Amirah Abdallah Elmadani Ibrahim MBBS, Omdurman Islamic

بسم اهلل الرحمن الرحيم

Knowledge, Attitudes and Practice Among Women in Reproductive Age Towards Female Circumcision in Arkaweet Quarter, Wad Medani, Gezira State, Sudan (2017)

Amirah AbdAllah Elmadani Ibrahim

MBBS, Omdurman Islamic University(2010)

A Dissertation

Submitted to the University of Gezira in Partial Fulfillment

of the Requirements for the Award of the Degree

of Master of Science

Family Medicine

Family and Community Medicine Department

Faculty of Medicine

May (2018)

Knowledge, Attitudes and Practice Among Women in Reproductive Age Towards Female Circumcision in Arkaweet Quarter, Wad Medani, Gezira State, Sudan (2017)

Amirah AbdAllah Elmadani Ibrahim

Supervision committee:

Name Position Signature

Prof. Magda Elhadi Ahmed Main Supervisor …………...

Prof. Salwa Elsanousi Hussein Co-supervisor …………...

Knowledge, Attitudes and Practice Among Women in Reproductive Age Towards Female Circumcision in Arkaweet Quarter, Wad Medani, Gezira State, Sudan (2017)

AmirahAbd Allah Elmadani Ibrahim

Examination Committee:

Name Position Signature

Prof. Magda Elhadi Ahmed Chairperson ………………….………

Dr.Abderrhman Ahmed Ismeil External Examiner …………………….……

Dr .ImadEldin Eljack Suleiman Internal Examiner …………………………..

Date of Examination: 13/ 5 /2018

Dedication

To my family members especially my Father, my mother ,my husband and children, my friends, who show me the light when it gets dark….

Amira

iii

Acknowledgement

I would like to express my deepest appreciation to Gezira University, Family medicine program and its supportive staff members.

A special gratitude I give to all those who provided me the possibility to complete this research.

Furthermore, I would like also to acknowledge with much appreciation the crucial role of my supervisor, Prof: Magda Elhadi Ahmed appreciating the guidance given by her that has improved my skills. Thanks to your comments and advices.

Finally, yet importantly, I would like also to acknowledge the staff of Arkaweet Health Center and the community of Arkweet especially the women who helped me to collect the data and to complete my task.

Knowledge, Attitudes and Practice Among Women in Reproductive Age Towards Female Circumcision in Arkaweet Quarter, Wad Medani, Gezira State, Sudan (2017)

AmirahAbd Allah Elmadani Ibrahim

Abstract Female genital mutilation/ cutting, is the ritual cutting or removal of some or all of the external female genitalia It is practiced mainly in Africa and in some Asian countries. A cross sectional descriptive and community-based study conducted in Arkaweet area, Gezira State, Sudan, during the period from September 2017 to December 2017, aiming at studying knowledge, attitudes and practice among women in reproductive age (15-49)toward female circumcision. Two -hundred-and-eighty -eight - questionnaires were distributed. they were aging from 17 to 49 years with mean age 33.98 years and SD 9.35 years, 176 (61.1%) were completed secondary education or higher,(96.2%)were Muslim, and(76.7%)of them were married. All participant know female circumcision, with(79.2%) of them were circumcised,(36.1%) of them affirmed that Female Circumcision is still practiced in the area, with presence of complication among circumcised daughters in (6.9%).The significant reasons why Female Circumcision persistent practice were; to insure virginity, avoid social stigma, for religious causes, with proportion of (16.3%), (10.1%), and (8.3%) respectively. The majority of participant were known its health consequences and (26%) stated that FC has health benefit according to their knowledge like reducing inflammations in (17.0%) and sexual hygiene in (6.2%), The attitude of participant towards (FC) was negative attitude in (33.0%) i.e. encouraging it. The negative attitudes were associated with social tradition (13.9%) marriage prospective (3.5%), safeguard virginity (4.5%), religious instruction (8.0%), removal of genitalia dirtiness (3.1%). Whereas Type I, clitoridectomy (Suuna) the most preferred type by (20.1%). And (31.9%)of the participant had intention to practice FC to their future daughters. All participating in the study aware about FC While, the practice and negative attitudes is still persistent, supported by social, tradition, religious and misconceptions. Keywords: FC, Knowledge, Attitudes, Practice

اميره عبداهلل المدنى ابراهيم

ملخص الدراسة

تشويه األعضاء التناسلية لإلناث، المعروف أيضا باسم قطع األعضاء التناسلية لإلناث وختان اإلناث، هو طقس قطع أو إزالة بعض أو جميع األعضاء التناسلية الخارجية لإلناث. وتوجد هذه الممارسة في أفريقيا وآسيا والشرق األوسط. هذه دراسة وصفية مقطعية ومجتمعية أجريت في منطقة أركويت، مدينة ود مدني في والية الجزيرة بالسودان، خالل الفترة من سبتمبر 2017 إلى ديسمبر 2017، بهدف دراسة المعرفة والمواقف والممارسة بين النساء في سن اإلنجاب نحو ختان اإلناث في المنطقة. مع عينة 288 امرأة في سن اإلنجاب )49-15( تم الحصول على النتائج التالية، كان المدى العمري من 15 إلى 49 سنة مع متوسط العمر 33.98 ± 9.350 سنة‘ كانت معظم المشاركات فى الدراسة نحو 176 )%61.1( قد حصلن على التعليم الثانوى فما فوق، وكان معظمهن من المتزوجات 221 )76.7٪(، وكان معظم المشاركات من المسلمين 277 )%96.2(. على الرغم من أن جميع المشاركين على دراية بختان اإلناث، كان 228 )%79.2( من المشاركات قد ختن، و(%36.1) من هن اكدن انه اليزال يمارس المنطقة، مع ظهور المضاعفات بين الفتيات المختونات بنسبة (%6.9).وكانت األسباب التي ساعدت على استمرار هذه العادة هى لتجنب الوصمة االجتماعية للبنت غير المختونة بنسبة (%10.1)،ولحفظ عذرية البنت بنسبة (%16.3)،وألسباب دينية بنسبة(%8.3)كانت اغلب المشاركات عرفن المضاعفات الصحية له، بينما (%26)اكدن ان لختان االناث فوائد مثل تقليل االلتهابات(%17.0)ومن النظافة(%6.2)،كما كان الموقف السلبي تجاه الختان بنسبة(%33.0)لدى أولئك الالئي يعتقدن أنه تقليد اجتماعي بنسبة )%13.9(والالتي يعتقدن انه من الدين بنسبة (%8.0). والالئى يعتقدن انه يحفظ العذرية فى)4.5%( والالتي يعتقدنه إلزالة االجزاء المتسخة فى )%3.1(.كما ان النوع االول السنة هو النوع المفضل بنسبة (%20.1). بينما (31.9%) لديهن الرغبة لختان بناتهن فى المستقبل.بالرغم من المعرفة الجيدة للختان اال ان الممارسة واالتجاهات السلبية مستمرة مدعمة بالعادات االجتماعية واألسباب الدينية والمفاهيم الخاطئة.

Table of Contents

Dedication ...... iii

Acknowledgement...... iv

Abstract ...... v

Arabic Abstract ...... vi

Table of Contents ...... vii

List of Tables ...... ix

List of Figures ...... xi

List of abbreviations ...... xii

Chapter One

Introduction ...... 1

Problem Statement: ...... 6

Justification…………………………………………………………………………………….. 7

Objectives………...…………………………………………………………………………… 8

Chapter Two

Literature Review ...... 9

Introduction: ...... 9

Terminology………………………………………………………………...………… 9

Origin of the practice ...... 10

The operation ...... 11

AGE at which circumcision done ...... 12

Decision to circumcise …………………………………………………………….…….. 12

Medicalization of the practice ...... 12

Classification ...... 14

Type I ...... 14

Type II ...... 14

Type III ...... 14 vii

Type VI ...... 15

Secondary FGM /C in Sudan (Re- - infibulation ) ...... 16

Clitoral Hood reduction ...... 16

Simulation of female sexual act ...... 17

Complications ...... 17

Short –term …………………………………………………………………………………. 17

Late – complication ...... 18

Pregnancy childbirth ...... 18

Psychological effects, sexual function ...... 19

Reasons behind the practice ...... 19

Socio economic reasons ...... 19

Religion ...... 20

Gender ...... 21

Sexual moriality and marriageability ...... 21

Effort to stop the practice in Sudan ...... 22

International respose ...... 23

Criticism of opposition to FC 25

Previous studies: ...... 27

Chapter Three

Methodology ...... 32

Chapter Four

The Results ...... 36

Chapter Five

Discussion ...... 59

Chapter Six

Conclusion and Recommendations

viii

Chapter Six

Conclusion and Recommendations ...... 62

Recommendations………...... 63

References ……………………………………………………………………………………….. 64

Annex…………………………………………………………………………………………….. 70

List of Tables Table 1: The socio-demographic characteristics of the study sample, n=288 37

Table 2: Knowledge of Types of FC among the study sample, n=288 39

Table 3: Types of complications of FC according the knowledge of the study sample, n=288 40

Table 4: Type of Benefits of FC according the knowledge of the study sample, n=288 ...... 41

Table 5: Possibility of eradication of FC according the knowledge of the study sample, n=288 42

Table 6: Status of females regarding practice of FC among the study sample, n=288 43

Table 7: Type of practiced FC among the study sample, n=288 43

Table 8: Practice of the study sample regarding circumcising their current Daughters FC, n=288 44

Table 9: Reasons behind practicing of Daughters FC among the study sample, n=288 45

Table 10: Presence of complications of FC among the circumcised daughters, n=288 45

Table 11: Type of complications among circumcised daughters, n=288 46

Table 12: Conception of FC may lead to death among the study sample, n=288 46

Table 13: Place of practicing FC among the study sample, n=288 47

Table 14: Decision maker of performing FC among the study sample, n=288 48

Table 15: Age for FC among the study sample, n=288 49

Table 16: Reason behind positive attitude towards FC among the study sample, n=288 ...... 50

Table 17: Reason behind negative attitude FC among the study sample, n=288 51

Table 18: Preference of certain type of FC among those have neegative attitude, n=288 ...... 52

Table 19: Preferred type of FC among those have negative attitude, n=288 52

Table 20: Reasons of preference of certain type of FC among those have negatie attitude, n=288 53

Table 21: Attitude among study sample towards eradication of FC, n=288 53

Table 22: Reasons for supporting eradication of FC among the study sample, n=288 ...... 54

Table 23: Reasons for not supporting eradication of FC among the study sample, n=288 ...... 55

Table 24: Attitude of study sample regarding their intention towards circumcising their future 55 daughters , n = 288 Table 25: Age groups vs Supporting Female Circumcision 56

Table 26: Educational level vs Supporting Female Circumcision 56

Table 27: Occupation vs Supporting Female Circumcision 57

Table 28: Marital status vs Supporting Female Circumcision 57

Table 29: Monthly income vs Supporting Female Circumcision 58

List of Figures

Figure 1: Definition of FC among the study sample, n=288 ...... 38 Figure 2: Presence of complications of FC according the knowledge of the study sample, n=288 ...... 39 Figure 3: Benefits of FC according the knowledge of the study sample, n=288 ...... 41 Figure 4: Method of eradication of FC according the knowledge of the study sample, n=288 ...... 42 figure5: Reasons behind not practicing Daughter FC among the study sample, n=288………………...44

Figure 6: Practioner of FC among the study sample, n=288 ……………………………………….47

Figure 7: Instrument used to practice FC among the study sample, n=288 ...... 48 Figure 8: Attitude towards FC among the study sample, n=288 ...... 49

xii

List of abbreviations

BBSAWS BabikerBadri Scientific Association for Women's Studies DFID Department for International Development DHS Demographic Health Survey FC Female Circumcision FGM Female Genital Mutilation FGM/C Female Genital Mutilation /cutting KAP Knowledge Attitude and Practice

MICS Multiple cluster Surveys SDHS Sudan Demographic Health Survey SFS Sudan Fertility Survey SHHS Sudan House hold survey TBA Traditional birth attendant UN United Nation UNFPA United Nations Population Fund UNICEF United Nations children’s fund UNPF United Nation Peace Forces USAID Untied State Agency for International Development WHO World health organization

xiii

Chapter One Introduction 1.1 Introduction:

Knowledge is defined by the oxford English dictionary as expertise and skills acquired by a person through experience or education, the theoretical or practical understanding of a subject, what is known in a particular field or in total facts and information, or awareness or familiarity gained by experience of a fact or situation.

