prevent kicks, the child’s legs Approximating the wound are held back by tying a rope to each of her ankles which is then tied to her In some cases, instead of suturing together the raw edges of the wound, these thighs thus keeping each leg in a tightly flexed position in what can roughly be are held together with thorns that are inserted on opposite sides of the wound described as a modified and forced Trendenlenberg.If available, this is the stage and then laced together with thread and left in place for seven days or until the at which a local anesthetic would be used. tissues of the wound have had time to fuse together. This type of infibulation is often practiced by nomads and agro–pastoralists. The element of speed and surprise is vital and the operator immediately grabs the clitoris by pinching it between her nails aiming to amputate it with a slash. Condition of Hands The organ is then shown to the senior female relatives of the child who will deci- • No gloves are worn during the operation. de whether the amount that has been removed is satisfactory or whether more • Hands may or may not be washed and in any case wet fingers are slippery is to be cut off. After the Clitoris has been ‘satisfactorily’ amputated, and also after and should the operator have difficulty in pinching the skin being removed, the female relatives have ‘ululated’ to let those outside know that the business at it is not unlikely for the operator to wipe his/her hands on the thighs hand is progressing well, the operator can then proceed with the total removal of the child or even on the sand on the ground in order to dry them of the labia minora and the paring of the inner walls of the labia majora . Since and thus improve dexterity! the entire skin on the inner walls of the Labia Majora has to be removed all the • The operator allows his/her nails to grow as they are used as pincers way down to the perineum, this becomes a very messy business as the child who during operations. Rings, amulets and other hand ornaments are rarely is by now screaming and struggling is also bleeding profusely making it difficult removed, as these items are not recognized by the traditional healer for the operator to hold with bare fingers and nails the slippery skin and the as likely sources of contamination. parts that are to be cut or sutured together.

Clothes and bedding It needs to be stressed here that it is important for the wound to heal by first Since bleeding will occur and since there will be some secretions for some days, intention not only to protect the child from a repeat operation, but also mainly the family usually finds an old mat or floor covering that can later be discarded. to preserve the popularity of the operator who would otherwise acquire a bad reputation and also would lose future potential clients if the wounds that she Sometimes sand is placed on the mat under the buttocks of the child in order to handles do not heal well. Having made sure that sufficient tissue has been remo- absorb blood and other secretions. ved to permit the desired fusion of the skin, the operator pulls together the opposite sides of the labia majora, ensuring that the raw edges where the skin had In the case of more affluent or educated families, they may be more likely to be been removed are well approximated. The wound is now ready to be stitched or aware of the risks of infection and usually such families would have clean sheets for thorns to be applied. and also gauze pads to absorb any blood or secretions from the wound. If a needle and thread are being used, close tight sutures will be placed to ensure The Operation Itself that a flap of skin covers the vulva and extends from the Mons Veneris to the Perineum and which, after the wound heals, will form a bridge of scar tissue that The child is made to squat on a stool or mat facing the operator at a convenient will totally occlude the vaginal entroitus. A small hole having the diameter of height that offers the operator a good view of the parts to be handled. This is im- a matchstick will be left un-stitched in order to permit the flow of urine and vagi- portant for the operator is often an elderly person whose sight may be impaired nal secretions. If thorns are being used, an equal number would have been inser- and who may find bending over difficult. ted into each side of the labia majora, and a string would then be used to pull the

12 13 thorns together and thus bring the raw edges of the labia majora together. The The Dangers of FGM string would be wound in the same way that sports shoes with hooks are laced. If the female genital cutting is being done by a person who has some knowledge FGM puts children at risk of life threatening complications at of dressing wounds, they would apply regular medical disinfectants. the time of the procedure as well as health problems that re- After the stitching, a raw egg is broken over the wound, which is then sprinkled, main with her for life. They may suffer bleeding at the time of with whatever herbs, sugar or concoction that were prepared according to the the procedure or develop severe infection, both of which can dictates of the local custom, or the practice of the ‘operator’. This concoction, consisting of egg, herbs, sugar, and the blood of the child, would all clog toge- lead to death if not treated promptly. Those who do not deve- ther and form a crust over the sutures or the strips of cloth holding the thorns lop life-threatening complications will still suffer from severe together. One can only wonder why more girls do not develop infections after pain and trauma. this rich culture medium for bacteria has been placed between the legs of these little girls. In order to prevent leg movement, the child’s legs are bound together The procedure also permits the transmission of viral infections such as hepatitis from the hips down to her toes and the child is then made to lie on her side. which can lead to chronic liver diseases and even HIV. The women may suffer complications such as recurrent infections, pain and obstruction associated with uri- No dressing is used and the legs are kept together for a week after which nation and they are at higher risk of painful menstruation and intercourse, pelvic the leg bindings are slightly loosened and the child allowed taking small infection and difficulties in becoming pregnant. Retention of urine and recurrent steps. The leg bindings will be removed altogether after a further week. infections often require repeated hospital admissions and some women carry a risk To ascertain that the urethra has not been accidentally closed, either by of developing nephritis. The development of cysts and keloids at the site of the scar a blood clot or suture, the child is encouraged to urinate a few hours after the are very common, often causing embarrassment and marital problems, and usually operation. Whether sutures or thorns were inserted, these will be removed on require surgery for removal. the seventh day but only after the operator is satisfied that the two sides of the labia majora have fused together and that the remaining hole for urination is not During pregnancy there are many further complications that may occur as a direct wider than three to five millimeters in diameter. result of the FGM. Labour may become obstructed and if early medical interven- tion is not provided this may lead to the death of both baby and mother. WHO De–infibulation at the time of Marriage estimates that many women giving birth die in the process, simply as a result of FGM 19. If the mother and baby survive there is the risk of damage to the vagina The closure of the introitus must be reopened at the time of marriage so that leading to the formation of fistulas into the bladder or bowel, which cause con- the woman is able to have sexual intercourse. The opening up of the infibulati- stant incontinence as a result of a vessico-vaginal fistula or recto-vaginal fistula. on occurs as part of a ceremony and in the presence of female members from Women in this condition are often rejected by their family and become social out- the bride and groom’s families to verify that the bride is a virgin at the time of casts. During the seven years that the Edna Adan Hospital has been functional, the marriage. The opening of the infibulation is performed by a senior female mem- fistulae of over 100 women have been surgically repaired. Apart from the many ber of the community, a TBA, or in a hospital by medical staff. Occasionally, the physical complications, the girls and women experience considerable psycholo- husband forcibly performs penetration and bursts through the scar of the infi- gical problems including depression, anxiety and post-traumatic stress disorder. bulation. These psychological problems are exacerbated at the time of marriage and often lead to increased distress and fear of intercourse. If de-infibulation is performed the woman is again exposed to the life threatening complications of sepsis and bleeding, and the transmission of chronic infections such as HIV and Hepatitis and also damage to the urethra if, as is common, the operator makes an error when performing the cut.

19 Press release of the 46th World Health Assembly, Geneva. WHO, 1993. 14 15 Complications • Recurrent Urinary Tract Infection: because of the flap of skin obstructing the urethra after infibulation, urine does not jet out during micturition. Considering the clumsy and un-hygienic conditions under which female genital Instead, it hits the flap of skin obstructing the vulva and is then sprayed back mutilation is usually performed, complications are frequent and numerous and into the vagina and then trickles out in drops. This obstruction also prevents can be classified in the order in which they are likely to occur. proper vaginal hygiene and drainage and causes urinary stasis which is likely to cause recurrent urinary tract infection 1. Immediate • Possible Second FGM: because the small artificial opening that had • Shock previously permitted the passage of urine becomes insufficient to permit • Fear the drainage of the more viscous consistency of menstrual bleeding, doctors • Pain often have to convince the parents of these girls that the small vaginal • Hemorrhaging opening be enlarged to permit the flow of menstrual blood. • Other lacerations: in addition to the intentional cuts on the clitoris, This the families resist because they fear that if the opening is too wide it labia minora and majora, there may be accidental lacerations inflicted may not be sufficient proof that their daughter is a virgin when her time on the child as a result of her struggles. comes for her to get married. These cuts may involve the vagina, urethra, anus and thighs. As a result, quite a few children are taken to hospitals for the control 2. At the time of Marriage of hemorrhage, or for the repair of severe lacerations. • De-infibulation: The infibulation opening that had until then permitted the passage of urine and vaginal secretions is no longer able to permit 1. Within the first 10 days intercourse. This will require that the husband make a forcible penetration • Infection: infection to the wound and septicaemia are often to burst the skin obstructing the entrance to the vagina, or the opening encountered and tetanus is not uncommon. will have to be cut open with scissors or a knife to allow the consummation – Retention of Urine: (5 possible causes) of marriage 1. Post-Traumatic Oedema of the vulva resulting from the damages • Dyspareunia: the scar tissue that surrounds the vaginal orifice may be rigid inflicted on the clitoris and labia impedes or obstructs the passage and inelastic and can cause pain during sexual intercourse of urine through the swollen urethra • Infertility: because of the constant stagnation of menstrual blood and 2. Obstruction of the urethra by a blood clot or by the thorns that other vaginal secretions that have accumulated in the vaginal cavity, were inserted to hold the sides of the labia majora together. the resulting pelvic inflammation may obstruct the fallopian tubes 3. Accidental suturing of the Urethra itself and block the normal travel of the ovum along the tubes, preventing 4. Over-tight application of the binds that were used to keep it from becoming fertilized by the male spermatozoa the thighs and legs together • Vulval keloids and dermal cysts: apart from their unaesthetic appearance, 5. Psychosomatic urine retention out of fear and pain these may interfere with consummation of marriage or with childbirth • Failure to Infibulate: when the two sides of the labia majora fail to fuse, during delivery it necessitates that the child undergoes a repeat operation at a later date. 3. During Pregnancy • It is not uncommon for an infibulated and pregnant woman to attend 1. At the onset of menstruation the antenatal clinic for follow up of the pregnancy or for a pregnancy • Dysmeorrhoea: when the post-infibulation vaginal whole is too small there related complaint and find that the opening of the infibulation will not is a constant stagnation of menstrual blood and other vaginal secretions, admit the introduction of even one finger into the vagina for diagnostic causing bacteria to spread into the vaginal and uterine cavities. This is likely and exploratory purposes. Such women will require a de-infibulation to increase the risk of chronic pelvic inflammation that might cause the severe during pregnancy if complications are to be avoided at the time of delivery abdominal cramps experienced by infibulated females during menstruation

