ARCHIVE 2013

Volume 3,

Issue 3

Dec, 2013

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Female genital mutilation between culture and health: a quanti-qualitative study

Ilaria Simonelli,  Alice Barbieri, Francesca Beraldo,  Fabrizio Simonelli

About the Authors: 

  Grant Holder, Bologna Local Health Authority, Bologna, Italy

  Modena Municipality, Modena, Italy

  Bologna University, Bologna, Italy

  Think and Action Tank on Child Right to Health, Bologna, Italy

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ABSTRACT

Background There are multiple impacts of Female Genital Mutilation (FGM) on Health Care services in immigration countries, both culturally and regarding human rights violations. The understanding of social representations of FGM, and the development of strategies in which health care services play a crucial role, are fundamental to abandon FGM practices. The aim of this study was to investigate how different study populations (in particular immigrant women, Italian women and health professionals) perceive the social representations of FGM.

Method a quanti-qualitative analysis, based on the comparison of questionnaires, and on the development of focus groups for the above mentioned study populations.

Results The social representations of FGM expressed by immigrant and Italian women presented several convergences, highlighting changes of immigrant-related attitudes for women who had lived in Italy for more than 5 years. Health care services are essential players in the pursuit of abandoning the practice.

Conclusion The convergences in the social representations of FGM represent an important and relatively quick cultural change in the attitude of immigrant women. Health care services, inspired by multidimensional models (therapeutic, preventive and salutogenic), cross-sectional activities (cultural integration), and models such as the Rights-based approach to health, represent a crucial asset for the abandonment of FGM.

Introduction

Migration flow produces social and cultural changes affecting both the provenance and migration countries. Traditions, social conventions, mind settings and behaviors of communities are a reflection of cultural systems which can be individuated through representations of social phenomena, events and processes. Their comparison allows a better understanding of their framework through convergences and divergences.

Migration processes offer new social and cultural challenges and new opportunities for mutual understanding and the strengthening of human development. A perfect example of these dynamics is
the issue of Female Genital Mutilations (FGM). When comparing the values of FGM within its traditional culture, it is difficult to accept the cultural reference system from which it emanates in respect of universal declaration of human rights, child and women protection. On December 20th 2012 the UN General Assembly approved the Draft Resolution “Intensifying Global Efforts for the elimination of female genital mutilation,” hereby expressing a clear and definitive condemnation
of harmful practices carried out on girls and children with particular reference to FGM, supporting all the necessary legislative measures to protect women and children from all forms of violence. The social and cultural impact of the above-mentioned declaration, concerns countries where FGM is performed, as well as countries receiving immigrants subjected to FGM.

The practices of FGM imply different issues, both for health care services and health care providers, concerning physical, psychological, relational and sexual issues, together with human rights affirmation. (1-4).


In order to abandon damaging and risky traditional practices like FGM, a multisectorial approach that combines cultural and health care actions is fundamental.

From a cultural standpoint, this issue can be addressed through the re-modeling of social representations which influence hereditary practices and social habits (5). The study of FGM and the comparison of social representations of migrant and native people might be useful to understand features and trends of the practice, as well as to find an effective approach for the definitive abandonment of the practice.

Considering the health care standpoint, the local authorities and the health professionals assume an outstanding role: they are in a privileged position for establishing contacts with women who have undergone the rite and, therefore, they are able to start therapeutic, preventive and health promotion interventions in accordance with cultural actions.

Conceptual framework of the research
FGMs are established practices carried out in specific ethnic groups. They include diverse types, which vary from excision to the partial or total removal of external genitalia.

In 1997 WHO defined four types of FGM, subsequently
updated in 2008 (6;7):

  • Clitoridectomy (type I): it consists in the removal, complete or partial, of the clitoris and of the  clitoral prepuce (type Ib). In rare cases, it consists in the clitoral prepuce removal only (type Ia);

  • Cutting (type II): partial or complete removal of the clitoris and of the labia minora, with or without excision of the labia majora;The aim of this study was therefore to explore HP practice, self-efficacy and OE among Nigerian physiotherapists in addressing arthritis and LBP, nutrition and overweight, PF-PA, and HD and stroke.

  • Infibulation (type III): removal of the clitoris, the labia minora, part of the labia majora with cauterization, followed by the stitching of the vulva, leaving a hole, with or without removal of the clitoris;

  • Other (type IV): all other procedures of female genital mutilation performed in absence of therapeutic needs: cutting, drilling or cutting of the clitoris and/or labia, stretching of the clitoris and/or labia, cauterization of the clitoris and surrounding tissues, scraping of tissue surrounding the vaginal orifice or cutting of the vagina; introduction into the vagina of salt, corrosive substances or herbs to shrink it. 