The term knowledge is also used to mean the confident understanding of a subject with the ability to use it for specific purpose if appropriate.

An attitude is a hypothetical construct that represents an individual’s degree of like or dislike for item. Attitudes are generally positive or negative views of a person, place, thing or event. The practice is to do or perform something habitually or repeatedly, in order to acquire or abolish skill. It also the condition of being skilled through repeated exercise. (Stallman,2002)

All societies have norms and behavior based on age, life style, gender and social class. the norms often referred to as traditional practice beneficial or harmless but some may be harmful, however culture is not static ,it is constant flux , adapting and reforming that people will change their behavior when they understand the hazards and indignity of harmful practice when they realize that is possible to give up harmful practice.(WHO, 1998).

Female genital mutilation comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non- medical reasons. (WHO, 2017)

Female genital mutilation (FGM) is a deeply embedded culturaltradition with meaning and symbolism for many communities. Thepractice of FGM is built on a ‘mental map’ of beliefs, values and codesof conduct. These are psychosexual, social and religious in nature andinclude the maintenance of chastity/virginity, family honor and controlover women’s sexuality, the belief that FGM is necessary for hygieneand aesthetic reasons (fears of ugliness and bad odor), and the beliefthat it is a religious requirement for spiritual cleanliness. FGM issustained by community enforcement mechanisms such as publicrecognition by celebration (use of rewards and gifts, poems and songscelebrating the circumcised while deriding the

uncircumcised), therefusal to marry uncircumcised women and fear of punishment byGod. (Broussard, P A, 2008)

Female genital circumcision internationally recognized as a violation of human rights of girls and women, reflecting deep rooted in equality between sexes, since FGM is almost always carried out on minors, it also aviolation of the rights of children .(Simister J, 2010)

Female circumcision is widely practiced in all regions of Sudan, with some variations in the prevalence and types of circumcision performed according to the indigenous local customs and traditions. (Abdel Magied, 2005). In classical Arabic FC is called “Khifad”which means reduction. In popular Arabic used in Sudan it is called “Tahur”which means purity and cleanliness. There are three main types of female circumcision practiced in Sudan: Suuna, intermediate and pharaoniccircumcision. However, the three types represent different degrees of mutilation of the external genitalia of the female (Abdel Magied, 2002). Female genital mutilation or Female circumcision is known and practiced in all regions of northern Sudan. (Bergreen, 2006)

The practice in Sudan was first seen as social problem in the late 1930 when it was widely discussed by the British administration and enlighten Sudanese. The majority of educated Sudanese felt that; it was the duty of their generation to polish custom (UNICEF,2006).

In early 1946 the legislative assembly passed a law making pharaonic type as offense punishable by five years’ imprisonment. (The Suuna circumcision was considered to be legal), this measure however proves to be failed. Female genital circumcision (FGC), also known as female genital mutilation (FGM), the term is almost exclusively used to describe traditional or religious procedures on a minor, which requires the parents’ consent because of the age of the girl. (Gruenbaum,2006)

FGM is widely practiced out in the open by many communities of varied faiths in its locus of concentration in Northeastern Africa; it is practiced in different parts of the Middle East. In the Arabian Peninsula, Types I and II FGM are usually performed, often referred to as Sunna circumcision. The practice occurs particularly in northern Saudi Arabia, southern Jordan, and northern Iraq (Kurdistan). In the Iraqi village of Hasira, a recent study found that 60 percent of the women and girls reported having undergone FGM. Before the study, there had been no solid proof of the prevalence of the practice. There is also circumstantial evidence to suggest

that FGM is practiced in the Kurdish regions of Syria, Turkey and Iran. In Oman, a few communities still practice FGM. (WHO,2008)

1.1.1Geographic Distribution of Circumcision: 1.1.2Female circumcision around the world: FGM is found mostly in what Gerry Mackie called an "intriguingly contiguous" zone in Africa—east to west from Somalia to Senegal, and north to south from Egypt to Tanzania. Nationally representative figures are available for 27 countries in Africa, as well as Indonesia, Iraqi Kurdistan and Yemen. Over 200 million women and girls are thought to be living with FGM in those 30 country. (UNICEF, 2016)

As a result of immigration FGM spread to Europe, Australia, and United states, with some families having their daughters undergo the procedure while on vacation overseas. As Western governments became more aware of FGM, legalization has come into effect in many countries to make the practice a criminal offense. (Georgia, 2010)

Smaller studies or anecdotal reports suggest that FGM is also practiced in Colombia, the Congo, Malaysia, Oman, Peru, Saudi Arabia, Sri Lanka, and the United Arab Emirates, by the Bedouin in Israel, in Rahmah, Jordan, and by the DawoodiBohra in India. It is also found within immigrant communities in Australasia, Europe and North America. (UNICEF, 2016)

Other reports claim the prevalence of FGM in countries not discussed by the 2013 UNICEF report.(P.Hosken,1989)the practice occur in Jordon, Iraqi, Syria, Oman, United Arab Emirates and Qatar.Earlier reports claimed the prevalence of FGM in Israel among the Negev Bedouin, which by 2009 has virtually disappeared.(IRIN, 2009)

1.1.3Female Circumcision in Sudan:

Circumcision is widely practiced in central, western, eastern and northern Sudan. This leaves out only southern Sudan and some area of Nubba Mountain in southern Kordofan with exceptions of some families who have migrated to the north in Sudan and adopted the practice. It is a clear that in both Muslims and Christians both pharaonic and Suuna circumcision are practiced and the strange thing is that Christians practice Suuna circumcision at 46.2% when compared to Muslims at 14.5%. It is noticed that, the province of Darfur and eastern province practiced circumcision at low percentage i.e. the percentage of circumcision are low in related to the rest of the provinces in Sudan. (WHO,2008)

Strong social pressure maintains high levels of circumcision, which is believed to promote premarital chastity among women. In most areas in Sudan uncircumcised women are generally viewed as impure and thus unmarriageable. Given their lack of choice and the powerful influence of tradition, most women accept circumcision as necessary, and even naturally part of life, and adopt the rationales given for its existence. (Yoder; Khan,2007)

FGM/C rates remains higher than 89% among women older than 34 years with only a slight decrease in the prevalence of FGM/C in 15 – 19 years compared to 45 – 49 years age categories. The survey findings indicate that most of the girls and women undergo FGM/C when they are 5 – 14 years old.(SHHS, 2010)

1.1.4Attitude towards FGM/C practice in Sudan

There is improvement in the anti-FGM/C attitudes among both women and men in Sudan. For example the SHHS - 2006 found that 51% of 15-49 years old women thought the practice should continue compared to 79% in 1989 – 1990 SMS. Also, 54% of ever-married women in 2006 intended to have their daughters cut compared to 82% in 1989-1990 (UNICEF, 2010). In another survey, it was found that 80% of the women and 79% of the men indicated that FGM should be stopped. In addition, 77% of the females and 73% of the males indicated they will not cut their daughters (Nafisa B, 2007). Furthermore, in a study among the university student of Khartoum, it was found that 78.8% of the males and 88.1% of females thought FGM/C should be abolished (E Herieka, J Dhar, 2003 ). Moreover, 65% of married males.preferred to be married to uncircumcised women and the same was indicated by 74.8% of the male respondents in the Khartoum University study (Nafisa B, 2007&E Herieka& J Dhar, 2003 ).

1.1.5Attitude towards FGM/C practice in Gezira State: The improvement in the anti FGM/C attitude among both women and men in Gezira State. For example:

Table (I): Attitude of women aged 15 -49yrs towards whether the practice of FGM/C should be continued or discontinued, (SHHS, 2010)

State Continued Depends Don’t Know Discontinue

Gezira 28.2 0.6 1.9 69.1

Table (II): Attitude of men aged 15 – 49yrs towards whether the practice of FGM/C should be continued or discontinued, (SHHS, 2010)

State Continued Depends Don’t Know Discontinue

Gezira 10.9 6.9 6.7 75.3

Table (III): percentage of ever married women aged 15- 49yrs who intend or not intend to FGM/C their daughters, (SHHS, 2010)

State Yes Don’t know No

Gezira 28.3 2.1 48.8

Table (IV): person who performed FGM/C by state (SHHS, 2010)

State Traditional Nurse or Doctor Other health Others Don’t mid wives Mid wife professional know or missing

Gezira 66.1 31.7 0.2 0 0 2.0

1.2Problem Statement:  Female genital mutilation/cutting (FGM/C) is a global concern. Not only is it practiced among communities in Africa and the Middle East, but also in immigrant communities throughout the world. Moreover, recent data reveal that it occurs on a much larger scale than previously thought. It continues to be one of the most persistent, pervasive and silently endured human rights violations. (UNICEF, 2008)  UNICEF estimated in 2016 that 200 million women living today in 30 countries—27 African countries, Indonesia, Iraqi Kurdistan and Yemen—have undergone the procedures.(UNICEF, 2016)  Estimates based on most recent prevalent data indicate that 91,5 million girls and women above 9 years old in Africa are currently living with consequences of female genital mutilation, also there are an estimated 3million girls at risk of undergoing female genital mutilation /cutting every year. (WHO,2017)  The total number of girls and women cut will continue to increase due to population growth. If nothing is done, the number of girls and women affected will grow from 133million today to 325 million in 2050.(UNICEF, 2014)  As compared to other African countries where the practice has been decreased, it has remained established in Sudan. Given the prevalence of this practiced, it is expected that over two million girls born between 2010– 2015 will have experienced FGM /C by 2030. (UNFPA, 2013)  Infibulation is practiced largely in countries located in north eastern Africa:( Djibouti, Eritrea, Ethiopia, Somalia and Sudan), Sudan alone accounts for about 3,5 million of women,According to UNFPA in 2010, 20% of women with FGM /C have been infibulated.(UNPF, 2010)  Although damage to female sexual organ and their function is extensive and irreversible yet the true magnitude of the problem is still underestimated due to limited information and mystery of the practice. (Population reference Bureau,2010)  The practice of FC in Arkaweet area is done in secrete way or in rural areas.

1.3Justification:

1. Estimated prevalence of female genital mutilation in girls and women 15 – 49 years in Sudan, northern (approximately 80% of total population in survey) is 90.0%. (Yoder; Khan, 2007). 2. Sudan is in the highest category of prevalence for countries with FGM/C, and 37% of the girls affected are under the age of 14.(UNICEF,2013). 3. From 2010 household surveys asked women about FGM status of all their living daughters. The figures suggest that a girl was one third less likely in 2014 to undergo FGM than she was 30 years ago. If rate of decline continues, the number of girls was one third less likely in 2014 to undergo FGM than she was 30 years ago. And almost some girls will be spared this grave assault to their human rights.(UNICEF,2014). 4. The highest maternal and infant mortality rates are in FGM practicing regions. The actual number of girls who die as a result of FGM is not known. However, in areas in the Sudan where health care services are not available, it is estimated that one-third of the girls undergoing FGM will die. (UNICEF, 2005). 5. It has been found that there was limited data about knowledge, attitudes and practiced among house holds about female circumcision. So it is very important to assess knowledge, attitudes and practice (KAP) for female circumcision among women in reproductive age in Arkaweet area because there is no data available.

1.4Objectives 1.4.1General objective:

To study knowledge, attitudes and practice among women in reproductive age towards female circumcision in Arkaweet – Wad Medani – Sudan, 2017.

1.4.2Specific objectives:

1. To measure the magnitude and pattern of female circumcision in Arkaweet area. 2. To assess knowledge, attitude and practice of women towards FC. 3. To determine factors enhancing or hindering the practice of FC. 4. To determine complications associated with FC. 5. To determine attitudes of female practicing this phenomena in their future daughters.

Chapter Two Literature Review

2.1Introduction: Female genital mutilation (FGM), also known as female genital cutting and female circumcision, is the ritual cutting or removal of some or all of the external female genitalia.