16 17 4. During Labour and Delivery 5. Other Complications • Caesarian: Some women arrive at the maternity hospital in labour with In recent years and since the HIV/AIDS pandemic, likelihood of transmission of the a very small infibulation opening. If the vagina is seen to be too rigid and AIDS virus has become added to the long list of complications associated with fe- scarred, and thought to be a possible cause of severe vaginal lacerations male genital mutilation. The risk is made real because the traditional healers who or third degree tears, it is likely that and elective caesarian section will perform circumcisions do not know the dangers of using unsterilized instruments be decided upon. If keloids have formed and are too large, a Caesarian that have previously been used on different individuals who might have been car- section might be the best option to deliver this woman. riers of the AIDS virus • Prolonged second stage of labour: because the vagina, perineum and the labia have all undergone mutilation that has left extensive scar Reasons Given for FGM formation, the vaginal canal becomes inelastic and the pelvic floor muscles rigid. Thus preventing the normal and gradual dilation of the vagina The reasons that drive the practice of FGM lie deep within tradition and cultural as well as the descent of the presenting part of the child during the second heritage and are complex and difficult to determine. Although there is variation stage of labour between societies there are common themes. FGM is often wrongly believed to • Foetal Complications: have a religious origin or to be a requirement of certain religions but this is not the 1. Large caput formation case. 2. Excessive molding of the head 3. Intra=cranial hemorrhage In the majority of societies FGM is believed to preserve the woman’s virginity be- 4. Hypoxia fore marriage and ensures fidelity during marriage. Other common beliefs include 5. Foetal distress that it is hygienic, aesthetically pleasing or increases fertility. 6. Intrauterine death • Maternal Complications: For many women it is part of social integration and the mutilating process is ac- 1. Obstructed labour cepted in return for benefits such as the promise of acceptance in society and the 2. Extensive vaginal and perineal lacerations improved prospect of marriage. Older women often believe they have benefited 3. Third degree tears from FGM and that it has been essential to their identity. By the same reasoning 4. Uterine inertia they allow it to be performed on their daughters fearing that failure to do so may 5. Uterine rupture bring them suffering and social isolation. 6. Impacted foetus 7. Maternal distress Understanding these complex, multifaceted thought processes within societies is 8. Maternal death key to the design of successful, culturally acceptable and correctly targeted eradication campaigns. 5. Post-natal Complications • Infection of the lacerations • Delayed healing of the repaired perineum and vaginal tissues • Sloughing of the vaginal wall, resulting in Vessico-vaginal fistula and/or recto-vaginal fistula • Anemia • Puerperal infection • Cystocele and Rectocele: because of the prolonged labour during each delivery, there is added stretching of the vaginal wall muscles. This causes a prolapse of either the bladder or rectum to bulge into the vagina

18 19 Campaign to Eradicate FGM The Campaign in Somalia/Somaliland The International Campaign In March 1977, during the formation of the Somali Women’s Democratic Organiza- tion (SWDO), Edna Adan Ismail was the first Somali person to publicly denounce The International Campaign against FGM has a long and diffi- FGM and pioneered the campaign for its eradication in Somalia and in Somaliland. From that time she has campaigned against FGM at many important occasions, in- cult history. Advocacy and resistance started with individual he- cluding during the WHO Seminar in Khartoum in 1979 on the Mental and Physical alth professionals from practicing African countries working in Complications of FGM; in 1980 during the Mid-Decade Conference for women in their communities. Their efforts are to be commended as they Copenhagen; in Lusaka in the same year; In Dakar in 1984 when she co-founded and was elected the Vice-President of the Inter-African Committee on Traditional worked in unreceptive environments with little support. Howe- Practices Affecting the Health of Women and Children; In 1986 in EMRO Egypt; ver there are not many records of these efforts and the extent of 1987 in Addis Ababa and the lobbying of the Organization of African Unity. During their impact in not known. the Beijing Women’s’ Conference in 1995 and between 1988 and 1997 when she tirelessly along with international colleagues, lobbied WHO/UNICEF and every Hu- man Rights Organization. UN involvement in the eradication of FGM That first gathering of SWDO was a golden opportunity to address the future lea- Although the UN support for the eradication of FGM is now strong and active, it ders of women in their respective regions of the country and Edna Adan took full was slow in coming. Lack of knowledge on the subject first prevented UN agen- advantage of the opportunity. It was the first time the problem ofFGM was spoken cies from addressing the issue. When awareness finally came to the UN about the about in public in Somalia/Somaliland. Thereafter Edna Adan lectured medical stu- extent of the practice and the serious health and psychological effects that re- dents at the University of Mogadishu as well as nursing students in various nursing sult from it, they recognized it as a major Human rights issue. Conferences were schools in Asia and Africa. The subject was included in the curricula of these schools held, studies were commissioned and discussions were finally opened on the to- and future health professionals all finished their education with knowledge of the pic. However, the mainly European representatives chairing these discussions did harmful effects ofFGM . not understand the deep cultural ties that propagated the practice and they were unprepared for the resistance they faced by recently decolonized African nations In the early 1980’s research into the physical, psychological and sociological as- who saw the attention on the issue as another intrusion. There were exceptions pects of FGM was carried out by the Somalia academy of arts and Sciences. In 1988 however. East African countries, including Somalia where the most severe forms of the government campaigned to eradicate the practice on health and religious FGM are practiced and who had more active campaigns were more appreciative grounds. The SWDO continued their struggle and joined with the Italian Associ- of UN involvement. After these first rounds of conferences around the 1980s, it was ation for women and development (AIDOS) in 1987 and over the following years realized even talking about the topic was sensitive, so immediate abolition was im- founded a campaign based on health complications fearing that one based on hu- possible. While mandates condemning Female Circumcision, as it was know then, man rights would fail. Both campaigns collapsed in 1991 with the overthrow of were taken, in terms of actual field work, the UN took the approach of funding local Siyad Barre and of the disintegration of the government in Somalia. efforts. These local efforts concentrated on the areas of education and advocacy. Training was needed for the health professionals dealing directly with the victims. In 1997, at the time when Edna Adan Ismail was WHO Representative in the Repub- Governments were lobbied to create policies against FGM or if such policies alrea- lic of Djibouti, UNICEF requested her to assist to obtain the approval of the govern- dy existed to implement them proactively. The general public was educated on ment of Somaliland for a seminar to be held in Hargeisa to launch the first seminar the subject, and this was the most important work that permitted the timid steps to revive the campaign to eradicate FGM. The seminar was approved and held and towards change to be achieved. The struggle continues to this day with varying a national committee and a regional task force were established to develop formal degrees of success. Complete eradication has not been achieved, nothing close has policies. This work continues and at the same time a variety of NGO’s and women’s even been attained, but the topic is more openly discussed now than it was thirty groups also run their own eradication campaigns. or forty years ago.