To understand the extent of this phenomenon, it suffices to report that the Agencies estimate that between 100 and 140 million of women have been subjected to FGM. Most of the girls and women are to be found in 28 African countries and a minority of them lives in Asia. DHS and MICS data for Africa updated to 2010 indicate that the states, in which the practice is most widespread for the age-group 15-39 years of age, are Burkina Faso, Djibouti, Egypt, Eritrea, Guinea, Mali, Sierra Leone and
Somalia (8).

The practice of FGM is, however, presently forbidden by International and European law and by various Declarations and Recommendations to the states:

 

  • The Universal Declaration of Human Rights Article 25 establishes that everyone has the right for a standard of living adequate for the health and well-being of himself and of his family, and that motherhood and childhood are entitled to special care and assistance;

  • The Convention of New York on the rights of the child, 1989, protects the gender rights of girls as equal to those of boys (art. 2) by establishing that ‘member States might adopt all effective measures towards the abolition of all traditional practices that endanger the health of minors (art. 24.3);

  • The EU Parliamentary Resolution on FGM (2001/2035 – INI) strongly condemns female genital
    mutilation as a violation of basic human rights and considers it a serious problem for society; it urges the EU and other member States to work together to bring uniformity to existing laws and, if this prove inadequate, to work out new specific legislation.

  • The Recommendation n. 1371 of 1998 of the Council of Europe, on child abuse, recommends that member States’ governments ensure that effective measures are taken against female genital mutilation and provide penalties in their regulations;

  • The Council of Europe ‘Convention on preventing and combating violence against women and domestic violence’, which is a strong declaration for the prevention of violence against women (Istanbul, 2011);

  • The European Parliament Resolution of 14th June 2012 on the abolition of female genital mutilation declares that, since female genital mutilation is mostly practised in developing age (up to 15 years of age), it constitutes a violation of children’s rights;

  • The sentence of the District Court of Colonia of 26th June 2012 established that circumcision of children for religious reasons violated the fundamental human right of physical integrity. The Court compared the child’s right to the physical integrity of his/her body, the parents’ right to religious freedom, and the right of the latter to educate their children in accordance with their own convictions. The conclusion was that the child’s rights inevitably constitute a limit to those of the parents, and that «they are not unacceptably compromised if the parents must wait until their offspring can decide for themselves whether to be circumcised or not»

  •  The Draft Resolution “Intensifying Global Efforts for the elimination of female genital mutilation” This Resolution was adopted by the UN General Assembly on 20th December 2012.

The appearance of this problem in the territory of Emilia-Romagna has brought health professionals to face a new series of needs with substantial cultural implications. In 2001 a regional project co-ordinated by the Local Health Authority of Forlì (9) highlighted some meaningful data: health professionals’ difficulties in identifying the mutilations; women’s difficulty in perceiving circumcision as a risk in childbirth; special need for interdisciplinary approaches for dealing with the practice within health services; the need to formulate guidelines for treatment as well as for prevention. The current research was rooted in these needs, and the aim is to deepen the social representations of FGM, to find different resources and actors for cultural exchange, and define possible interventions.

In particular, the objectives of the current research are divided into two different but correlated groups:

Objectives for the Community level:

  • to outline and to examine the social representations of the practice of FGM among foreign women, focusing on cognitive, emotional and behavioural aspects;

  • to outline and to compare the social representations of the practice of FGM among Italian women, focusing on cognitive, emotional and behavioural aspects;

  • to compare the connotations of social representations for the two different populations, identifying similarities and differences.

The research was conducted within the Emilia Romagna Region, and in particular in the Local Health Authorities (LHA) of Bologna, Forli, Parma and Reggio Emilia. We defined three target population groups:

  • The foreign population, which comprises 80 immigrant foreign women – interviewed by anonymous questionnaire – of which 46 declared having undergone FGM, and 34 selected for their general knowledge of the issue because their ethnic communities were known to practice FGM;

  • The Italian population, which comprises women resident in Emilia Romagna Region: in total 268 women from four different cities in the Emilia Romagna area (Bologna, Forli, Parma and Reggio Emilia) answered the questionnaire;

  • Health professionals, which comprises social and health professionals of the four LHAs; in total 212health professionals answered to the questionnaire.

In general, the attitude towards the research and the participation to the focus groups was positive, with some difficulties in ‘recruiting’ foreign women.

Method

We followed qualitative and quantitative criteria, adding to the traditional methods of statistic data analysis different qualitative methods combining the following methods, theories, models and frameworks:

Survey
A survey method (named “specular research”) was used to compare the FGM social representations of foreign and Italian women (two of the study populations). Hence, two different survey questionnaires were prepared for the data collection, targeted specifically to the two study populations. The questionnaires were divided into two sections: the first part focused on personal experience (immigrant women) and perception (Italian women), and the second part focused on general statements and opinions on FGM. This section was the same for the two populations.

 

As the Social representations theory does not provide a methodological set of tools, indicators and standards, through which monitoring their evolution, we fixed a % standard (≥ 50% for both groups), to be able to extract similarities and differences between Italian and foreign women on key aspects of FGM. After a first empirical standard testing phase, we found some interesting core convergences between the social representations of the two groups. Only in one case (‘psychologically offended’)
the % value was inferior to the standard, but it was reported for its meaning in terms of FGM impact on women’s health.
 