Typically carried out by a traditional circumciser using a blade, FGM is conducted from days after birth to puberty and beyond. In half the countries for which national figures are available, most girls are cut before the age of five. Procedures differ according to the country or ethnic group. They include removal of the clitoral hood and clitoral glans; removal of the inner labia; and removal of the inner and outer labia and closure of the vulva. In this last procedure, known as infibulation, a small hole is left for the passage of urine and menstrual fluid; the vagina is opened for intercourse and opened further for childbirth.(Abdulcadir et al, 2011)

The practice is rooted in gender inequality, attempts to control women's sexuality, and ideas about purity, modesty and beauty. It is usually initiated and carried out by women, who see it as a source of honour, and who fear that failing to have their daughters and granddaughters cut will expose the girls to social exclusion(UNICEF, 2013&Toubia&Sharif, 2003). Health effects depend on the procedure. They can include recurrent infections, difficulty urinating and passing menstrual flow, chronic pain, the development of cysts, an inability to get pregnant, complications during childbirth, and fatal bleeding. (Abdulcadir et al, 2011)There have been international efforts since the 1970s to persuade practitioners to abandon FGM, and it has been outlawed or restricted in most of the countries in which it occurs, although the laws are poorly enforced. Since 2010 the United Nations has called upon healthcare providers to stop performing all forms of the procedure, including re-infibulation after childbirth and symbolic "nicking" of the clitoral hood (UN,2010). The opposition to the practice is not without its critics, particularly among anthropologists, who have raised difficult questions about cultural relativism and the universality of human rights. (Bettina SD, 2008)

2.2Terminology Until the 1980s FGM was widely known in English as female circumcision, implying an equivalence in severity with male circumcision. (Martha N, 1999). References to the practice as mutilation increased throughout the 1970s.

The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children began referring to it as female genital mutilation in 1990, and the (WHO) followed suit in 1991. (UNICEF, 2013).Other English terms include female genital cutting (FGC) and female genital mutilation/cutting (FGM/C), preferred by those who work with practitioners.(WHO, 2008).

The commonly used "female genital mutilation" is a problematic. some forms of FGC are less extensive than the newborn male circumcision commonly performed in the west .in addition" mutilation "is inflammatory term that tend to foreclose communication and that fails to respect the experience of many women who have had their genitals altered and who do not perceive themselves as " mutilated. (lane SD, 1996).

A common Arabic term for purification has the root t-h-r, used for male and female circumcision (tahur and tahara). It is also known in Arabic as khafḍ or khifaḍ . (AsmaniIet al, 2008)

Communities may refer to FGM as "pharaonic" for infibulation and Sunna circumcision for everything else.(Ellen Gruenbaum, 2001) The term infibulation derives from fibula, Latin for clasp—the Ancient Romans reportedly fastened clasps through the foreskins or labia of slaves to prevent sexual intercourse. The surgical infibulation of women came to be known as pharaonic circumcision in Sudan, but as Sudanese circumcision in Egypt. (Leonard J et al, 1985)

2.3Origin of the practice;

The origin of the practice is unclear. It predate the rise of Christianity and Islam. It is said some Egyptian mummies display characteristics of FGM. historian such as Herodotus claim that, in the fifth century BC, the Phoenicians, the Hittites and Ethiopians practiced circumcision rites were practiced in tropical Zone of Africa, in the Philippines, by certain tribes in the Upper Amazon, by women of the Arunta tribe in Australia, and by certain early Romans Arabs. As recent as the 1950s, Clitoridectomy was practiced in Western Europe and the United States to treat perceived ailments including hysteria, epilepsy, mental disorders, masturbation, nymphomania and melancholia. In the other words, the practice of FGM has been followed by many different peoples and societies across the ages and continents.(UNFPA, 2017)

In the United State, physician have also incised the clitoral prepuce to treat frigidity, and perform aesthetic vaginal labiapatsies to reduce the size of the clitoris and labia.(Hodgkinson D,1983).

American immigrant girls have undergone genital surgeries in Europe and Canada, and London physicians performed clitordectomies on refugees in the 1980s. (Hosken F,1994)

It is believed that,through trade from Arabian countries and the red sea coast, the practice spreads to Sudan and subsequently with the spread of Islam, deeper into Africa.(Gruenbaum,2006)

2.4 The operation: The little girl , entirely nude , is immobilized in the sitting position on a law stool by at least three women .One of them with her arms tightly around the little girl’s chest two others hold the child’s thighs a part by force ,in order to open wide the vulva. The child’s arms are tied behind her back, immobilized by two other women guests. The traditional operator says a short prayer, then the old women takes her razor and excises the clitoris. The little girl howls and writhers in pain although strongly held down. The operator wipes the blood from the wound,as well as the guest ‘verify’ her work,sometimes putting their fingers in. The amount of scraping of the large lips depends upon the ‘technical ‘ability of the operator .The opening left for urine and menstrual blood is minuscule. (Elnashar,2007) The operator applies a paste and ensures the adhesion of the large lips by means of three or four acacia thorns,which pierce one lip and pass through into the other.These thorns are then held in place either by means of sewing thread, or with horse hair.The role of the circumciser is an inherited one.In rural communities the Traditional Birth Attendant(TBA) is the circumciser.In recent years medically trained midwives and nurses have played an important role in the medicalization of the practice.Some doctors are also providing circumcision,although most medical association condemn the practice.(Elnashar,2007) It may be argued that because of the secrecy and illegalness that surrounds the practice, FGM is still predominantly performed at home.(Bergreen,2006).Because of poverty and lack of medical facilities, the procedure is frequently done under unhygienic conditions, often by non-medically trained personnel, and usually without anesthesia.(WHO, 2008) When traditional cutters are involved, non-sterile devices are likely to be used, including knives, razors, scissors, glass, sharpened rocks and fingernails.(Elizabeth et al, 2005).

2.5Ages at which circumcision is done: The age at which they circumcised girls varies according to culture within it the communities .In some cultures girls circumcised in infancy,while in others is done when the girl at the age of marriage .In Sudan the age ranges from (5-10)years,in Ethiopia at the 8th day after birth,in Somalia between (13-14)year, in Egypt (3-8)year, in Kenya shortly after marriage,while in some tribes of Guinea after the delivery of the first child. In Sudan,the most common age is between (5-9)years as shown by the Sudan fertility survey (SFS) where it was reported that 74% of the women studied in theMentioned survey were circumcised before they were 10 years old.(Rahman,Toubia,2000) 2.6Decision to Circumcise: Pressure in relation to genital mutilation generally originates fromwithin the family. Sometimes family members other than the parentsdecide the genital mutilation. In particular this applies to girls livingwith their grandparents, and where one of the parents wants theprocedure to be performed. (WHO, 2008) Members of the family are usually involved in decision-makingabout female genital mutilation, although women are usuallyresponsible for the practical arrangements for the ceremony.(UNICEF, 2005). 2.7Medicalization of the practice:

According to WHO it is when FGM performed by healthcare provider, such as a community health provider, midwife, nurse, or doctor. Medicalzed FGM can take place in public or private clinic, at home, or elsewhere. It also includes the procedure of re-infibulation at any point in time in a women’s life. In 2010, a joint interagency Global Strategy to Stop Health – Care Providers from Performing FGM was released. In 2016, WHO also releasedguidelines on the management of health complications from FGM. This strategy reflects consensus between international experts, United Nations entities and the member states they represent. In addition the global commitment to eliminate all forms of FGM by 2030 is clearly stated in target 5.3 of the Goals (SDG).(UNFPA, 2017).

FGM can neverbe “safe” Even when the procedure is performed in sterile environment and by a health – care professional, there can be serious health consequences immediately and later in life. Medicalized FGM gives a false sense of security. There are serious risks associated with all forms FGM. Advocating any form of cutting or harm to the genitals of girls and womenand suggesting that medical personnel should perform it is unacceptable

forms a public health and human rights perspective . Trained health professionals who perform female genital mutilation are violating girls, and women’s rights to life, physical integrity and health. They are also violating the fundamental medical ethic to “do no harm”.When medical personnel perform FGM, they wrongly legitimize the practice as medically sound or beneficial for girls and women’s health. And because medical personnel often hold power, authority and respect in society, it can also further institutionalize the procedure. (UNFPA, 2017).

In Sudan however, the most recent data on FGM/C is show that almost all the FGM/C is carried out by health care providers who are always either traditional and nurse midwives i.e. almost all the circumcisers are health care providers. This means that FGM/C is fully medicalzed in Sudan. It is worth noting that the contribution of doctors in this practice is negligible in almost all the states apart from Khartoum where doctors performed 1.2% of all the FGM/C. In Khartoum State specifically, almost all (98.2%) FGM/C is performed by midwives whether traditional or nurse, usually for financial gains. (VanjaBet el, 2004). Medical doctors perform less than 2% of the FGM/C. Usually these medical doctors are supported by some religious groups who still advocating for a milder form of FGM/C (clitoridectomy). (Vanja B, et al, 2004, and UNICEF, 2010).

According to Shell-Duncan, medicalization of FGM could be considered as an “interim solution” for reducing the harm of FGM/C, since complete abandonment of the practice by the community is not an achievable target. However, among the challenges to this approach are the possibilities that this may encourage communities to continue to perform the procedure, the slow process of changing attitudes of supporters of FGM/C, and encourage others to adopt the practice or overburden healthcare systems by adding another service to the package(Bettina Shell-Duncan, 2001). It has been shown that medicalization of FGM/C to be an easy lucrative service for underpaid health workers in Egypt and Nigeria(John Cet al, 2000). In addition, the FGM/C rate trends in Sudan is falling but at a slow rate with only 6% reduction the past 10 years. This could be explained by the addition of medicallegitimacy to FGM/C practice and institutionalization(SusanD et al,2004& WHO,2011).Further contributing to the persistence of this practice.In addition, a report from Kunnskapssenteret in Sweden stated that while FGM that is performed by medical personnel in hospitals and health clinics may reduce some short-term complications regularly seen when it is performed by traditional practitioners, it is not necessarily less severe or done in sanitary conditions.

Moreover, there is no evidence that medicalization reduces obstetric or other long-term complications associated with FGM.(Kunnskapssenteret, 2009)

2.8 Classification: FGC consists of several distinct procedures. The procedure vary considerably according to ethnicity and individual practitioners.Their severity is oftenviewed as dependent on how much genital tissue is cut away. TheWHO which uses the term Female Genital Mutilation (FGM) dividesthe procedure into four major types, although there is some debate as to whether all common forms of FGM fit into these four categories, as well as issues with the reliability of reported data. (Obermeyer, 2005)

WHO Types: TypeI :is "partial or total removal of the clitoris and/or the prepuce".

Type Ia (circumcision) involves removal of the clitoral hood only. This is rarely performed alone.

Type Ib (clitoridectomy),The more common procedure, is complete or partial removal of the clitoral glans (the visible tip of the clitoris) and clitoral hood. (WHO, 2008& WHO, 2014)

Type II(Excision), is the complete or partial removal of the inner labia, with or without removal of the clitoral glans and outer labia. TypeIIa is removal of the inner labia; Type IIb, removal of the clitoral glans and inner labia; and Type IIc, removal of the clitoral glans, inner and outer labia. Excision in French can refer to any form of FGM. (WHO, 2014)

Type III(infibulation or pharaonic circumcision): The WHO defines Type III FGM as narrowing of the vaginal orifice with creation of a covering seal by cutting and repositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulations)." It is the most extensive form of FGM, and accounts for about 10% of all FGM procedures described from Africa. Infibulation is also known as "pharaonic circumcision”. In a study of infibulation in the Horn of Africa, Pieters observed that the procedure involves extensive tissue removal of the external genitalia, including all of the labia minora and the inside of the labia majora. The labiamajora are then held together using thorns or stitching. In some cases the girl's legs have been tied together for two to six weeks, to prevent her from moving and to allow the healing of the two sides of the vulva.Nothing remains but the walls of flesh from the pubis down to the anus, with the

exception of an opening at the inferior portion of the vulva to allow urine and menstrual blood to pass through. Generally, a practitioner recognized as having the necessary skill carries out this procedure, and a local anesthetic is used. (Berggren, 2006) However, when carried out "in the bush", infibulation is often performed by an elderly matron or midwife of the village, without sterile procedure or anesthesia. A reverse infibulations can be performed to allow for sexual intercourse or when undergoing labor, or by female relatives, whose responsibility it is to inspect the wound every few weeks and open it some more if necessary. During childbirth, the enlargement is too small to allow vaginal delivery, and so the infibulations is opened completely and may be restored after delivery. Again, the legs are sometimes tied together to allow the wound to heal. When childbirth takes place in a hospital, the surgeonsmay preserve the infibulations by enlarging the vagina with deepepisiotomies. Afterwards, the patient may insist that her vulva be closed again. (Berggren, 2006) Women who have been infibulated face a lot of difficulty in delivering children, especially if the infibulations is not undone beforehand, which often results in severe tearing of the infibulated area, or fetal death if the birth canal is not cleared. The risk of severe physical and psychological complications is more highly associated with women who have undergone infibulations as opposed to one of the lesser forms of FGM. Although there is little research on the psychological side effects of FGM, many women feel great pressure to conform to the norms set out by their community, and suffer from anxiety and depression as a result "There is also a higher rate of posttraumatic stress disorder in circumcised females" A five-year study of 300 women and 100 men in Sudan found that "sexual desire, pleasure,and orgasm are experienced by the majority ["nearly 90%"] of women who have been subjected to this extreme sexual mutilation, in spite of their being culturally bound to hide these experiences."(Toubia;Sharief,2003) The woman is opened further for childbirth (defibulation or deinfibulation), and closed again afterwards (reinfibulation). Reinfibulation can involve cutting the vagina again to restore the pinhole size of the first infibulation. This might be performed before marriage, and after childbirth, divorce and widowhood. (Asma E, 1982)