20 21 There have been encouraging signs that the awareness campaigns are having the Location of Study: The Edna Adan Maternity and desired effect. A recent Save the Children publication on child rights in Somaliland found that most girls and boys, and some care givers, community leaders and go- Teaching Hospital vernment officials, point to the harmful traditional practices of FGM as the most negative aspect of Somaliland society and culture 20. The Edna Adan Maternity and Teaching Hospital is situated in Hargeisa, which is the capital of the Republic of Somaliland. Education and the empowerment of women brought about by eradication campaigns are changing the views of Somalilanders on FGM, but it is only by the im- The hospital is a non-profit charity that was built by Edna plementation of audits like this one conducted at the Edna Adan Hospital that the Adan Ismail who donated her UN pension and other personal rate of change can be accurately recorded and evaluated. In a society where the assets to build the hospital in order to address some of the he- practice is almost universally accepted change will occur slowly for as long as people fear discrimination for choosing to break with tradition. alth problems that endanger the lives of women and children in the Horn of Africa. The Edna Adan Maternity and Teaching Hospital is a major player in the campaign against FGM. The next pages provide information about the hospital and its The construction of the hospital was started on the 1st of January 1998 and the vital role in this work. hospital opened its doors to the sick on the 9 st of March 2002 with 25 maternity beds. However, as the need for hospital beds became pressing, and as personnel became trained, the hospital services expanded to accommodate an additional 8 pediatrics and 16 medical and surgical beds, and several Private Rooms. Mrs. Edna Adan Ismail was asked to join the Somaliland government soon after the hospital’s opening. She was first appointed Minister of Social Welfare in August 2002 and then Minister of Foreign Affairs in May 2003 and served in that post until August 2006. She continued to run the hospital while holding those posts but is now the full time Director and runs the hospital activities with appointed Deputy Directors and the Hospital Administrators. A 9 Member Honorary Board of Trustees, consisting of persons of good standing, and from different nationalities and different clans of Somaliland, have been identified and invited by the proprietor, Mrs. Edna Adan Ismail, to advise on Management and verify to the Authorities the Charity Status of the facility as well as to scrutinize Auditing results.

Health Profile of the People of Somaliland The health of the people of Somaliland is among the worst in Africa. This statement is supported by the fact that even before the civil war and the separation of the two Somali states, Somalia had one of the highest Maternal and Child Mortality rates in the world (Ref. UNICEF, The Progress of Nations, 1997, 160 maternal deaths per 10,000 live births).

While recent valid data is not available, what national Maternal and Child Mortality rates have become after the destruction that has taken place during the civil war is a frightening thought. Maternal Mortality rates for Edna Adan Hospital are listed on the next page.

20 Child Rights situation Analysis in Somaliland. Save the Children Publication, Magdalene Lagu, July 2003. 22 23 The hospital was created to provide quality care to this population and to have · To make available to women Pre-Natal and Post-Natal outpatient services, that care continue to all areas of Somaliland by training nurses and midwives in the as well as Immunization for women and children soundest methods and with the most recent technologies. The nurses and midwi- · To make available to women and children, diagnostic Laboratory facilities as ves that graduate from Edna Adan Maternity and Teaching Hospital are a beacon well as a Blood Bank for emergencies. in the country and they ensure a solid base of knowledge and professionalism for · To make available Ultrasound and visual monitoring facilities. this struggling nation. · To make available treatment for Gynecological problems including Management of Infertility, as well as the diagnosis and treatment Services Provided by the Hospital of Sexually Transmitted Diseases including testing for HIV/AIDS Since the existing Public Maternal and Gynecological facilities were over-crowded, and providing counselling as appropriate. ill-equipped and under-staffed, the establishment of the Edna Adan Maternity Hos- · To make available facilities for carrying out medical research, studies and pital has provided much needed Reproductive Health Care to meet the require- counselling, with particular attention to the health problems associated with ments of the expanding population of Hargeisa and in the rest of Somaliland. The Female Genital Mutilation (FGM), as part of the Comprehensive Reproductive Hospital was designed to be run according to strict internationally accepted stan- Health services that are offered by the hospital dards of Maternal and Child Care. With the services and supervision that is carried · In collaboration with the Ministry of Health, UNICEF, and WHO, carry out out by highly qualified Medical, Midwifery and Nursing personnel, it is possible to training programs for health workers, with particular attention to the training provide patients with the type and quality of personalized care that women and of nurses and midwives their babies everywhere have a right to expect. It is gratifying to note that during the short time that the hospital has been functional, the facility has become a re- The Hospital and FGM ferral hospital for obstetrical as well as medical emergencies. Cases with severe The Edna Adan Maternity and Teaching Hospital confronts the effects and com- complications have been received from a wide geographical area in the Horn of plications of FGM almost on a daily basis. Cases include children who have been Africa, including all parts of Somaliland, Somalia, as well as from the 5th Region mutilated hours and sometimes days before being brought to the hospital and of Ethiopia. Maternal Mortality Rate of the patients referred or admitted to who are still bleeding quite heavily or unable to pass urine because of their new the Edna Adan Maternity Hospital from March 2002 to December 31st 2008 has stitches. The severest case of a mutilated child seen at the hospital was one where been dramatically lower than the national rate and has been 32 deaths out of the the child had been so badly cut, that there was virtually no skin to suture together 8164 women who were delivered, or who were referred to the hospital after be- to stop the gushing blood coming from her little body. Common cases also include ing delivered elsewhere. This makes the MMR for the Edna Adan Maternity newly married girls and women just de-infibulated and suffering from bleeding, Hospital 39.1/10,000. MMR has been going steadily down every year. With infection or just plain pain. Also, women in Labour for much longer than they need continued training of personnel, and with better equipment and supplies, we are be because scarring due to FGM prevents the birth canal from dilating properly. confident that this can be reduced even further. Some of those women end up with third degree lacerations and other post natal complications. Edna Adan has been dealing with cases of this nature in her 50 years Objectives of the Hospital of midwifery experience and has been engaged in a life-long struggle to see the · To make available in Somaliland a modern, well-equipped and efficient health end of this practice. With the establishment of her maternity hospital and with the care facility that provides a much higher standard of patient care than that still much needed services to deal with FGM, It has become essential for the hospi- which was previously available to women and children tal to lead the campaign. it is fast becoming a repository of all information relating · To make available a model Health Care Institution, which provides not only to FGM in Somaliland and the region. The hospital has started an auditing process good health care, but which also provides Training and Research opportunities to have baseline data about the prevalence of FGM and the survey in this report is to Medical and Para-Medical personnel. the first data to come out of that auditing initiative and it is believed to be the first · To serve as an example to others and thus encourage national as well as of its kind in Somaliland. The hospital holds educational and sensitization seminars international initiatives to invest in health services in order to improve for concerned groups. At a patient level, counselling services are provided to the the over-all welfare of the nation. victims of FGM and their families. There is no other institution in the country better · To make available to women and children 69 beds for Obstetrical, Neonatal equipped with the experience, knowledge, facilities, and above all, dedication and care and general patient care, including Incubators for premature babies. sheer ‘Will’ to tackle this issue.

24 25 The Study Purpose of Survey: · To obtain baseline data on the current prevalence of FGM among women This study was compiled from a survey carried out on the wo- of childbearing age attending the prenatal Clinic of the hospital. · To obtain information about the prevalence of each type of FGM men attending the Prenatal Clinic at the Edna Adan Maternity · To record data on observed complications in pregnancy, Labour, and Teaching Hospital in Hargeisa, Somaliland between March and delivery 2002 when the hospital was opened up to August 2006. The fin- · To collect data on the age when the procedure was performed, who performed it and where dings were diligently recorded on the Prenatal Charts of each · To collect information on why the women think the practice is done; woman so that the information could be compared with future whether they are pleased it was done on them; whether they will findings during subsequent surveys. do it to their daughters and why · To determine whether any progress has been made towards The data that was obtained has provided information on the prevalence of FGM, attitudinal changes after 32 years of campaigning the type of procedures that had been performed on the persons examined, the · To use the information obtained for future planning of actions ages when the procedure had been performed on them, and details of those who to eradicate the practice had performed it on them. The data also provided an insight into what motivates the continuance of the practice and a prediction of the future risks to young girls. Methodology of the Data Collection. It is believed that the results from such a reliable audit on the prevalence of FGM would be a crucial element in achieving the goal of eradication of the practice sin- Physical Examination ce the information obtained can be used as a baseline data for directing future Examination of the vulva of the patient as part of the physical examinations carried awareness campaigns and auditing their success. Finally, the data collected is of out on all pregnant women attending the clinic for Antenatal Care. On occasions, it interest to the local community in Somaliland and also to medical professionals, was not clear whether the person had undergone any form of FGM and a confirma- NGO’s, International Aid agencies, women’s groups, and to all those who are figh- tion was obtained from the woman herself to record whether the answer should be ting the practice wherever they may be in the world. a ‘Yes’ or a ‘No’. If the answer was a ‘No’, it would be recorded as such and the finding was included in the number of women who had no FGM performed on them. If the The Edna Adan Maternity and Teaching Hospital is the main site in Somaliland for answer was a ‘Yes’ then the rest of the questionnaire would be completed. holding campaigns against FGM. Its founder and director, Mrs. Edna Adan Ismail is a pioneer in the fight to end FGM in Somalia and Somaliland who started her Questionnaire advocacy work on the subject as far back as 1977. In order to ensure the uniformity of the data, a simple questionnaire was developed and printed on the Antenatal Cards of the hospital so that all women who attended the Antenatal clinic had the findings recorded on their individual patient card.

26 27 Post-Natal Chart Edna Adan Maternity Hospital, Pregnancy Record Hospital Number: Date of delivery: Type of delivery: High risk: Yes No Reason for operative delivery: Reason: Colour red if high risk

Complication of 3rd stage: Name: Age: PPH Retained placenta Other Adress: Tel no: Education: Occupation: Birth weight: Sex: Alive Still Birth Died Marital Status: Height: Weight:

Feeding: Breast Bottle Both History Preveious Pregnancies

No of pregnancies Para 5 or more Y N

No of normal deliveries Caesarean section Y N

No of assisted deliveries Post-partum haemorrhage Y N Post Natal Visit No of caesarean sections Retained placenta Y N

No of abortions Labour over 1 day Y N Mother No of abortions Last baby stillborn or Y N Vital signs: T P BP Weight No of abortions died in the first week General health: No of abortions Breasts: No of abortions NB: If yes to any of the above = high risk Uterus: No of abortions Lochia: Perineum or abdominal scar: Other problems with past pregnancies:

Baby General health: Weight: Curent Pregnancy LMP EDD Feeding: Breast Bottle Both Nutritional advice given (tick): Blood group Rhesus Allergies Vaccinations Vaccinations: OPV BCG Other: FGM: YES NO Family Planning: Where: Age: Type: Remarks: By whom: Why: Will you do it to your daughter YES NO Why: Type:

The survey questions developed and changed over time. The number of questions asked of each atten- dee increased with time, so the women involved at the beginning of the study were asked fewer questions than those involved later on. There were no differences to bias the results between the women who attended early in the study compared to later attendees. The next page contains a flow diagram of the number of women that answered each question.

28 29 Flow diagram of Sample: Results Only Only ? FGM ? FGM Sample 1 ? Type ? Type 1234 ? Why it was done to them ? Do it to child ? Type for child Attendees ? FGM Sample 2416 4500 3968 ? Type ? Why it was done to them ? FGM ? Do it to child ? Type ? Type for child ? Why it was done to them 2734 ? Do it to child Basic Questions ? Type for child 1. Age? Non-responders ? Why do it to child 2. Level of Education? 532 318 3. Have you undergone FGM? Sample 2: Age of women Sample 3: Prevalence of FGM 4. What type of FGM was performed? Age was collected on all 3968 patients. Ages Details of whether or not the women had 5. At what age was FGM performed? ranged from 13 to 51. In 28 cases the age undergone FGM was recorded on all 3968 6. Who performed the FGM? was not determined. women. As shown below 97% (3833) had 7. Where was the FGM performed? undergone FGM and 3% (135) had not. Age of respondents Series 1 Age of respondents Prevalence of FGM Percentage 3968 Series 1 Percentage 1 200 Prevalence of FGM 1 200 100% 1 000 100% 1 000 Age of respondents 80% 800 Series 1 80% Percentage 800 Prevalence of FGM 600 1 200 60% Age of respondents 600 Series 1 100% 60% 400 1 000 40% Prevalence of FGM Percentage Basic Questions 1-7 + Additional Answers to the questions 1 200 400 80% 40% 800 200 100%20% 8. Why was the FGM performed concerning ‘Why’ it was 1 000 200 0 60% 20% 600 80% on you? performed provided 800 0 0% >14 400 50 + 40% 0% YES NO >14 40 – 44 50 + 20 – 24 30 – 34 35 – 39 25 – 29

14 – 19 60% YES unknow 9. Will you have FGM performed answers that reflected 600 NO 40 – 44 20 – 24 30 – 34 35 – 39 25 – 29

200 14 – 19 unknow 20% on your daughter? the opinion of the woman. 400 40% 0 Age at FGM 0% Number 5 10. What type of FGM would you 200 Sample 4: Type of FGM Sample 5: Age at which FGM was performed >14 Age at FGM 50 + 20% Number 5 YES 90 NO 40 – 44 20 – 24 30 – 34 35 – 39 25 – 29 0 99% (3796)14 – 19 of the 3833 women who had un- have performed on your Answers to questions unknow The average age for FGM90 to be carried out FGM Type Series 1 80 0%

>14 dergone FGM had the most severe mutilati- 50 + FGM Type Series 1 was 8 years in our sample80 and ranged from YES daughter? asking whether or not she 70 NO 40 – 44 20 – 24 30 – 34 35 – 39 25 – 29 14 – 19 100% on, the pharaonicunknow or WHO type 602 days of age to 17 years.70Age at FGM Number 5 would perform FGM on 100% 60 2734 50 90 her daughter were given 80% 50 80% Series 1 40 Age at FGM 80 Number 5 FGM Type 40 by the woman according 60% 30 70 90 30 100% 60% 20 60 to her opinion. FGM Type Series 1 80 20 40% 10 50 80% 40% 70 0 10 100% 60 40 20% 1 5 8 1 0 1 1 Questions 1-10 + Additional 30 60% 20% 50 1 4 1 7 5 8 1 1 1 80%0% 20 1 4 7 11. Why would you have FGM Pharaonic 0%Suna 40 40% 10 60% Pharaonic Suna 30 performed on your daughter? 0 20% 20 40% 1 5 8 1 1 1 318 10Percentage of women with each level No FGM 1 4 7 0% 0of education with and without FGM PercentageYes FGM of women with each level No FGM Mother's Education No Pharaonic Suna 20% Mother's Education 1 5 8 1 of 1 education 1 with and without FGM Yes FGM Intermediate No 90 90 1 4 7 0% Secondary Intermediate80 Pharaonic Suna 80 Primary Secondary70 Percentage of women with each level No FGM 70 Mother's Education Primary 60 of education with and without FGM Yes FGM University No 60 30 University50 Percentage of women with90 each level 31 Intermediate 50 No FGM 40 of education with and without80 FGM Yes FGM Mother's Education No Secondary 40 30 70 Primary 90 30 Intermediate 20 University 80 60 Secondary 10 20 70 50 Primary 0 10 60 40 No 0 University 30 50 No Primary 20 University 40 Secondary Primary Intemediate University 10 Secondary 30 Intemediate 20 0 No 10 Primary % 0 University Somaliland Secondary % Somaliland No Intemediate Somalia 90 Somalia Primary 90 Ethiopia 80 University Secondary Ethiopia Intemediate Djibouti 70 80 % U.A.E SomalilandDjibouti 60 70 U.A.E 60 Kenya Somalia 50 90 Kenya 50 SomalilandSaudi Arabia Ethiopia 40 80 % Saudi Arabia 40 Sudan Djibouti 30 70 Somalia 90 30 U.A.ESudan 20 60 Ethiopia 80 20 Kenya 10 50 Djibouti 70 10 Saudi Arabia 0 40 U.A.E 60 Rura Tow 0 Unknow Who performed the procedure Kenya Percentage Sudan 50 I n 30 n Rura Tow Unknow Who performed the procedure Percentage 20 I n n 50% Saudi Arabia 40 10 50%Sudan 30 The reasons women gave for why FGM 0 The reasonsPercentage women gave for why FGM 20 was preformed on them Rura Tow Unknow 40% was preformed on them Percentage 40%Who performed the procedure Percentage 10 I n n 60% 0 30% 50% Rura Tow 60% Unknow 30% 50% Who performed the procedure Percentage I n 50%The reasonsn women gave for why FGM was preformed on them Percentage 20%50% 40% 40% 20% 40% The reasons women gave for why FGM 30% 60% 10% 30% was preformed on them 30% Percentage 40% 10% 50% 20% 60% 20% 0% 20% 40% 30% 0% 10%

Old 50% TBA Man

Aunt 10% Sister Nurse Old

TBA 30% Man Doctor Aunt Mother 't know 0% Sister Midwife

10% Hospital Nurse 40% 20% Doctor Don't know Religion Tradition Mother 't know 0% Midwife Hospital

Don 20% Don't know Religion Tradition Grandmother 0% Don 30%

10% Grandmother 10% Old TBA Man Aunt

Sister 20% Nurse Doctor Mother Would you perform FGM 't know 0% Midwife 0% Hospital The type of FGM women Don't know Religion Tradition on your daughter WouldPercentage you perform FGM 10% The type of FGM women Don Old will perform on their daughters Percentage TBA

Man Percentage

Aunt on your daughter Sister Grandmother

Nurse will perform on their daughters Percentage Doctor Mother 't know 0% Midwife 70% Hospital 100% Don't know Religion Tradition 70% 60% Don 100% Grandmother Would you perform FGM The type of FGM women 60% Percentage 80% 50% on your daughter 80% will perform on their daughters Percentage 50% 60% 40% Would you perform FGM70% The type of FGM women Percentage 100% 60% on your daughter 40% will perform on their daughters Percentage 60% 40% 30% 40% 30% 80% 70% 50% 100% 20% 20% 60% 20% 60% 20% 40% 80%0% 10%50% 10% Suna Pharaonic40% 0%Don’t know 0% 30% 60% Suna Pharaonic Don’t know 40% Yes No Don't know 0% 20% 20% Yes No Don't know 40% 30% Reasons given for performing FGM No FGM daughter 10% 0% Reasons given for performing FGM 20% on their Daughters YesReasons SunaFGM daughter given forPharaonic performing FGMDon’t knowNo FGM daughter 20% ReasonsPercentage given for performing FGM on their Daughters 0% Donon't their know Daughters Yes FGM daughter Yeson their DaughtersNo Don't know Percentage Don't know 10% 0% 100% 100% Suna Pharaonic Don’t know 100% 100% 0% Reasons given for performing FGM No FGM daughter Yes No Don't know 80% Reasons given for performing FGM 80% on their Daughters Yes FGM daughter 80%on their Daughters Percentage 80% Don't know Reasons given for performing FGM No FGM daughter 60% Reasons given for performing100% FGM 60% on their Daughters 100% Yes FGM daughter on their Daughters 60% Percentage 60% Don't know 80% 40% 80% 100%40% 100% 40% 40%