Type IV Type IV is "all other harmful procedures to the female genitalia for non-medical purposes", including pricking, piercing, incising, scraping and cauterization. It includes nicking of the clitoris (symbolic circumcision), burning or scarring the genitals, and introducing substances

into the vagina to tighten it (WHO,2008& UNICEF,2013). Labia stretching is also categorized as Type IV. Common in southern and eastern Africa, the practice is supposed to enhance sexual pleasure for the man and add to the sense of a woman as a closed space. From the age of eight, girls are encouraged to stretch their inner labia using sticks and massage. Girls in Uganda are told they may have difficulty giving birth without stretched labia. (Brigitte B &Esmeralda M, 2011)

Secondary FGM/C in Sudan (Re-infibulation):

An additional form of cutting or circumcision is carried out after primary FGM/C. This secondary form is called re-infibulation and is usually performed to previously infibulated women by re-stitching together the scar tissue after childbirth and is called locally "El Adel". Re-infibulation is described as a desirable and necessary procedure to be performed after childbirth to mimic the narrow vulva of a virgin so as to increase the sexual pleasure of the husband. In 1982, El Dareer estimated that over 50% of the Sudanese women underwent re- infibulation. Also, Ahmed et al in 2000 stated that most infibulated Sudanese women had re- infibulation after childbirth. Usually, the re-infibulation is performed by midwives to the women between 2 hours and 40 days after childbirth (Vanjaet al,2004). In fact, there are two types of re-infibulation; Khiata (English translation=“suturing”) and Adel (English translation = “repair”). Midwives consider Khiata to be medically necessary since they reconstruct the vaginal orifice to the size before childbirth. On the other hand, El Adel is an extensive operation to regain the size of primary infibulation.

Clitoral Hood reduction :also termed Clitoral hoodectomy, clitoral un hooding ,Clitoridotomy or (partial) hoodectomy.This involve the clitoral hood removal, but it preserves the clitoris and the posterior larger parts of labia Minora. In Islamic culture, circumcision is known as Sunna (tradition), because it is mentioned in some A hadith. This kind of cutting can be equated to male circumcision. (Maria C b,2009).

The hood is homologous to male circumcision which is also legal every Where.Female circumcision or Hoodectomy is done more commonly to allow women to experience heightened arousal by reducing the tissue that forms the hood (prepuce)covering clitoris, almost always resulting in greater and faster orgasm. To some extent it has been suspected that excessive prepuce tissue can also result in some hygiene – related issues as well for

women giving sanctuary to increase bacterial count, and sometimes resulting in what are commonly termed yeast or vaginal infection. (Sammy thatcher, 2015).

2.9 Stimulation of female sexual act: Successful performance of the female sexual act dependson both psychic stimulation and local sexual stimulation.Also the thinking of erotic thoughts can lead to femalesexual desire and these aids greatly in the performance ofthe female sexual act. Such desire is probably based as on physiological drive,thought sexual drive does increase inproportion to the level of secretion of the sex hormone.Desire also changes during sexual month, reaching a peak nearthe of ovulation probably because of the high level ofestrogen secretion time during the pre –ovulation period. Localsexual stimulation in women occurs as in men for massage,irritation, or other types of stimulation of perinea regionsensation .The glands of the clitoris are especially sensitivefor initiating sexual sensation. (Johnson, 2007) 2.10 Complications: FGM harms women's physical and emotional health throughout their lives. It has no known health benefits.(Rigmor et al, 2014)The short-term and late complications depend on the type of FGM, whether the practitioner has had medical training, and whether they used antibiotics and sterilized or single-use surgical instruments. In the case of Type III, other factors include how small a hole was left for the passage of urine and menstrual blood, whether surgical thread was used instead of agave or acacia thorns, and whether the procedure was performed more than once (for example, to close an opening regarded as too wide or re-open one too small).(Abdulcadir et al, 2011)

2.10.1Short-term:Common short termcomplications include swelling, excessive bleeding, pain, urine retention, and healing problems/wound infection. A 2015 systematic review of 56 studies that recorded immediate complications suggested that each of these occurred in more than one in ten girls and women undergoing any form of FGM, including symbolic nicking of the clitoris (Type IV), although the risks increased with Type III. The review also suggested that there was under-reporting.(Rigmor C, 2014). Other short-term complications include fatal bleeding, anemia, urinary infection, septicemia, tetanus, gangrene, necrotizing fasciitis (flesh-eating disease), and endometritis.(Reisel&Creighton, 2015 and Christos I et al, 2013).It is not known how many girls and women die as a result of the practice, because complications may not be recognized or reported. The practitioners' use of shared instruments

is thought to aid the transmission of hepatitis B, hepatitis C and HIV, although no epidemiological studies have shown this. (Reisel&Creighton, 2015)

2.10.2 Late complications: vary depending on the type of FGM. They include the formation of scars and keloids that lead to strictures and obstruction, epidermoid cysts that may become infected, and neuroma formation (growth of nerve tissue) involving nerves that supplied the clitoris. (Amish J. D et al, 2011)

An infibulated girl may be left with an opening as small as 2–3 mm, which can cause prolonged, drop-by-drop urination, pain while urinating, and a feeling of needing to urinate all the time. Urine may collect underneath the scar, leaving the area under the skin constantly wet, which can lead to infection and the formation of small stones. The opening is larger in women who are sexually active or have given birth by vaginal delivery, but the urethra opening may still be obstructed by scar tissue. Vesicovaginal or rectovaginal fistulae can develop (holes that allow urine or faces to seep into the vagina). This and other damage to the urethra and bladder can lead to infections and incontinence, pain during sexual intercourse and infertility. (Hamid R, 2013)

Painful periods are common because of the obstruction to the menstrual flow, and blood can stagnate in the vagina and uterus. Complete obstruction of the vagina can result in hematocolpos and hematometra (where the vagina and uterus fill with menstrual blood). The swelling of the abdomen that results from the collection of fluid, together with the lack of menstruation, can lead to suspicion of pregnancy.(Abdulcadir et al, 2011)Asma El Dareer, a Sudanese physician, reported in 1979 that a girl in Sudan with this condition was killed by her family.

2.10.3 Pregnancy, childbirth FGM may place women at higher risk of problems during pregnancy and childbirth, which are more common with the more extensive FGM procedures. Infibulated women may try to make childbirth easier by eating less during pregnancy to reduce the baby's size. In women with vesicovaginal or rectovaginal fistulae, it is difficult to obtain clear urine samples as part of prenatal care, making the diagnosis of conditions such as pre-eclampsia harder. Cervical evaluation during labor may be impeded and labor prolonged or obstructed. Third-degree laceration (tears), anal-sphincter damage and emergency caesarean section are more common in infibulated women.(Mumtaz R, 2007)

Neonatal mortality is increased. The WHO estimated in 2006 that an additional 10–20 babies die per 1,000 deliveries as a result of FGM. The estimate was based on a study conducted on 28,393 women attending delivery wards at 28 obstetric centers in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan. In those settings all types of FGM were found to pose an increased risk of death to the baby: 15 percent higher for Type I, 32 percent for Type II, and 55 percent for Type III. The reasons for this were unclear, but may be connected to genital and urinary tract infections and the presence of scar tissue. The researchers wrote that FGM was associated with an increased risk to the mother of damage to the perineum and excessive blood loss, as well as a need to resuscitate the baby, and stillbirth, perhaps because of a long second stage of labor. (Emily B et al, 2006)

2.10.4 Psychological effects, sexual function According to a 2015 systematic review there is little high-quality information available on the psychological effects of FGM. Several small studies have concluded that women with FGM suffer from anxiety, depression and post-traumatic stress disorder. Feelings of shame and betrayal can develop when women leave the culture that practises FGM and learn that their condition is not the norm, but within the practising culture they may view their FGM with pride, because for them it signifies beauty, respect for tradition, chastity and hygiene. (Jasmine et al, 2011)

Studies on sexual function have also been small. A 2013 meta-analysis of 15 studies involving 12,671 women from seven countries concluded that women with FGM were twice as likely to report no sexual desire and 52 percent more likely to report dyspareunia (painful sexual intercourse). One third reported reduced sexual feelings. (Sibiani&Rouzi A, 2008)

2.11Reasons behind the practice: 2.11.1 Socio-economic reasons: In many regions women need to undergo FGM to get married. In those communities where women are economically dependent on men,the questioning of FGM is not a possibility. The economicdisadvantages of FGM, such as medical costs or the loss of Productivity because of illness, are often not recognized as beingcaused by FGM. Circumcisers themselves also gain a living through the performance of the “operations” and enjoy a certain status as guardians of tradition, two factors that have an influence on the

resistance to abandon FGM (Talle,2007). Girls who have not undergone FGM are subjected to great social pressure. They are ridiculed and called ghalfa (uncircumcised), impure and undesirable or attractive trait in the context of marriage.(Berggren,2006) 2.11.2 Religion Surveys have shown a widespread belief, particularly in Mali, Mauritania, Guinea and Egypt, that FGM is a religious requirement. Gruenbaum has argued that practitioners may not distinguish between religion, tradition and chastity, making it difficult to interpret the data. (Gruenbaum, 2001)

There is no mention of FGM in the Bible. (Samuel, 2008)Christian missionaries in Africa were among the first to object to FGM, but Christian communities in Africa do practice it. A 2013 UNICEF report identified 17 African countries in which at least 10 percent of Christian women and girls aged 15 to 49 had undergone FGM; in Niger 55 percent of Christian women and girls had experienced it, compared with two percent of their Muslim counterparts. The only Jewish group known to have practiced it are the Beta Israel of Ethiopia. Judaism requires male circumcision, but does not allow FGM. FGM is also practiced by animist groups, particularly in Guinea and Mali. (UNICEF, 2013)

Female circumcision in Islam:

There is huge difference between female genital mutilation and female circumcision in Islam, FGM is serious crime punishable by payment of Diaya. And an it is African practice not Islamic .Female circumcision is different, and is permissible in Islam. It is also legal in all countries around the world even in the USA.(Sammy T, 2015)

FGM's origins in northeastern Africa are pre-Islamic, but the practice became associated with Islam because of that religion's focus on female chastity and seclusion.(Gerry M, 1996). In 2007 the Al-Azhar Supreme Council of Islamic Research in Cairo ruled that FGM had "no basis in core Islamic law or any of its partial provisions". (Roald A S, 2003)

Senior Muslim religious authorities appear to agree that FGM is not required by Islam or is prohibited by it.(RouziA, 2013). The Quran doesn’t mention FGM or male circumcision. FGM is praised in a few daif (week) hadith (sayings attributed to Muhammad)as noble but not required. (Asmani I et al, 2008).

Sunna view:

Different schools of Islamic jurisprudence have expressed different views on FGM. The Maliki school of Islamic jurisprudence views it as makrumahlilnisa (noble but not required). The Hanbalischool sees it as Sunna(good practice) for the Hanafi, school it is preferred and Shafi, school it is obligatory (wajib).(Roald A S, 2003).