20%80% 60% 20%80% 60% 20% 20%

60%0% 40% 60%0% 40% Don't know Religion 0% Tradition No 0% Yes Don't know Religion Tradition No Yes 40% 20% 40% 20%

20% How the decision to perform0% No 20% 0% Don't know Religion Tradition How the reasons given for womens Religion forNo daughter Yes FGM on their daughters varies YesHow the decision to perform No own FGM varies with the reasons given HowTradition the reasons daughter given for womens Religion for daughter with mother education DonFGM't know on their daughters varies Yes for performing FGM on their daughters ownDon FGM't know varies daughter with the reasons given Tradition daughter 0% with mother education Don't know 0% Don't know Religion Tradition No for performingYes FGM on their daughters Don't know daughter 80% 80% 80% 80% 70% How the decision to perform No How the reasons given for womens Religion for daughter 70% 60% FGM on their daughters varies Yes 60% own FGM varies with the reasons given Tradition daughter 50% 60%with mother education Don't know for60% performing FGM on their daughters Don't know daughter How the decision to perform 50% No How the reasons given for womens Religion for daughter 40% FGM on their daughters 80%varies Yes 40% own FGM varies with the reasons80% given Tradition daughter 40% 40% 30% with mother education 70% Don't know for performing FGM on their daughters Don't know daughter 30% 20% 60% 20% 60% 80% 20% 80% 20% 10% 50% 70% 10% 0% 40% 0% 60% 60% 40% No 0% 0% 30% 50% No Primary 20% Religion 't know 40% University Tradition20% Secondary Primary 40% Religion 't know Intemediate University Don Tradition 10% Secondary 30% Intemediate Don 0% 20% 20% 0% No 10% Primary Religion 't know 0% University 0% Tradition Secondary No Intemediate Don

Primary Religion 't know University Tradition Secondary Intemediate Don Age of respondents Series 1 Prevalence of FGM Percentage 1 200 Age of respondents Series 1 100% Percentage 1 000 Prevalence of FGM 1 200 80% 800 100% 1 000 60% 600 80% 800 400 40% 600 60% 200 20% 400 40% 0 200 0%

>14 20% 50 + YES NO 40 – 44 20 – 24 30 – 34 35 – 39 0 25 – 29 14 – 19 unknow 0%

>14 Age of respondents

50 + Series 1 YES PrevalenceNO of FGM Percentage 40 – 44 20 – 24 30 – 34 35 – 39 25 – 29 14 – 19 Age of respondents 1 200 Series 1 unknow Age at FGM Number 5 Prevalence of FGM100% Percentage 90 1 200 1 000 Age at FGM FGM Type Series 1 100%80 80% Number 5 800 1 000 70 90 100% 80% 60% 800 600 FGM Type Series 1 60 80 50 70 600 80% 400 60% 40% 100% 40 60 400 60% 200 40%30 50 20% 80% 0 20 40 200 20% 0% 40% 10 30

60% >14 0 50 + YES 0 NO 40 – 44 20 – 24 30 – 34 35 – 39

25 – 29 20

14 – 19 0% 20% unknow

>14 1 5 8 1 1 1 40% 50 + 10 YES NO 1 4 7 40 – 44 20 – 24 30 – 34 35 – 39 25 – 29 14 – 19 0% unknow 0 Pharaonic20% Suna 1 Age 5at FGM 8 1 1 1 Number 5 Age of respondents Series 1 1 4 7 Age of respondents Series 1 Prevalence of FGM Percentage 0% Age at FGM 90 Number 5 Prevalence of FGM Percentage Pharaonic Suna 1 200 FGM Type Series 1 80 1 200 100% 90 Percentage of women with each level No FGM 100% of education with and without70 FGM 1 000 Mother's Education Series 1 80 Yes FGM 1 000 FGM Type 100% No 60 80% 90 Percentage of women with each level 800 80% Intermediate 70 No FGM 800 of50 education with and without FGM 100% 80% Mother's EducationSecondary No 8060 Yes FGM 600 60% 40 600 60% 7050 90 80% 60% Primary Intermediate 30 400 40% 6040 80 400 40% University Secondary 20 60% 40% Primary 5030 70 200 20% 10 200 20% 4020 60 0 40% University 0 0 0% 20% 3010 50 1 5 8 1 1 1 0% >14 20 0 50 + 40 1 4 7 >14 YES NO 50 + 20% 0% 40 – 44 20 – 24 30 – 34 35 – 39 25 – 29 1 5 8 1 1 1 YES NO 14 – 19 10

unknow 30 40 – 44 20 – 24 30 – 34 35 – 39 25 – 29 Pharaonic Suna 14 – 19

unknow 1 4 7 0% 0 20 Pharaonic Suna No 10 Age at FGM Number 5 Age at FGM Number 5 Primary 0 Percentage of women with each level No FGM University 90 Noof educationSecondary with and without FGM 90 Intemediate Yes FGM Age of respondents Series 1 Mother's Education No Percentage of women with each level No FGM FGM Type Series 1 Prevalence80 of FGM Percentage 90 Primary FGM Type Series 1 80 Intermediate of education with and without FGM Yes FGM University 70 Mother's Education No Secondary 1 200 70 80 Intemediate 100% 100% Secondary 90 100% Age of respondents Series 1 60 Intermediate 1 000 60 Prevalence of FGM Percentage Primary 70 % Sample 6: Women’s level of education Sample 7: 50 Sample 10 :Secondary PersonsSomaliland performing FGM 80 Sample 11: Reasons given for why FGM had 1 200 80% 50 80% 60 800 80% Details on the education of the women were The mother’s education40 was compared 84% of proceduresSomalia on our respondentsUniversity were 70 90 40 100% Primary been performed50 on them % 1 000 60% 60% 30 UniversityEthiopia Somaliland 60 80 600 60% recorded on all 3968 respondents. A majori- to whether30 she had undergone FGM. performed by Old women or TBA’s (46% and 2735 of the respondents40 were asked why they 20 80% Djibouti Somalia 50 70 90 800 30 400 ty of 3142 (79%) had received no education. 20 38% respectively). 1.9% were performed by 40% 40% 10 U.A.E Ethiopia 40 thought60 FGM had80 been performed on them. 40% 10 20 600 60% 200 157 (4%) had received a primary education, 0 midwives, 1.4%Kenya by doctors andDjibouti 1% by nur- 30 They50 were given70 the options of 1) Traditional/ 20% 0 20% 10 20% 1 5 8 1 1 1 20 40 60 0 400 390 (10%) an intermediate level of educati- 1 5 8 40% 1 1 1 ses. ThereforeSaudi a total Arabia of 4.3%U.A.E were perfor- cultural reasons,0 2) Religious reasons or 3) 1 4 7 10 0% 0% 1 4 7 Sudan Kenya 30 50 No 0% on, 258 (7%) a secondary level and only 21 med by professional medical staff. >14 200 did not know the reasons. 55% did not know Pharaonic50 + Suna 20% 0 20 40 YES Pharaonic Suna NO Saudi Arabia Primary 40 – 44 20 – 24 30 – 34 35 – 39 25 – 29 No 14 – 19 University 0 (<1%) had receivedunknow a university education. a10 reason, 34% felt30 it was because of religion,Secondary 0% Sudan Intemediate 0 Primary

>14 20

50 + and 11% because of tradition/culture.University Percentage of women with each level Rura TowSecondary Unknow YES NO No FGM Intemediate 40 – 44 20 – 24 30 – 34 35 – 39

25 – 29 Percentage of women with each level 14 – 19 Age at FGM No FGM 10 unknow of education with and withoutNumber FGM 5 Who performed the procedure Percentage I n n of education with and without FGM Yes FGM Mother's EducationMother's Education No Yes FGM 0 No 90 90 50% Rura Tow Unknow % Intermediate 90 Somaliland Intermediate Who performed the procedure Percentage I n n FGM Type Series 1 Secondary 80 80 Age at FGM Number 5 The reasons women gave for why FGM Secondary 80 Somalia was preformed on90 them Percentage% 70 70 40% 50% Somaliland Primary 70 90 Ethiopia 80 100% Primary 60 Somalia 90 The reasons women gave for why FGM 60 80 60% FGM Type UniversitySeries 1 60 Djibouti 70 Percentage University 50 50 30% Ethiopia 80 was preformed on them 80% 50 70 40% U.A.E 50% 60 40 40 Djibouti 70 100% 40 60 Kenya 60%50 30 60 60% 30 50 20% 30% U.A.E 40% 30 Saudi Arabia 50%40 80% 20 20 Kenya 50 40% 20 40 Sudan 30% 30 10 10 10% Saudi Arabia 40 40% 60% 10 30 20% 20 0 0 Sudan 30 20% 20% 0 1 5 820 1 1 1 10 No 20 30% 40% No 10 0% 10% 1 4 7 10% 0

0% Primary Old 10 Rura Tow Unknow TBA Man

Primary 0 University Aunt 20% Sister Pharaonic Suna University Secondary Nurse Who performed the procedure Percentage I n n 20% Intemediate Doctor 0 Mother 1 Secondary 5 8 1 1 1 't know 0% Midwife Intemediate 0% Hospital Rura Tow Unknow 1 4 7 Don't know 10% Religion Tradition

50% Old TBA Don Who performed the procedure Percentage Man I n n

0% Aunt Sister Nurse Grandmother

Pharaonic Suna Doctor The reasons women gave for why FGM Mother 't know 0%

Percentage of women with each level Midwife No FGM Hospital 50% Donwas't know preformed on them Religion TraditionPercentage of education with and without FGM Yes FGM % 40% Don Mother's Education No Somaliland % The reasons women gave for why FGM Somaliland Would you perform FGM Grandmother was preformed on them Percentage Intermediate Somalia 90 90 Percentage of women with each level The type60% of FGM women Sample 8: CountriesSomalia where FGM Sample90 9 : 40% No FGM on your daughter Percentage 80 of education with and without FGM 30% will perform on their daughters Percentage Mother's EthiopiaEducationSecondary EthiopiaNo 80 Yes FGM 60% 50% had been performed 70It80 was also recorded whether the proce- Would you perform FGM Primary Djibouti 9070 30% 70% The type of FGM women Djibouti Intermediate 70 20% on your daughter Percentage 50% 100% 40% The 3833 women with FGM were asked 60dure was carried60 out in the rural areas or will perform on their daughters Percentage University U.A.E 80 60% U.A.E Secondary 5060 Sample 12: Number of women who would Sample 13 : Type of FGM women would per- where this had been performed.Kenya Sixteen the towns. 84%70 of50 women questioned had 20% 70% 40% 80% 30% Kenya Primary 4050 50% perform10% FGM on their daughters form on their daughters100% Saudi Arabia 6040 different countriesSaudi Arabia were mentioned.University Eighty 30had40 FGM performed in towns. 60% 30% 60% 20% Sudan 5030 10% 40% 2734 of the women were asked if they would Of the 1701 62%80% of woman who said they four percent ofSudan procedures were performed 2030 50%0% 4020 perform FGM on their daughters. 62% said 20% would perform FGM10% on their daughters 92% 20 Old 40% TBA Man

10 30% Aunt 60% Sister in Somaliland, 7% in Ethiopia, 6% in Somalia 3010 0% 40% Nurse Doctor Mother 10 they would perform FGM't know on their daughter, said they would perform0% the Sunna type, 6% Midwife 0 Hospital 10% Old

0 TBA Don't know Religion Tradition 20 Man 20% 20% Aunt and 1% in Djibouti. Other countries were 0 No Sister 40% Rura Tow Unknow Nurse Don

Doctor 30%37% said no, and 1 % did not know. pharaoinc and 2% did not know Mother Rura Tow Unknow 't know 0% Midwife Hospital Who performed the procedure Percentage 10 I n n Grandmother Who performedEgypt, the procedure Kenya, Kuwait,Percentage Nairobi, Qatar, Saudi I Primary n n 10% 0%Don't know Religion Tradition University Don 0 Secondary 20% Suna 20% Pharaonic Don’t know 50% Intemediate 50% Arabia, South Africa, Sudan, The United Arab No 0% Grandmother The reasons women gave for why FGM Yes 10% NoWould you performDon't knowFGM 0% The type of FGM women Emirates, Yemen, Norway and the United The reasons women gave for whyPrimary FGM Percentage was preformed on them University on your daughter Percentage Suna Pharaonic Don’t know 40% was preformed on them PercentageSecondary will perform on their daughters Percentage 40% Intemediate Would you perform 0%FGM Kingdom. TheReasons type given of FGM for performingwomen FGM No FGM daughter 60% % on your daughter Yes PercentageNo Don't know Somaliland 60% Reasons given for70% performing FGM willon theirperform Daughters on100% their daughters PercentageYes FGM daughter 30% on their Daughters Percentage Don't know 30% Somalia 90 50% 60% 50% 70% 100% Reasons given for performing FGM No FGM daughter Ethiopia % Reasons given for performing FGM 80% Yes FGM daughter 20% Somaliland 80 40% 100% 50% 100% on their Daughters 40% 60% on their Daughters Percentage 20% Djibouti 70 Don't know Somalia 90 80% 60% U.A.E 60 30% 50%80% 40% 80% 10% Ethiopia 30% 80 100% 100% 10% Kenya 50 60% 40% Djibouti 20%70 40% 30% 20%40 60% 80% 0% Saudi Arabia U.A.E 60 60% 80% 40% 0% 30 10% 30% 20% 20%

Old Sudan TBA

Man 10% 50 Aunt

Old Kenya Sister TBA Man Nurse

Aunt 20 Doctor Sister 60% Nurse

Mother 60% 't know 0% 40% 20%40% 0% Midwife Hospital 40 20% Doctor Saudi Arabia 10% Mother 't know 0%

Midwife Don't know Religion Tradition Hospital Suna Pharaonic Don’t know 10 Don't know Religion Tradition Don Sudan 30 0%

Don 0%

Grandmother 0 10% 20% Yes No Don't know 20% 40% Grandmother Rura 20 Tow Unknow 40% Suna Pharaonic Don’t know Who performed the procedure Percentage I 10 n n 0% Yes No Don't know Would you perform FGM 0 0% 20% 0% 20% Reasons given for performing FGM No FGM daughter 50% Would you perform FGM The type of FGM women Reasons given for performing FGM No Yes on your daughter Percentage The type of FGM womenRura Tow Unknow Don't know Religion Tradition on their Daughters Yes FGM daughter Percentage The reasons women gave for whywill FGM perform on their daughters Percentage Percentage on your daughter Who performed the procedure Percentage will perform on theirI daughters Percentagen n on their Daughters Reasons given for performing FGM No FGM daughter Don't know was preformed on them Percentage Reasons given for performing0% FGM on their Daughters 0% Yes FGM daughter 40% 50%70% Don't know Percentage Religion Tradition No Yes 70% 100% on their Daughters 100% 100% Don't know 60%100% 60% The reasons women gave for why FGM 30%60% was preformed on them 100% PercentageHow the decision to perform No 100% How the reasons given for womens Religion for daughter 40% 50% 80% 80% 80% 50% 80% FGM on their daughters varies Yes own FGM varies with the reasons given Tradition daughter 50% 32 33 60% with mother education Don't know for performing FGM on their daughters Don't know daughter 20% 40% 60% 80% How the decision to perform No 80% How the reasons given for womens Religion for daughter 30%40% 60% 60% 60% 40% 50% 80% FGM on their daughters varies Yes 80% own FGM varies with the reasons given Tradition daughter 30% 40% with mother education Don't know 10% 30% 40% 60%70% 60% for performing FGM on their daughters Don't know daughter 30% 20% 40% 40% 40% 20% 20% 60% 80% 60% 80% 20% 20% 20%0% 30% 40%50% 70% 40% 10% 10% 0% 20% 20% Old 40% TBA 10% 60% 40% Man 60%

Aunt 0%

10% Sister Suna Pharaonic Don’t know Nurse 20%

Doctor Suna Pharaonic Don’t know 30% Mother 't know 0% 50% Midwife Hospital 20% 0% Don't know Religion Tradition 20% 0% Yes No Don't know 20% 40% 0% 20% 0%

Don 10% 40%

Yes NoOld Don't know Don't know Religion Tradition No Yes TBA Man Aunt Grandmother