2.11.3Gender:

FGM/C is linked to gender related conceptions on the female body shape, physical cleanliness and the necessity to make this body different from that of males. In many communities, the girls who have undergone FGM/C are considered beautiful and physically clean (UNICEF, 2010). Also, beauty is associated with smoothness; therefore women's bodies need to be "carved" through removing protrusions by carrying out infibulations. In many cultures the clitoris is seen as "male-like" organ that needs to be amputated to define the child's sex and ensure pure femininity(WHO, 2011&Nafisa M, 2007 and FMH, 2010),In addition, some cultures perceive the clitoris as a dangerous organ that if it touches the baby’s head during childbirth it lead to its death. Also, if the clitoris is not removed it will grow and hang between legs like a penis(Nafisa M, 2007). Many cultures associate the closeness of infibulation with the value of enclosure that is related to endogamy and honor necessary components in an appropriate marriage. More so, re-infibulations is perceived in Sudan as a normal thing and a necessity needed to be done for the husband's sexual satisfaction (Vanja B et al, 2004)

FGM/C is also perceived as an essential step in the transition from girlhood to womanhood and girls are considered marriageable after undergoing the procedure.(Susan D et al,2004)

2.11.4 Sexual morality and marriage ability:

In communities where FGM/C is practiced, the procedure is strongly associated with sexual morality and people perceive the clitoris as the origin of sexual desire. Accordingly, the clitoris has to be removed in order to ensure chastity, premarital virginity, reduce promiscuity, marital fidelity, decent behavior and sexual modesty (WHO, 2011&Elmusharaf S et al, 2006)

The three qualitative studies in Egypt and Senegal as well as the findings from other studies in Burkina Faso, the Gambia and Sudan, found that a desire to control women's sexuality is a strong motivation for practicing FGM/C and this practice aims to improve women's ability to comply with local sexual norms of premarital virginity, marital fidelity and sexual modesty (WHO, 2011). On the other hand, being uncut is often linked to misbehavior and is associated with low status and prostitution,(UNICEF,2010). While girls who are cut are considered decent, chaste, morally pure and hence suitable for marriage.

Sexual morality, virginity at the time of marriage and fidelity after marriage, are crucial factors encouraging FGM/C in many cultures. Therefore, FGM/C in these communities is not viewed as a dangerous act and a violation of rights but as an important step to raise girls “properly” and as a mechanism for ensuring that girls arrive at their marriage beds untouched.(Susan D, 2004&UNICEF, 2010)

2.12Efforts to Stop the PracticeIn Sudan;

The early efforts:

In 1930 a British member of parliament attacked the custom and urged the Colonial administration in Sudan to take steps to prohibit it by law. Dr. Attabani wrote an article attacking female circumcision in newspaper when he was a student in the medical school in 1930.In 1943 the general governor of the Sudan published a report by medical services, signed by nine members ,the report include the danger of the practice. This was followed by the mufti sheikh Ahmed Altahir, who clearly indicated that Islam opposed to the custom .In1947 the national committee for fighting circumcision was formed with members from various social categories.Number of leaders condemned the custom and encouraged their followers to do likewise.(Karrar,1998) Current Sudanese Organizations Fighting FemaleCircumcision: The most outstanding organizations fighting female circumcision in Sudan are:-BabikirBadri Scientific Association for Women Studies and the Sudanese National Committee on the eradication of the traditional practices affect the health of women and children. Both organizations succeeded in bringing the issue to the surface of health problems area. Information is made accessible to broad range of educated women and men and disseminated on a wide scale Substantial body of public opinion has been raised against the practice. (Abdel Magied, 2001).

Despite the fact that FGM/C is still widely practiced in all regions of northern Sudan, women’s intention to circumcise their daughters has decreased significantly over the last 16 years, attitudes have positively changed. A number of social networks and pressure group have emerged and voiced a consistent and clear stance against FGM/C.(Nylund; Ahmed,2009).Among women who are against FGM, the main reasons given are medical complications and pain.(Obermeyer,2005). Also Efforts to combat FGM/C in Sudan include The Saleema Communication Initiative (Saleema Initiative), launched in 2008 by the National Council for Child Welfare.Saleema means ‘complete’ or ‘whole’ in Arabic, referring to the state of being that Allah has created. The Saleema Initiative aims to “promote collective abandonment” of FGM/C by stimulating discussion about this issue within communities. However, this campaign has been met with strong criticism for its vague message. The campaign does not actually mention FGM/C, but rather says “She is born Saleema, let her grow Saleema”. Other FGM opponents in Sudan claim this ambiguity is the Saleema Initiative’s attempt “to avoid clashes with the extremists who do not want to see FGM/C eradicated.”(Abbas R, 2013)

SUDANESE LAW There is no national legislation banning the practice of FGM/C.28 In 2012, the Sudanese government claimed to be working on national legislation banning the practice, but they have yet to propose or pass any such legislation. Despite the various regional laws, specialists warn this practice continues to grow. (El yasK ,2015).Counter to some reports, there is little to no decline in the practice of FGM/C in Sudan. Enforcement of these regional laws on the ground is a challenge in itself. A 2014 report from UNFPA notes that Sudan’s efforts to tackle the issue of FGM/C – such as ratifying various international human rights agreements – as having little impact, stating: “Despite all these long term efforts, FGM/C in Sudan has continued with little interruption.(UNFPA, 2014)The Sudanese government removed an article from the Child Act in 2009 that would have criminalized FGM/C, drawing national and international condemnation; as is shown in a petition presented in the Sudan Tribune online. (Unionist Party et al, 2009). 2.13 Internationa lResponse: Building on work from previous decades, in 1997, WHO issued a joint statement against the practice of FGM together with the (UNICEF) and (UNFPA).

Since 1997, Great efforts have been made to counteract FGM, through research, work within communities, and changes in public policy. Progress at international, national and subnational levels includes; Wider international involvement to stop FGM; international monitoring bodiesand resolutions that condemn the practice; Revised legal frameworks and growing political support to end FGM ( this includes a law against FGM (this include FGM in 26 countries in Africa and Middle East, as well as in33 other country with migrant populations from FGM Practicing countries ); The prevalence of FGM has decrease in most countries and an increasing number of women and men in practicing communities support ending its practice. Research shows that, if practicing communities themselves decide to abandon FGM, the practice can be eliminated very rapidly. In 2007 UNFPA and UNICEF initiated the joint Programme on female Genital Mutilation/ Cutting to accelerate the abandonment of the practice. IN 2008 WHO together with 9 other United Nations partners , issued a statement on the Eliminating of FGM to support increased advocacy for its abandonment, called “Eliminating female genital mutilation; an interagency statements” this statement provided evidence collected over the previous decade about the practice of FGM. In 2010, WHO published a “Global Strategy to stop healthcare providers from performing female genital mutilation” in collaboration with other key UN agencies and international organizations. In December 2012, the UN General Assembly adopted a resolution on the elimination of female genital mutilation. Building on previous report from 2013, in 2016 UNICEF launched an update report documenting the prevalence of FGM in 30 countries, as well as beliefs, attitudes, trends, and programmatic and policy responses to the practice globally. In May 2016, WHO in collaboration with the UNFPA – UNICEF joint programme on FGM launched the first evidence –based guidelines on the management of health complications from FGM .the guidelines were developed based on a systematic review of the best available evidence on health interventions for women living with FGM. To ensure the effective implementation of the guidelines, WHO is developing tools for front- line health –care worker to improve Knowledge, attitudes, and skills of health care providers in preventing and managing the complications of FGM. (WHO,2017)

2.14Criticism of opposition to FC:

Tolerance versus human rights:

Anthropologists have accused FGM eradicationists of cultural colonialism, and have been criticized in turn for their moral relativism and failure to defend the idea of universal human rights(Eric K, 2004). According to critics of the eradicationist position, the biological reductionism of the opposition to FGM, and the failure to appreciate FGM's cultural context, serves to "other" practitioners and undermine their agency—in particular when parents are referred to as "mutilators".(Vicky K, 2005). Comparison with other procedures The WHO does not define procedures such as labiaplasty and clitoral hood reduction as FGM, but its definition aims to avoid loopholes, so several elective practices do fall within it.(WHO, 2008) Some of the laws banning FGM, including in Canada and the US, cover minors only, but several countries, including Sweden and the UK, have banned it regardless of consent. The legislation in those countries does seem to cover cosmetic procedures. Sweden, for example, has banned operations "on the outer female sexual organs with a view to mutilating them or bringing about some other permanent change in them, regardless of whether or not consent has been given for the operation".(European Union) Opinion of some doctors and religious researcher: ` Some doctors pointed out that female genital mutilation had specific medical benefits, some of these benefits Dr. Hamed al-Ghawabi says: "The accumulation of secretions of labia minorain galfalead tobad smell and inflammation of the vagina or urethra, and he had seen many cases of illness caused by the not doing circumcision in women". He also said that the benefits from circumcision reduce the excessive craving of the clitoris, which may be grown rapidly to a length of 3 centimeters at the erection and this is very annoying to the husband, especially during intercourse and Circumcision of women prevent which called (Inaz of women) which is the enlargement of the clitoris in a harmful way associated with recurrent pain at the same site. He also said that circumcision prevents the irritation in women, and prevents ulcers which caused by the irritation of the clitoris and accompanied by fluttering motion.

According to the female doctor, Sit Albanaat Khalid, in her article entitled "Circumcision of girls a healthy vision". She said that the benefits of female circumcision is to eliminate the hyper sexuality in women and the intensity of the desire and obsession, in addition to the

prevention of unpleasant smells that are produced due to accumulation of secretions under clitoris and reduction in rate of urinary tract infection and reduction in the percent of sexual tracts inflammations. (Amal A, 2007).

Dr. Amal also said that "the Medical organizations and social studies did not establish any risk for circumcision and that the legal circumcision (Khifad) was not forbidden from the WHO, and there are explicit definition was found in some of the published books of the Organization earlier, but in recent years the WHO included the legal circumcision with the first type on the pretext that the practice of Muslims is incorrect and the she mentioned that in a study entitled "female circumcision in medicine between excessiveness and negligcance". According to medical and social studies, the debate on FGM has no valid medical basis. In a Western study, some doctors and specialists announced that no evidence to suggest risks of circumcision. And some studies came with conflicting results and cannot be confirmed and indicate the existence of circumcision benefits.(Amal, 2014).

Previous Studies:

Previous studies of female circumcision in the world: In a study done in Ethiopia to assess labor, delivery and postpartum complications in nulliparous women with FGM/C and evaluate the attitude of mothers towards elimination of FGM. Methods, they found that Two hundred sixty-four (92.0%) of the women had FGM/C with most (93.0%) undergoing Type III FGM. The mean age of the women was 22 yr. Almost all complications were more frequently seen in circumcised compared to non- circumcised women. Conclusions: The prevalence of FGM is high and it substantially increases the risk of many maternal complications. Health professionals should be aware of these complications and support/care of women with FGM should be integrated at all levels of reproductive health care provision. Capacity building of responsible health professional should be initiated in the area with intensification of FGM eradication activities.(Gudu W and Abdulahi M, 2017)

An Iranian study with the aim to explore factors associated with FGM behavior among Iranian mothers and their daughters. Based on Ajzen's theory of planned behavior, we examined the predictive value of attitudes, subjective norms, perceived behavioral control and several socio-demographic variables in relation to mothers' intentions to mutilate their daughters. A paper-and-pencil survey was conducted among 300 mothers (mean age = 33.20, SD = 9.09) who had at least one daughter and who lived in Ravansar, a county in Kermanshah Province in Iran. Results indicate that attitude is the strongest predictor of mothers' intentions to allow their daughters to undergo FGM, followed by subjective norms. Compared to younger mothers, older mothers have more positive attitudes toward FGM, perceive themselves as having more control over their behavior and demonstrate a greater intention to allow their daughter to undergo FGM. Furthermore, we found that less educated mothers and mothers living in rural areas had more positive attitudes toward FGM and feel more social pressure to allow FGM. The model accounts for 93 percent of the variance in the mothers' intentions to allow their daughters to undergo FGM. (Pashaei T et al, 2016)

In a study conducted in Female genital cutting (FGC), which is widely practiced in Kenya. However, its prevalence has declined over the last two decades (38.0% in 1998 KDHS, 32.2% in 2003 KDHS and 27.1% in 2008-09 KDHS), implying changes in behaviours and attitudes of Kenyans towards FGC. This study provides an overview of changing attitudes of women towards FGC in Kenya. About 68% of these women wanted to discontinue FGC, and

attitudes towards discontinuation were found to vary with women's background characteristics. Surprisingly, 92.5% of circumcised women of the North-Eastern province still wished to continue FGC, and for Muslims the percentage was 72.2%. About 36% of circumcised women responded that their daughters were already circumcised. Only 13% of circumcised mothers intended their daughters to be circumcised in the future. The study shows that the attitude of Kenyan women, irrespective of their circumcision status, has been changing gradually towards the discontinuation of circumcision of their daughters.(Patra S and Singh RK, 2015)

Another study done in Nigeria to assess the level of FC, daughters' circumcision and attitude towards discontinuation of the practice among women of reproductive age. Data were extracted from the 2008 Nigeria Demographic Health and Survey. Data were analyzed using Chi-square and binary logistic regression models (a = 0.05). Among the respondents, prevalence of FC was 49.2% with 30.6% having circumcised their daughters and 25.8% wishing the practice to continue. About 56% of circumcised women also circumcised their daughters whereas only 2.9% of uncircumcised women circumcised their daughters. Approximately 69.8% of women who had circumcised their daughters would like FC to continue compared to 8.8% of those who never circumcised any of their daughters. The likelihood of FC was higher (OR = 2.07; C.I = 1.85-2.30) among Moslems compare to Christians. Igbo women were less likely to discontinue FC compared to women of Hausa/Fulani ethnic group despite controlling for the confounding variables (OR = 0.57; C.I = 0.35-0.91). (Gbadebo B et al, 2015)

Another study from Iran aiming to describe the epidemiology, regional characteristics, knowledge, and attitude toward FGM/C in Southern Iran. This cross-sectional study was conducted during a 36-month period from 2010 to 2013 in Hormozgan, a southern province of Iran near the Persian Gulf. We included 780 women in six major rural areas of the province who referred to healthcare centers for vaccination, midwifery, or family planning services. All participants underwent complete pelvic examination to determine the type of FGM. The questionnaire consisted of several sections such as demographic and baseline characteristics, and two self-report sections addressing the knowledge and attitude toward FGM/C and its complications. Baseline sociodemographic characteristics including age, educational level, marital status, religion, and nationality were the independent variables. Among the participants, 535 (68.5%) had undergone FGM/C. FGM/C was associated with

higher age (P = 0.002), Afghan nationality (P = 0.003), Sunni Islam as religion (P = 0.019), illiteracy (P < 0.001), and family history of FGM/C in mother (P < 0.001), sister (P < 0.001), and grandmother (P < 0.001). Ancient traditions in the area (57.1%) were mentioned as the most important factor leading to FMG/C. Urinary tract infection was the most common reported complication (60.4%). (Dehghankhalili M et al, 2015)

In a study conducted among medical students in Egypt to assess the awareness and predictors of FGM/C in young Egyptian health advocates. A cross-sectional study of 600 medical students from a total of 2,500 members of the International Federation of Medical Students' Associations (IFMSA)-Egypt, across all Egyptian medical schools, was conducted using a previously validated online Google survey. The overall prevalence of circumcision was 14.7/100 female students, with a significantly higher prevalence in students from rural areas (25%) than in non-rural areas (10.8%, P=0.001), and in those residing in Upper (southern) Egypt (20.6%) than in Lower (northern) Egypt (8.7%, P=0.003). The students' mean percentage score for knowledge about the negative health consequences of FGM/C was 53.50+/-29.07, reflecting a modest level of knowledge; only 30.5% had a good level of knowledge. The mean percentage score for the overall attitude toward discontinuation of the practice of FGM/C was 76.29+/-17.93, reflecting a neutral attitude; 58.7% had a favorable attitude/norm toward discontinuation of the practice. Of circumcised students, approximately one-half (46.8%) were unwilling to have their daughters circumcised, and 60% reported no harm from being circumcised. After controlling for confounders, a negative attitude toward FGM/C was significantly (P<0.001 in all cases) associated with male sex, residency in Upper Egypt, rural origin, previous circumcision, and the preclinical medical phase of education. The low level of knowledge among even future health professions in our study suggests that communication, rather than passive learning, is needed to convey the potentially negative consequences of FGM/C and to drive a change in attitude toward discontinuation of this harmful practice. (Abolfotouh S et al, 2015)

Another Nigerian study aiming at using accurate information to dispel the traditional myths and beliefs about FGM among woman.knowledge of the respondents on the true meaning of FGM was 54% and that of the 6 complications enlisted on average was 22.2%. Seventy (70.0%) believed that FCM is good and should be continued based mainly on culture and tradition (85.7%). Among the 29(29.0%) respondents against FGM, 26(89.7%) and 24(82.8%) said it increases risk of HIV/AIDS and pregnancy complications respectively.

Respondents displayed a high negative and stigmatizing attitude toward the uncircumcised women. Seventy-four (74.0%) said they are promiscuous. Additionally, 49% said they are shameful, 14% cursed/outcast while 66% would not recommend them for marriage. (Ekwueme O et al, 2010)

Previous studies of female circumcision in Sudan:

In Sudan, prevalence of FGM is declining; likely as a result of changing attitude surrounding FGM, as more women believe the practice should be discontinued and growing awareness about its health dangers. DFID Sudan opinion poll data collected from 2012 to 2014 was used. Bayesian geo-additive mixed models were used to map the spatial distribution of the likelihood of pro-FGM attitude at the state-level accounting for associated risk factors. During 2012 to 2014, the overall proportion of pro-FGM was 27.5% and 18.3% respectively with striking variations within states. People with pro-FGM attitude were more likely to be un-educated, living in rural settings with strong tribal identity. Individuals from Darfur were more likely to be pro-FGM when compared to the North state. The decrease in the practice of cutting observed between the 2006 and 2010 Sudanese Household Surveys and the resulting shift in attitude make a compelling case for public health policy to eradicate the FGM practice.(Hamilton A and Kandala,NB, 2016)

A cross-sectional descriptive study was conducted in Ombada province, Khartoum State, Sudan with objectives to assess knowledge, attitudes and practices among mothers towards female circumcision.All mothers know female circumcision, (80.2%) of them affirmed that it is still practiced in their society. The significant reasons why FC persistent practice were; to insure virginity, compliance religious instructions, avoid social stigma, good for prospective marriages, with proportion of (52.2%), (32.9%), (10.2%) and (4.7%), respectively. The majority of mothers were known its health consequences, (85.0%) of mothers know that female circumcision it can be eradicated through increasing mother’s awareness (68.0%). The attitude of mothers towards (FC) was negative attitude (71.5%) i.e. encouraging it. The negative attitudes were associated with marriage prospective (29.7%), safeguard virginity (27.4%), religious instructions (19.0%), husband pleasure (11.4%), removal of genitalia dirtiness (5.7%), and tradition practice (5.3%). Whereas Type I, clitoridectomy (Sauna) the most preferred type by mothers (43.9%). (Esmeal EA et al,2016). Another study done To evaluate the frequency of female genital mutilation (FGM) among Sudanese women incomparison to other African countries. To review the immediate and the

late complications of FGM. Tosuggest possible ways of its prevention and eradication.This is a retrospective cross sectional study involving two groups of Sudanese women. The first group which comprises 1200 women was university students and this group representsnearly all parts of the Sudan as University students come from different ethnic and cultural groups. The second group which included 800 women was selected as a sample of women coming to the outpatientUrology clinic of Soba University Hospital in Khartoum, which is a tertiary referral hospital, seeking medical advice for different urological problems. All the two groups signed consent to be part of this study. All patients in group A were given a written questionnaire including all the information’s about their experience with FGM to answer.Out of the 2000 women who were included in this study, 1468 were victims of FGM. Their ages ranged between 20 and 62 with a mean age of 46 years. The FGM was performed below the age of six year in 1423 (96.9%). It was performed by a midwife at home set up in 1416 (94.5%). There were 267immediate complications and 618 late complications. The most serious complications were bleeding, sepsis and vesico-vaginal fistula. Other complications are discussed.(Sharfi AR, 2013).

Chapter Three

Methodology

3.1 Study Design: Across sectional descriptive and community-based study.

3.2 Study Area: This study was conducted in Arkaweet, Wad Medani at Gezira State, which is located in the Southern part of Wad Medani city, the area is surrounded by Habeeb Allah from the East, Almuneera area from the West, Awooda area from the South, and Citys center from the North.The population of moderate education,the main tribe is Fallata and other tribes, mainly they are labors and employees and the area is of low and medium socioeconomic status.And most of them were Muslims.

There are 3mosques, one club and 2 health center, there is safe water source. Most of latrines are not properly built and there is good disposal of waste.

Inside the area there isUniversity of AL Quran AL Kareem for boys, there are one secondary school and one primary school both for girls.

According to statistical survey performed in Arkaweet area by family medicine program (2014);

The population count was (3529) people and number of women in reproductive age was (1160)

 The health center:

Thehealth center provides many health services, outpatient and short stay clinics, vaccination and maternity services.It consists of four offices and two halls.

The working staff:

1family doctor,1 medical officer, 1 lab technician,2 lab assistants, 2 nurses, 2 midwives, 1 vaccinator, 1 nutritionist, 1 assistant pharmacist, 1 statistician,1 receptionist, 1 accountant and 2 cleaning workers.

3.3 Study duration: The study was conducted from September 2017 to December 2017.

3.4 Study Population: All Women in reproductive age (15-49) living in Arkaweet.

3.5Inclusion criteria:

 Women in reproductive age (15-49) who agree to participate.

3.6Exclusion criteria:

 Female below 15 or above 49.

3.7Sample Size and sample technique: 3.7.1 Sample size :

The sample size was calculated using the following equation.

N  p1 p n  N 1d 2  z 2  p1 p n=the required sample size

N= the total population. = 1160 p= the probability (the prevalence) estimated to 0.6 according to pre-survey. d= the desire margining or error (d=0.5) z=the value in the normal distribution that gives the level of confidences = (1.96). n= 280, increased to 288 due to the availability of respondents.

Final sample size= 288

3.7.2 Sample technique: The sample was chosen systemically, using systemic simple random sampling technique, the sampling interval 1160/ 288= 4 by choosing one house every 4 houses. The first house was chosen randomly by through of stone in the street of the health center, and if in the selected house no female in the reproductive age, to go to following house.

3.8Data Collection Tool: The data was collected bysemi -structured questionnaire which was constructed in Arabic language using simple Arabic expressions.The questionnaire was checked and reviewed under supervision, and then it was finalized and printed.After the data have been collected it was checked to ensure that it was complete and in good quality.

3.9 Data processing and analysis:

3.9.1 Data processing:

Collection of data done by 3 females , their ages more than 20 years, and resident in Arkaweet area and had previous experience with data collection. They were trained by researcher for one day in the health center about how to fill the questionnaire and how to do sampling technique in proper way, after taking permission from the participant, and to ask question in confidential area in the house like room or way from other family member alone, the data were collected between 10 October to 10 November 2017, from 9:00 AM - 2:00 PM. They cover almost the area but some household refuse and fire them away.

3.9.2 Data Analysis: Data were coded, transferred to data master-sheetand then entered into the computer, organized and analyzed using Statistical Package for Social Sciences (SPSS) software version 22,by statistician from 15th November to 30th November 2017.General tabulations including frequency and percentage distribution were used together with Chi–squire test, data about the knowledge, attitude and practice against socio-demographic characteristics. Categorical data were analyzed using chi squire test. P-value <0.05 was considered statistically significant.

3.10Study variables: Socio-demographic data (age, educational level, occupation …).

Questions about knowledge of FC.

Questions to assess attitude of women toward FC.

Question to assess practice of women toward FC.

3.11Studylimitation:

Self –funded study.

Generalizability cannot be afforded due to limitation of the study in one area.

3.12Constraint of the study:

FGM is sensitive topic and based on expectation may have respondent bias.

3.13Ethical Consideration:

Approval of the research study obtained as follow:

 Permission from Ministry of Health-health Center administration.  Ethical consideration from administration of health affairsinMadani locality.  Technical approval from University of Gezira.  Informed written consent from females in reproductive age, andparticipants were assured that collected data will be strictly confidential, and will not be disclosed for any reason, and will be used only for research purposes.