Sister 10% Nurse 30%

Doctor 0% 0% Mother 't know 0% Midwife Hospital Reasons given for performing FGM No FGM daughter No Yes Don't know No FGM Religion daughter 0% TraditionDon't know 20% Religion Tradition 0% 20% Reasons given for performing FGM Reasons given for performing FGM Yes FGM daughter Don on their Daughters No Reasons given for performing FGM on their Daughters Yes FGM daughter 10% Would you perform FGMon their Daughters Grandmother Percentage on their Daughters Percentage The type of FGM women Don't know on your daughter Percentage Don't know Primary0% Religion 't know Percentage How the decision Universityto perform No 0% HowTradition the reasons given for womens Religion for daughter will perform on their daughters Secondary 100% 100% IntemediateNoFGM on their daughters varies Yes own FGM varies withDon the reasons given 100% 100% Tradition daughter 70% Would you perform FGM How the decision to perform with motherNo education Don't know How the reasons given for womensfor performing Religion FGM on for their daughter daughters Don't know daughter 100% The type of FGM women Primary Religion 't know on your daughter Percentage FGM on their daughters varies Yes University Tradition 80% 80% will perform on their daughters Percentage Secondary own FGM varies with the reasons given Tradition daughter 80%60% 80% with mother education80% Don't knowIntemediate 80% Don 80% for performing FGM on their daughters Don't know daughter 50% 70% 70% 60% 60%100% 80% 80% 60% 60% 60% 60% 60% 60% 70% 40% 80% 50% 60% 60% 40%50% 40% 40%40% 40% 40% 40%30% 60% 50% 40% 30% 20% 40% 40% 20% 20% 20% 20% 20% 20% 20% 40% 30% 30% 0% 10% 10% 20% 20% 0% Suna 0%20% Pharaonic Don’t know 0% 0% 0% 20% Don't know Religion Tradition 0% No 10% Yes 0% Don't know Religion Tradition No Yes No Yes No Don't know 0% 0% 0% 10% Primary Religion 't know Suna Pharaonic Don’t Noknow University Tradition Secondary 0% Reasons given for performing FGM No FGM daughter Intemediate Don Primary Religion 't know Reasons given for performing FGM Yes No Don't know University Tradition on their Daughters Yes FGM daughter Secondary How the decision to perform No How the reasons given for womens Religion for daughter Intemediate Don Howon their the decision Daughters to perform No Percentage How the reasons given for womens ReligionDon for't knowdaughter FGM on their daughters varies Yes own FGM varies with the reasons given Tradition daughter FGM on their daughters varies Yes own FGM varies with the reasons givenReasons givenTradition for performing daughter FGM No FGM daughter with mother education Don't know for performing FGM on their daughters Don't know daughter 100% with mother education Reasons givenDon for't performingknow FGM 100%for performing FGM on their daughterson their DaughtersDon't know daughter Yes FGM daughter Percentage 80% on their Daughters 80% Don't know 80% 80% 80% 70% 80% 70% 100% 100% 60% 60% 60% 60% 60% 50% 60% 50% 80% 80% 40% 40% 40% 40% 30% 40% 30%40% 60% 60% 20% 20% 20% 20% 20% 10% 20% 10% 40% 40% 0% 0% 0% No 0% 0% No 0% 20% 20% Don't know Religion Primary Tradition No Yes Religion Tradition 't know Primary University Religion 't know University Secondary Tradition Secondary Intemediate Don 0%Intemediate 0% Don Don't know Religion Tradition No Yes

How the decision to perform No How the reasons given for womens Religion for daughter FGM on their daughters varies Yes own FGM varies with the reasons given Tradition daughter with mother education Don't know for performing FGM on their daughters Don't know daughter How the decision to perform No How the reasons given for womens Religion for daughter 80% FGM on their daughters varies Yes 80% own FGM varies with the reasons given Tradition daughter 70% with mother education Don't know for performing FGM on their daughters Don't know daughter 60% 60% 80% 80% 50% 70% 40% 40% 60% 60% 30% 50% 20% 20% 40% 40% 10% 30% 0% 0% 20% No 20% 10% Primary Religion 't know University Tradition 0% Secondary 0% Intemediate No Don

Primary Religion 't know University Tradition Secondary Intemediate Don Age of respondents Series 1 Prevalence of FGM Percentage 1 200 100% 1 000 80% 800

600 60% 400 40% Age of respondents Series 1 Percentage 200 Prevalence of FGM 1 200 20% 0 100% 1 000 0% >14 50 + YES 80% NO 40 – 44 20 – 24 30 – 34 35 – 39 25 – 29

800 14 – 19 unknow

600 60% 400 40% Age at FGM Number 5 90 200 20% FGM Type Series 1 80 0 0% 70

>14 100% 50 + 60 YES Age of respondents Age of respondents Series 1 Series 1 NO 40 – 44 20 – 24 30 – 34 35 – 39 25 – 29 14 – 19 Percentage Percentage unknow Prevalence50 of FGM Prevalence of FGM 80% 1 200 1 200 40 100% 100% 30 1 000 1 00060% Age at FGM Number 5 80% 20 80% 90 800 80040% 10 Series 1 80 600 FGM Type600 60% 0 60% 20% 70 1 5 8 1 1 1 400100% 400 60 40% 40% 1 4 7 0% Pharaonic Suna 50 200 80% 200 20% 20% 40 0 0 60% 30 0% 0%

>14 >14 Percentage of women with each level 50 + 50 + 20 No FGM YES YES NO NO 40 – 44 40 – 44 20 – 24 30 – 34 35 – 39 20 – 24 30 – 34 35 – 39

25 – 29 25 – 29 of education with and without FGM 40% 14 – 19 14 – 19 Yes FGM Mother's Educationunknow No unknow 10 0 90 20% Intermediate 1 580 8 1 1 1 Secondary Age at FGM 1 Age at FGM 4 7 Number 5 Number 5 0% Primary 70 Pharaonic Suna 90 90 University 60 FGM Type FGM Type Series 1 Series 1 80 50 80 70 40 70 100% 100% Percentage60 of women with60 each level No FGM of education with30 and without FGM 50 50 Yes FGM 80% Mother's Education80% No 20 90 Intermediate 40 10 40 30 30 60% 60% Secondary 80 0 Primary 70 20 No20 40% 40% 60 10 10 University Primary University 50 0 0 Secondary 20% 20% Intemediate 40 1 5 8 1 1 5 1 8 1 1 1 1 1 4 7 1 4 7 0% 0% 30 Pharaonic PharaonicSuna Suna 20 % Somaliland 10 Somalia 0 90 Percentage of women withPercentage each level of womenNo with FGM each level No FGM Ethiopia No of education with80 and withoutof education FGM with andYes without FGM FGM Yes FGM Mother's EducationMother's EducationNo DjiboutiNo Primary 70 University 90 90 Secondary Intermediate U.A.EIntermediate 60 Intemediate 80 80 Secondary KenyaSecondary 50 70 70 Primary SaudiPrimary Arabia 40 60 60 University SudanUniversity 30 % Somaliland 50 50 20 Somalia 4090 40 10 Ethiopia 30 30 80 0 Djibouti 2070 20 Rura Tow Unknow Who performed the procedure U.A.E Percentage 1060 10 I n n 50% Kenya 500 0 Saudi Arabia 40 No TheNo reasons women gave for why FGM Percentage 30 Primary was preformedPrimary on them 40% Sudan University University Secondary Secondary Intemediate Intemediate 20 60% 30% 10 50% 0 Rura Tow Unknow Who performed20% the procedure SomalilandPercentage Somaliland I 40% n n % % 50% Somalia Somalia 90 30% 90 10% Ethiopia Ethiopia 80 The reasons women80 gave for why FGM 20% Percentage Djibouti Djibouti 70 was preformed on70 them 40% 0% U.A.E U.A.E 60 10% 60

Old 60% TBA Man Aunt Sister 30% Kenya Nurse Kenya 50 50 Doctor Mother 't know 0% Midwife

Hospital 50% Saudi Arabia Saudi Arabia 40 40 Don't know Religion Tradition Don 40%30 30 20% Sudan Grandmother Sudan 20 20 30% 10% 10 10 Would you perform FGM 0 0 The type of FGM women Percentage 20% on your daughter Rura Tow willRura perform Unknow on theirTow daughters UnknowPercentage 0% Who performed the procedureWho performed the procedurePercentage Percentage I n I n n n 10% Old TBA

70% Man Aunt

50% 50% Sister 100% Nurse Doctor Mother 't know 0% Midwife 60% Hospital DonThe't knowreasons women ReligiongaveThe for whyreasons FGM women Tradition gave for why FGM 80% Don was preformed on them was preformed on themPercentage Percentage 50% 40% 40% Grandmother Sample 14: Reasons for wanting to perform Sample 15: How60% the decision to perform 40% 60% 60% Recommendations 30% FGM30% on their daughters Would you perform FGM FGM50% on theirThe type daughters of40%50% FGM women differs between wo- 30% Percentage on your daughter318 women were asked their reasons for men with willand perform without on their FGM daughters Percentage 20% 20% 40% 40% 20% 20% The battle for the abolition of FGM is definitely one that is too 70% performing FGM on their daughters. 235 We have compared how the decision to 100%30% 30% 10% 10%(74%)10% stated they would do it for traditional perform FGM on0% their daughters varies 60% Suna Pharaonic Don’t know difficult to be left to individual crusaders and little old women. 20%80% 20% 50% or0% cultural reasons, 65 (20%) for Religious re- with whether or not they had undergone 0% 0% Yes No Don't know It has to be fought by all and particularly by government and asons and 18 (6%) did not know why. FGM10%60% themselves.10% Of the women that did Old Old TBA TBA 40% Man Man Aunt Aunt Sister Sister Nurse Nurse