Chapter Four

The Results This chapter presents the findings of investigating 288 women in the reproductive age attending Arkaweet area in Gezira state. The data obtained were analyzed assess the level of Knowledge, attitude, and practice (KAP) towards female genital mutilation/ circumcision among woman in a reproductive age (15-49) in Arkaweet-Gezira State (2017).

The result of this investigation are presented in two sections: section one contain the descriptive analysis of the socio demographic, knowledge, attitude, and practice variables , while the second section present further statistical analysis correlation between major variables

 Section 1

 Socio-demographics characteristics of respondents.  Knowledge about Female circumcision.  Attitudes toward Female circumcision.  Practice of Female circumcision.  Factors  Section 2

Further data analysis and correlation.

Table 1: The socio-demographic Variables among women in reproductive age in Arkaweet, Wad Madani, Sudan, (2017)n=288

Frequency Percent Age groups 15-24 50 17.4 25-34 103 35.8 35-44 75 26.0 45-49 60 20.8 Occupation Housewife 209 72.6 Employee 32 11.1 Laborer 13 4.5 Student 34 11.8 Educational level Illiterate 43 14.9 Basic 69 24.0 Secondary 85 29.5 University 84 29.2 Post-graduated 7 2.4 Marital status Married 221 76.7 Single 46 16.0 Divorced 11 3.8 Widow 10 3.5 Religious Muslim 277 96.2 Christian 9 3.1 Other 2 .7 Monthly household income < 500 18 6.3 500-1000 128 44.4 > 1000 142 49.3 Total 288 100.0

Table 1:The study revealed that the age descriptive of the participants was: Minimum age 17 years, Maximum age 49 years,mean age 33.98 years and Std. Deviation ±9.35 years, the most frequent age group was 25-34 with 103 (35.8%), and the least one was 15-24 with 50 (17.4%). Most of the women were housewives (72.6%) while only 13 (4.5%) were laborer, 176 (61.1%) completed secondary education or higherwhile 43 (14.9%) of the sample were illiterate. More than three quarters were married 221 (76.7%). Almost the participants were Muslims 277 (96.2%). Only 18 (6.3%) were having household monthly income less than 500

SDP and almost half of the sample, 142 (49.3%) their income was more than a thousand pounds.

 The Knowledge about FCamong females in reproductive age,n=288; was found to be (100.0%) the study sample know female circumcision.

200 198 180

160

140

120

100 79 80

60 7 40 4 20

0 PARTIAL REMOVAL TOTAL REMOVAL OF ALL THE ABOVE OTHER OF FEMALE FEMALE GENITALIA GENITALIA

Figure 1: Definition of FC among the study sample, n=288

Figure1: showed that(68.8%) of the study sample defined femalecircumcision as a partial removal of female genitalia.

Table2: Knowledge of Types of FC among the study sample, n=288

Frequency Percent

Type I (Sauna) 5 1.8

Type II (Intermediate) 2 0.6

Type III (Pharaonic) 7 2.5

All of the above 274 95.1

Total 288 100.0

Table2:Showed that(95.1%) of the participant know all the types of female circumcision.

20%

80%

Yes No

Figure2: Presence of complications of FC according the knowledge of the study sample, n=288

Figure 2:show that (80.0%) of the participantswere knowledge about complications of FC.

Table 3: Types of complications of FC according the knowledge of the study sample,n=288

Yes No Total Types of complications No. % No. % No. %

Urine retention 210 72.9 78 27.1 288 100.0

Hemorrhage 215 74.7 73 25.3 288 100.0

Wound infection 214 74.3 74 25.7 288 100.0

Psychologicaltrauma 212 73.6 76 26.4 288 100.0

Surroundingtissues damage 206 71.5 82 28.5 288 100.0

Delivery problems 212 73.6 76 26.4 288 100.0

Painful sex 206 71.5 82 28.5 288 100.0

Others 4 1.4 284 98.6 288 100.0

Table 3:showed that the most knowledgeable type ofcomplications of (FC) among participants is hemorrhage in(74.7%).

26%

74%

Yes No

Figure 3: Presence of Benefits of FCaccording the knowledge of thestudy sample, n=288 Figure 3:showed(26.0%)of study sample said there is benefit to FC.

Table 4: Type of Benefits of FCaccording the knowledge of thestudy sample,n=288

Frequency Percent

Reduces the inflammations 49 17.0

Increases the sexual pleasure 4 1.4

Sexual hygiene 18 6.2

Others 4 1.4

No benefit 213 74. 0

Total 288 100.0

Table 4: (17.0%) of participant stated that benefit from FC is to reduce inflammations.

Table 5: Possibility of eradication ofFCaccording the knowledge of thestudy sample,n=288

Frequency Percent

Yes 225 78.1

No 63 21.9

Total 288 100.0

Table5: (78.1%) of study sample said FC can be eradicated.

140 129 120

100

80 67 63 60 29 40

0 HEALTH EDUCATION RELIGIOUS BY THE LAW CAN NOT BE INSTRUCTIONS ERADICATED

Figure 4: Method of eradication of FC according the knowledge of the study sample, =288

Figure 4:show that the most preventive method of eradication of FC is the health education in (44.8%) according to the knowledge of participant

Table 6: Status of females regardingpractice of FCamong the study sample,n=288

Frequency Percent

Yes 228 79.2

No 60 20.8

Total 288 100.0

Table 6: showed that (79.2%) of the participants were circumcised, while, (20.8%) weren’t undergone circumcision

Table 7: Types ofpracticed FCamong the study sample,n=288

Frequency Percent

Type I (Suuna) 109 37.8

Type II (Intermediate) 17 5.9

Type III (Pharaonic) 102 35.4

Not circumcised 60 20.8

Total 288 100.0

Table 7:The most practiced type of FC among the study sample was type I (Suuna) in (37.8%), followed by type III (pharaonic) in (35.4%).

Table 8: Practice of the study sample regarding circumcising their currentDaughters,n=288

Frequency Percent

Yes 104 36.1

No 184 63.9

Total 288 100.0

Table 8:showed that the practice of circumcision is done in(36.1%) of daughters.

200

150

100 155 50 104 20 9 0 Harmful practice No religious origin Others practing FC

Harmful practice No religious origin Others practing FC \

Figure5: Reasons behind not practicing DaughtersFCamong the study sample, n=288

Figure5: the common reason for not practicing FC to daughters is a harmful practice in (53.8%).

Table 9: Reasons behind practicing ofDaughtersFCamong the study sample,n=288

Frequency Percent

Insure virginity 47 16.3

Avoid social stigma 29 10.1

Religious 24 8.3

Others 4 1.4

Not practicing FC 184 63.9

Total 288 100.0

Table 9: Demonstrate the common cause forpracticing FC for their daughter is to insurevirginity in (16.3%).

Table 10: Presence of complications of FCamong the circumcised daughters,n=288

Frequency Percent

Yes 20 6.9

No complication 84 29.2

Not circumcised 184 63.9

Total 288 100.0

Table 10: showed that (6.9%) of circumcised daughters had FC complications.

Table11: Types of complicationsamong circumcised daughters,n=288

Yes No Total Types of complications No. % No. % No. %

Hemorrhage 11 3.8 277 96.2 288 100.0

Urine retention 12 4.2 276 95.8 288 100.0

Wound infection 13 4.5 275 95.5 288 100.0

Others 1 .3 287 99.7 288 100.0

Table11: demonstrate the commoncomplications in circumcised daughters was found to be wound infection in (4.5%).

Table12: presence or hearing that FC may lead to deathamong the study sample, n=288

Frequency Percent

Yes 9 3.1

No 279 96.9

Total 288 100.0

Table12:Showed that only 9 (3.1%) had hearing that female circumcision lead to death.

300 284

250

200

150

100

0 50 4

0 TRADITIONAL BIRTH DOCTORS NURSE ATTENDANT (TBA)

Figure 6: Practitioners of FC among the study sample, n=288

Figure 6:(98.6%) of the study sample reported that the most known practitioner of FC is the traditional birth attendant (TBA).

Table13: Place of practicing FCamong the study sample, n=288

Frequency Percent

Home 270 93.8

Hospital 0 0.0

Clinics 0 0.0

Others 18 6.3

Total 288 100.0

Table 13:showedthat(93.8%) said that the place for practicing FC is home.

300 269 250

200

150

100 19 50 0 0

0 RAZORS SCISSORS KNIVES OTHERS

Figure 7: Instruments used to practice FC among the study sample, n=288

Figure 7: Show thatthe most used instrument for FC in scissors in (93.4).

Table 14: Decision maker of performing FCamong the study sample, n=288

Frequency Percent

Parents 260 90.3

Allfamily members 26 9.0

Others 2 .7

Total 288 100.0

Table 14: showed that Parents are the decision maker for the FC performing in (90.3%).

Table15: Age for FCamong the study sample,n=288

Frequency Percent

1-5 19 6.6

6-10 237 82.3

11-15 32 11.1

Total 288 100.0

Table 15: demonstrate that Most of the participants (82.3%) stated that age for FC is (6-10) years.

33%

67%

Positive attitude Negative attitude

Figure 8: Attitudes towards FC among the study sample, n=288

Figure 8: Showed The attitudes of the participants towards FC was positive (discouraging) in 193 (67.0%), while the negative attitude (encouraging) was found in 95 (33.0%).

Table16: Reason behind positive attitude towardsFC among the study sample, n=288

Yes No Total Reason No. % No. % No. %

Complications 185 64.2 103 35.8 288 100.0

Non-circumcised also get married 65 22.6 223 77.4 288 100.0

Affect education 53 18.4 235 81.6 288 100.0

Against religious 74 25.6 214 74.3 288 100.0

Against dignity of woman 55 19.1 233 80.9 288 100.0

Others 35 12.2 253 87.8 288 100.0

Negative attitude (Encouraging) 95 33.0 193 67.0 288 100.0

Table16:Showed that the most common reason behind positive attitude was the complications of FC in (64.2%).

Table17: Reason behind negative attitudeFCamong the study sample,n=288

Frequency Percent

Social traditions 40 13.9

For getting married 10 3.5

Saves virginity 13 4.5

Religious 23 8.0

For removal of dirty parts 9 3.1

For husband pleasure 0 0.0

Others 0 0.0

Positive attitude (discouraging) 193 67.0

Total 288 100.0

Table 17: Showed that the negative attitude was found mainly in those who think it is a social tradition 40 (13.9%).

Table 18: Preference of certain type of FCamong those have negative attitudes,n=288

Frequency Percent

No 25 8.7

Yes 70 28.3

Positive attitude 193 67.0

Total 288 100.0

Table 18:Showed that (28.3%) of those have Negative attitude prefer a certain type of FC.

Table 19: Preferred type of FC among those have negative attitudes, n=288

Frequency Percent

Type I (Suuna) 58 .20.2

Type II (Intermediate) 4 1.4

Type III (Pharaonic) 8 2.8

Not preferring 25 8.6

Positive attitude 193 67.0

Total 288 100.0

Table 19:The most common preferred type was type I (Suuna) in (20.2%).

Table20: Reasons of preference of certain type of FCamong those have negative attitudes,n=288

Frequency Percent

Has no complications 43 14.9

From religious 27 9.3

Not preferring 25 8.6

Positive attitude 193 67.0

Total 288 100.0

Table 20: Showed that the main reason for the preferring type because it has no complications in 43 (14.9%).

Table21:Attitudes among study sample towards eradication female circumcision,n=288

Frequency Percent

Yes 196 68.1

No 92 31.9

Total 288 100.0

Table21: demonstrate those who support eradication of FC were (68.1%).

Table22: Reasons for supporting eradication of FCamong the study sample,n=288

Frequency Percent

Harmful tradition `196 68.1

No religious origin 0 0

A + B 0 0

Others 0 0

Not supporting 92 31.9

Total 288 100.0

Table 22:All those who were supporting because it is a harmful tradition (68.1%)

Table23: Reasons for not supporting eradication of FCamong the study sample,n=288

Frequency Percent

For saving virginity 42 14.5

Social reasons 20 7.0

From religious 30 10.4

Hygiene and beauty 0 0

Others 0 0

Supporting 196 68.1

Total 288 100

Table23:showed those who were not supporting because is saves virginity in (14.5%).

Table24: Attitude of the study sample regarding their intention towards circumcising their future daughters,n=288

Frequency Percent

Negativeattitude 89 30.9

Positive attitude 199 69.1

Total 288 100.0

Table 24:showed that intention of study sample towards circumcising their future daughters is positive in (69.1%) and negative in (30.9%).

Table 25: Age groups vs Supporting Female Circumcision

Supporting Female Age groups Circumcision Total P. value Yes No 15-24 6 44 50 25-34 32 71 103 35-44 31 44 75 0.000 > 45 26 34 60 Total 95 193 288

Table 25:showthe relation between age group of the participant and supporting female circumcision, there was a significant statistical relationship and P. value was (0.000).

Table26:Educational level vsSupporting of Female Circumcision.

Supporting Female Circumcision Total P. value Educational level Yes No Illiterate 20 23 43 Basic 21 48 69 Secondary 28 57 85 0.053 University 26 58 84 Post-graduate 0 7 7 Total 95 193 288

Table26: Demonstratethereis association between educational level of the participant and supporting female circumcision, there was no significant statistical relationship and P. value was (0.053)

Table27: Occupation vs Supporting Female Circumcision

Supporting Female Occupation Circumcision Total P. value Yes No Housewife 77 132 209 Employee 12 20 32 Labor 2 11 13 0.002 Student 34 14 11.8 Total 95 193 288

Table27: Demonstratethe relation between occupation of the participant and supporting female circumcision, there was a significant statistical relationship and P. value was (0.002)

Table28: Marital status vs Supporting Female Circumcision

Supporting Female Circumcision Marital status Total P. value

Yes No

Married 83 138 221

Single 6 40 46

Divorced 2 9 11 0.004

Widowed 4 6 10

Total 95 193 288

Table 28:Demonstratethe relation between marital status of the participant and supporting female circumcision, there was a significant statistical relationship and P. value was (0.004)

Table 29: Monthly income vs Supporting Female Circumcision

Supporting Female Circumcision Monthly income Total P. value Yes No

< 500 2 16 18

500-1000 37 91 128 0.007 > 1000 56 86 142

Total 95 193 288

Table 29:Demonstrate, the relation between the monthly income of the participant and supporting female circumcision, there was a significant statistical relationship and P. value was (0.007)

Chapter Five Discussion

5.1 Discussion: This study was conducted in Arkaweet, aiming at studying knowledge, attitudes and practices among women in reproductive age towards female circumcision, and revealed the following findings:

The study revealed that the age descriptive of the participants was: Minimum age 17 years, Maximum age 49 years, mean age 33.98 years and Std. Deviation ±9.35 years, this was nearly to be identical to an Iranian study which reported that the mean age = 33.20, SD = 9.09.(Pashaei T et al, 2016)

Although all the participants were knowledgeable about female circumcision, and 247 (95.1%)were knowledgeable about types of FC, only 79 (27.4%) were aware about the correct definition of the FC which is lower than Nigerian level of knowledge of correct definition by (Ekwueme O et al, 2010) which was found to be (54%). (80.2%) has knowledge about presence of FC complications, this is higher than the level of knowledge about negative health consequences found in the Egyptian study (53.5%±29.0%)(Abolfotouh S et al, 2015), the most common knowledgeable complication was hemorrhage in 215 (74.7%).

75 (26.0%) of the respondents stated that FC has benefits according to their knowledge, which was lower than another Nigerian study which found that (70%)believed that FCM is good and should be continued based mainly on culture and tradition in (85.7%)(Ekwueme O et al, 2010).

According to the knowledge of the study sample; the most preventive method of FC is the health education in 129 (44.8%), which is lower than Sudanese study which found that (85.0%) believed that F/C can be eradicated,through increasing mother’s awareness in (68.0%).(Esmeal EA et al,2016). 228 (79.2%) of the participants were circumcised, The most practiced type of FC among the study sample was type I (Suuna) in 109 (37.8%), then type III (pharaonic) in 102 (35.4%), this is higher than the prevalence found by (Gbadebo B et al, 2015)in Nigeria which was (49.2%), but lower than another Ethiopian study which found that Two hundred sixty-four

(92.0%) of the women had FGM/C with most (93.0%) undergoing Type III FGM which is higher than this study (Gudu W and Abdulahi M, 2017).

104 (36.1%) still practice FC their daughters which is similar to Kenyan study which showed that about (36%) of circumcised women respond that their daughters were already circumcised(Patra S and Singh RK, 2015),

(12.9%) of the circumcised daughters had a presence of FC complications, type of complication was a wound infection in 13 (4.5%), urine retention in 12 (4.2%), and hemorrhage in 11 (3.8%).Which is different from Iranian study which found that UTI was the most common reported complication in (60.4%)(Dehghankhalili M et al, 2015).

284 (98.6%) of the study sample reported that the most known practitioner of FC is the traditional birth attendant (TBA), 270 (93.8%) said that the place for practicing FC is home, while the rest 18 (6.3%) said it is another place rather than hospital or clinic(rural areas).which is similar to another Sudanese study shows that FC was performed by a midwife at home set up in 1416 (94.5%) (Sharfi AR, 2013).Most of the participants 237 (82.3%) stated that age for FC is 6-10 years, 32 (11.1%) said it is (11-15) yrs, while 19 (6.6%) said it is (1-5) yrs.Which is different from Sudanese that shows The FGM was performed below the age of sixyear in 1423 (96.9%)(Sharfi AR, 2013).

The attitudes of the participants towards FC was positive in 193 (67.0%), while the negative attitude was found in 95 (33.0%).this different from Egyptian study which found that the mean percentage score for the overall attitude toward discontinuation of the practice of FGM/C was 76.29+/-17.93, reflecting a neutral attitude; 58.7% had a favorable attitude/norm toward discontinuation of the practice(Abolfotouh S et al, 2015)But is also higher than another Sudanese study which found that the overall proportion of pro-FGM attitude was 27.5% and 18.3% during 2012 to 2014 respectively (Hamilton A and Kandala NB, 2016). 110 (8.6%) of the study sample did not prefer a certain type of FC, while (24.3%) do prefer. The most common preferred type was type I (Suuna) in (20.1%),which is lower than another Sudanese study which found that type I (Suuna) the most preferred type by mothers in (43.9%)(Esmeal EA et al,2016).

The attitude of study sample regarding their intension towards circumcising their future daughters is positive in (69.1%), and the intension is negative in (30.9%),which is also higher

that the portion of mothers who had an intension to circumcised their daughters in the future in Kenya, who were only 13%(Patra S and Singh RK, 2015).

A chi squire test was performed to measure the relation between age group of the participant and supporting female circumcision, there was a significant statistical relationship and P. value was (0.000). This matches the results of the Iranian study which found that FGM/C was associated with higher age (P = 0.002). (Dehghankhalili M et al, 2015)

Another chi squire test was done to measure the relation between educational level of the participant and supporting female circumcision, there was no significant statistical relationship and P. value was (0.053) Another Sudanese study stated that people with pro- FGM attitude were more likely to be un-educated. (Hamilton A and Kandala NB, 2016). Also, an Iranian study found that less educated mothers had more positive attitudes toward FGM. (Pashaei T et al, 2016)

Chapter six Conclusion and Recommendations

6.1Conclusion: o The knowledge among women in reproductive age towards female circumcision in Arkaweet, Wad Medani,Gezira State, Sudan, 2017 was generally good about (64.5%). o The magnitude and of female circumcision in the study area, was found to be (79.2%) according to the results of this study. And most practiced type is Suuna in (37.8%). o The factors enhancing the practice of FC among the study sample is to insure virginity in (16.3%).and the factors hindering isharmful practice in (53.8%). o The complications associated with FC in circumcised daughters were found to be wound infection in (3.5%). o The attitude of females regarding their intention to circumcised current or future daughters FC was found to be negatives in (30.9%) and positive in (69.1%).

6.2Recommendations The researcher recommended the following:

 Health education about FGM and its complications by regulations of lectures to the mothers in the health centers or mosques.  Health education material such as posters, pamphlets, flyers and toys should be available at health centers, and to distribute it to household.  Linkage of FGM/C program to School Health.  Targeting rural areas where there is limited restriction on FGM/C practice “some mother take their daughter to rural areas”.

 More researches with larger sample size, different locations to be conducted to assess the effectiveness of interventions on sustaining eradication of FC.

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Appendix

Gezira University Faculty of Medicine

Questionnaireabout Knowledge , Attitude and Practice among

Female In the Reproductive age towards Female Circumcision in Arkaweet Health center , wad Madani , Gezira state , Sudan .

Demographic data :

1-age in years ………………….

2-Occupation : a-house wife b- employee c-labour d- others

3-Education level : a- illiterate b - primary d- secondary e-university f- post graduate

4-Marital status : a-married b- single c-divorced d-widow

5-Religion : a-muslim b- Christian c-other

6- Monthly income : a-500 b-500 - 1000 c-1000

Knowledge section :

7-Do you know female circumcision ?a- Yes b- No

8-If the answer in question (7) is yes ,what is female circumcision ? a-total removal b- partial removal c- all mentioned d- other

9- If the answer in question ( 7) is yes , what are the type of female circumcision ? a – type 1 (suuna ) b – type 2 ( intermediate ) c- type 3 ( pharonic) d- all above 10 – Do you think that female circumcision has health complication ? a- Yes b- No 11- If the answer in question ( 10) is yes , what are these complication? a-Urine retention b-hemorrhage c- wound infection d-psychological trauma e- surrounding tissue damage f-difficulties in labour g- painful sex h-others 12 do you think that female circumcision has health benefits ? a-Yes b- No

13- if the answer is yes in question (12) what are these benefits ? a -reduce genital tract infection b- help female to reach orgasm c- cleanliness d- others

14 – do you think that female circumcision could be prevented ? a-Yes b-No 15 –If the answer in question (14 ) is yes , what is the best method for female circumcision prevention? a-Health education b- religious instruction c- laws The practice :

16-are you circumcised? A- Yes b- No 17-what type of circumcision done to you ? a-type( 1) sunna b- type( 2) intermediate c- type( 3) pharonic 18-Do you practice female circumcision to your current daughters?or your future daughters? a-YES b-No 19-If the answer in question (18) is No , what are the reasons ? a- Harmfull habit b- No religious origin c- others 20-If the answer in question ( 18) is yes , what are the reasons ? a- Insure virginity b-to avoid social stigma c- religious e- other

21- if there is any health complication occur during circumcision of your daughter? a- Yes b- No 22- if the answer is yes in question( 21) what are these complication? a- Hemorrhage b- urine retention c- wound infection d- other 23- if there is any death for girls during circumcision ?or are you hear that FC lead to death ? a- Yes b- No 24- who is performing the operation of circumcision ? a- Nurse b- traditional mid wife c- doctor d- other 25-In what place female circumcision is performed a- Home b- hospital c- clinics d – others 26- what are instruments used in female circumcision? a- razors b- scissors c- knives e- others 27- who decide to perform female circumcision in the family ?

a- Parent b- family member c- other 28-in which age female circumcision was practice ? a- (1 -5) years b- ( 6- 10 ) years c- (11– 15) years The attitude:

29-What is your attitude toward female circumcision ? a- Agree b- dis agree 30-If the answer in question (24) is dis agree , what are the reasons? a-Health complication b- uncircumcised are married c- affect girl education d-against religion

e=-against dignity of women f- others

31–If the answer in question is agree ,what are the reason ? a- tradition b- good for prospective marriage c- preserve virginity d- husband pleasure e- remove dirty genitalia f – religious e- others

32- if the answer in question (29) is agree , what do you prefer specific type of female circumcision? a- Yes b- No 33 -If the answer is yes, what is preferable type? a- Type (1) suuna. B- type (2) intermediate c-type (3) pharonic

34- why do you prefer that type ? a- Has no health complication b- has no religious origin c- other 35- what is your attitude towordcompating female circumcusion? a-Positive b-negative

36 – if the answer in question( 35)is positive , what are the reason? a- Harmfull practice b- has no religious origin c – both a+ b d-others 32- if the answer in question (35) is negative ,what are the reason? a- Insure girl virginity b- social reasons c- hygiene d- religious reason e- other

 Amal Ahmed, 2007 "The medical benefits of gentile circumcision", Dr. Amal Ahmed Albasheer, specialist on community medicine and a researcher on Islamic medicine , date of publication September 2007.  Amal Ahmed 2014,: "female circumcision in Islam and medicine", Um AtiyaAlAnsaria Organization Dr. Amal Ahmed Albasheer on the website: way back medicine.