Doctor Doctor No FGM daughter Mother Mother 't know 't know not0% have FGM 90%0% Reasons would given not for performing perform FGM it Midwife Midwife Hospital Hospital 40% by professionals such as Obstetricians, Gynecologists, Pediatri- 30% Reasons given for performing FGM Don't know ReligiononDon their't Daughtersknow Tradition Religion Yes TraditionFGM daughter on theirDon Daughters Don Percentage on their daughters compared with 3% who Don't know Grandmother Grandmother cians, Nurses and Midwives who are the ones who have to deal 20% would.20% Of those who had FGM themselves 100% 100% 10% 63%0% would perform FGM on their daugh- with the serious complications caused by female genital muti- Would you perform FGM Would you perform FGM TheSuna type of FGMPharaonic womenThe typeDon of’t FGMknow women 80% Percentage Percentage 80% 0% on your daughter on your daughter ters comparedwill perform with on36% their who daughterswill perform would onPercentage not. their daughters Percentage Yes No Don't know lation. 70% 60%70% 100% 60%100% Reasons given for performing FGM No FGM daughter 60% 60% Reasons given for performing FGM on their Daughters Yes FGM daughter Percentage 80% 80% 50% on their Daughters40%50% 40% Don't know Strategies for the eradication of FGM 60% 60% 100%40% 40% 100% 20% 20% 40% 40% 80%30% 30% 80% 1. GETTING A LAW IN PLACE IN SOMALILAND 0% 0% • To date the government has made no legal declaration or resolution against 20% 20% Don't know Religion Tradition 20% 20% No Yes 60% 60% FGM. The first priority is to lobby the government to enact a law forbidding 10% 10% 0% 0% Suna PharaonicSunaDon’t knowPharaonic Don’t know the practice. 40%0% Sample0% 16: Factors influencing the mothers 40% Yes decisionHowNo the to decision mutilate Yes to Don'tperform their know No daughtersNo Don't know How the reasons given for womens Religion for daughter • The international community needs to play a more important role in assisting FGM on their daughters varies Yes own FGM varies with the reasons given Tradition daughter 20% 20% The mother’swith mother educationeducation has beenDon't know compared Reasons givenfor performingfor performingReasons FGM FGM on given their forNodaughters performingFGM daughter FGMDon't knowNo daughter FGM daughter the government to put such a law in place. Reasons given for performingReasons FGM given for performing FGM on their Daughters on their DaughtersYes FGM daughter Yes FGM daughter 80%to their decision to perform FGM on their 0% on their Daughters on their Daughters Percentage Percentage 0% 80% Don't know Don't know Don't know70% daughters. Religion There Tradition is a trend for a greater pro- No Yes 100% 100% 100% 100% 60%portion of those with a better education not 60% 2. RELIGIOUS LEADERS ARE KEY 50% 80% 80% themselves80% and why80% they would perform it 40%to want to perform FGM on their daughters. 40% • More than any other group, religious leaders are looked up to for trusted How the decision30%71% to perform of those withNo a university education said onHow theirthe reasons daughter. given for womens Of thoseReligion who for daughter thought FGM on their daughters varies Yes own FGM varies with the reasons given Tradition daughter advice and social direction. If they state with a unanimous voice that FGM 60% 20% 60% 60% 60% with mother educationthey would notDon 't infibulate know their daughters theirfor performing own FGM20% on their had daughters been performedDon't know daughter for tra- 10% is prohibited in the Islamic religion, it will go along way in convincing 80% compared with 29% who said they would. ditional reasons 64% would perform it on 40% 0% 40% 80% 40% 0% 40% the general population to abandon the practice. 70% For thoseNo with no education 66% said they their daughters for religious reasons 60% 60% • UNDERSTAND: FGM is thought of as a women’s issue. Somali men don’t 20% 20% Primary For20% those who thought20%Religion theirs had been done 't know would infibulate their daughtersUniversity compared Tradition 50% Secondary Intemediate for religious reasons the majority (79%) sta-Don generally think very much of it, that includes religious Somali men too. 40% with 34% who will not. 318 of the respon- 0% 0% 40% 0% 0% 30% Don't know dents ReligionwereDon't knowasked Tradition for Religionboth the reasons Tradition why ted tradition asNo the reason forNo performing Yes it Yes Most have probably never considered the legality or illegality of FGM in 20% they believed FGM had been performed on 20%on their daughters a religious context. They can be made aware of existing religious scholarly 10% work available on the subject. If possible they can be sent for training and 0% 0% NoHow the decision to performHow the decisionNo to perform No How the reasons given forHow womens the reasons givenReligion for womens for daughter Religion for daughter sensitization to religious centres and universities in Islamic countries FGM on their daughters variesFGM on their daughtersYes varies Yes own FGM varies with the ownreasons FGM given varies withTradition the reasons daughter given Tradition daughter Primary Religion 't know with mother education with mother educationDonUniversity't know Don't know for performing FGM on theirforTradition performingdaughters FGMDon on 'ttheir know daughters daughter Don't know daughter Secondary to learn from the experiences of communities who have abandoned Intemediate Don 80% 80% 80% 80% the practice. 70% 70% 60% 60% 60% 60% • SUPPORT: Other initiatives that have undertaken the sensitization 50% 50% of religious leaders have found that once this group understands the issue 40% 40% 40% 40% and the severity of the problem, they become strong supporters of its 30% 30% 20% 20% 20% 20% abolition. 10% 10% • ADVOCATE: from support to advocacy. Once religious leaders are on board 0% 0% 0% 0% No No their stand must be shown to the public; Through the weekly sermons

Primary Primary Religion Religion 't know 't know University University Tradition Tradition Secondary Secondary Intemediate Intemediate Don Don

34 35 in Mosques, through television and radio programs, through religious schools or madrasas. Information tools such as video cassettes and tapes with BUSINESS PEOPLE and PROFFESIONALS recorded messages can be developed so their testimony can be taken This group falls into the category of those who have weight within the community. to remote locations. These key agents of change must be put to full use. Generally they have a higher level of education and have an appreciation for Heal- th matters. Educating them about FGM can effect the decisions they make in their SENSITIZING FRONT LINE HEALTH PROFFESIONALS own families and the advice they dispense in their circles of influence • MORE PEOPLE: Sensitizing front line health professionals will increase the number of persons in the field actively working against FGM 4. USING MEDIA TO ESTABLISH A PERMANENT PRESENCE • ONE VOICE: FGM training must be uniform, to increase impact and avoid The campaign against FGM cannot be a sporadic nor an annual event. This is mixed messages. Partners working against FGM need to coordinate efforts a serious human rights and health violation issue that effects young children and to ensure a consistent training approach women. There must be a strong and permanent presence, through boards and • TOOLS: training needs to include tools health professionals can use to counsel pamphlets, videos and cds, seminars and workshops, websites and blogs. But these and if possible intervene in FGM. Tools could include booklets and pamphlets, efforts need to have a smart design that combines sensitivity with practicality. videos and cds etc, all in the local languages of the communities being addressed • DATA: informed and equipped health professional can help collect data 5. RESEARCH about the current state of FGM in Somaliland as well as keep a record • Much research needs to be done on FGM in the Somali regions. As of now of the progress they make in their individual locations there is no reliable data although this study aims to remedy that. But there is still much more work that needs to be done.

3. SENSITIZING THE COMMUNITY • GIRLS AND YOUNG WOMEN: need to be targeted directly so they become POSSILBE RESEARCH QUESTIONS: informed about their condition and options. Establishing communication • More data on Prevalence is needed and types of FGM performed. with this group at an early age can influence decisions they make • Which type of FGM is more frequent? regarding their own daughters later on. • Why do those who choose type 3 make that decision? • Efforts should be made to make FGM education as part of the regular • Why do those who choose a less invasive type make that decision? curriculum of all schools for health professionals. • Can the underlining reasons for choosing one type vs. another be used • PARENTS: and especially MOTHERS As the primary decision makers of FGM, to influence families to choose a less invasive procedure or to abandon are the most essential group to persuade. Contact with them needs to be the practice altogether? consistent and continuous if progress is to be made in the campaign. • What about those that have not undergone FGM? How did they come • MEN: FGM : although they may not think much of it, FGM is done primarily to that decision? What kind of difficulties have they faced? What would to garner their pleasure, and to secure marriage proposals from them. have made their choice easier to live with? They need to be brought into the picture and informed of the undesirability • What are the correlations between education and FGM? Income and FGM? of the practice from a health stand point, cultural standpoint and sexual • Most Somalis have family members living abroad who maintain strong ties relations standpoint. If this group no longer feels that a girl must go and who send remittances. How do Somalis in the Diaspora feel about FGM? through FGM in order to be suitable for marriage, then the stigma of being Do they have any influence over their families in their homelands regarding free of FGM can be alleviated and more families will have the freedom FGM? Can this connection be used in the eradication campaign? to abandon it. • What ideas about women’s sexuality are inherent in the practice of FGM? Are those reasons openly spoken about or more hidden?

36 37 • What about Age, Attitude and FGM? How do youth, male and female feel about it? Can intensive education campaigns aimed at this group help to stop this practice? • What about health professionals? They’re expected to be partners in the elimination of FGM but what are their personal views on the subject? Do they practice the custom in their private lives? • How about religion and FGM? Can a campaign more focused on the religious impermissibility of the practice be more effective than one that stresses health complications or human rights violations?

6. MONITORING AND DOCUMENTING • To take full advantage of resources and to measure achievements when necessary, careful monitoring and documenting techniques must be applied.

These recommendations show the need for a wide, and all-encompassing approach in the fight to eradicate Female Genital Mutation. Because the practice is so pervasive, all areas of society must be targeted, simultaneously and continuously.

Edna Adan Maternity HospitalHargeisa Somaliland Tel: (00 252 828) 5999 Tel: (0025221) 38014 Tel/fax (00 252 828) 5226 www.EdnaHospital.org 38 Female Genital Mutilation Survey In Somaliland At the The Edna Adan Maternity and Teaching Hospital, Hargeisa, Somaliland 2002 to 2009

By Mrs. Edna Adan Ismail, Nurse/Midwife