The health professionals’ questionnaire was divided into a first section on the professional experience and a second section on their opinions on FGM and the role of health care services.

The theory of cognitive psychology formed the theoretical framework for analyzing social representations of FGM. In fact, the idea of “behaviour” is similar to the one of “social representation”, in particular in its articulations of: knowledge aspects (ideas and beliefs), emotional
aspects (emotions, reactions, feelings) and behavioural aspects (attitudes) (10). We also added cultural and symbolic aspects to point out principles and causes of the theme under analysis, to offer a complete research of social representations of FGM;

The health models (therapeutic, preventive and health promotion) (11), formed the framework for defining the role of health systems in the practice of FGM. These models have been used for creating and analyzing both the questionnaires and the focus groups;

The Child Rights framework (12;13) and the Rightsbased Approach to Health (14;15) has guided the collection and the organization of opinions and proposals emerged in health professionals’ focus groups. This approach comes by various International Declarations and Recommendations, all of them inspired by the Universal Declaration of Human Rights, that recapture the role of the socio-health services to four principal dimensions: ensuring the availability of the health system, its accessibility without cultural or ethnical discrimination, its social and cultural acceptability, and its scientific quality.

Following this background, we planned (Table 1):
a) Two different surveys with two questionnaires for immigrant and Italian women with the aim of investigating the social representations of FGM. The respondents were selected on a voluntary basis and the recruitment was performed by facilitators and cultural mediators.


b) Questionnaire directed at health professionals, to investigate the professional approaches towards FGM and the role of health care services. The recruitment was performed by the main coordinator of the regional research and by the representatives of the local health services.

c) Four different focus groups composed by Italian women to analyse the data collected in the questionnaires and to reflect upon meanings, behaviours, ideas and intervention plans related to FGM. The participants were selected on a voluntary basis and with the help of cultural mediators.


d) Two different focus groups with immigrant women to analyse the data collected with the questionnaires, to reflect upon meanings, behaviours, ideas and intervention plans related to FGM. The participants were selected on a voluntary basis.
e) Four different focus groups with health professionals to discuss data, analyse issues and collect suggestions on FGM. The participants were selected by the representatives of the local health services.

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The first step of the research consisted in a wide literature review on the main declarations and studies on FGM. Subsequently, a questionnaire for the three study populations was carried out and tested involving representatives from each target group. The questionnaires adapted after the testing phase were submitted to Italian and foreign women in their life settings, and to the professional staff after working hours. The collected data were elaborated statistically and standardized for the comparison. The results of the questionnaires elaboration were presented, discussed and validated during the focus groups carried out in different local health authorities. The focus groups were led by the researcher and supported by conceptual maps for the collection and systematization of the comments. The final data collected with the questionnaires and the comments emerged in the focus groups have been systematized into a Research Report.
Strengths and Limitations
Among the strengths in this study, it is important to mention that it was a fundamental asset to be able to work in collaboration with national and international experts who suggested bibliographic sources, thoughts and opinions on the results of the present research with the aim of improving and enhancing the results. This was particularly relevant to be able to compare similarities and differences with other national and international studies and researches dealing with a social approach to FGM.
Moreover, the research followed an approach oriented to empower foreign women in order to find solutions for the complete abandonment of the practice in their own communities and to create an active social role also for circumcised women.
Finally, we followed a multidisciplinary approach, with the participation of different professionals as sociologists, psychotherapists, gynaecologists, obstetricians, paediatricians, health professionals and cultural mediators. The added value of this approach was the possibility to mix different analysis levels of FGM: from health risks and clinical interventions to social and cultural interpretations of the practice.
The main limitation of the research is the non-statistical sampling of the target population interviewed with the questionnaire as it was difficult to find foreign women available to contribute to the research and talk freely about their personal experiences. Another limitation was the lacking possibility to identify the type of FGM that the foreign women who were interviewed had undergone,
since they were not examined by a gynaecologist, due to time restraints.
Results
Referring to the objectives on the community level, we observed a meaningful convergence area (Figure 1) between the social representations of FGM given by Italian and immigrant women (Table 2). It clearly emerges that there are 7 main convergences in Italian and immigrant women’s opinions about female circumcision:
• it is practiced in African countries;
• mainly to girls under 12 years of age;
• it causes sexual damages;
• it is a physical mutilation and a psychological offence;
• when confronted with Western culture, immigrant women could change their opinion about FGM;
• it is a violent and uncivilized practice,
• it is a violation of Human Rights and for this reasons it should be abandoned and abolished

These convergences constitute an important finding testifying that a radical cultural change in the social representations of FGM can take place, and can do so already within the first 5 years of immigration, thanks to the possibility of comparison with the host community. Divergences persist, and in the view of Italian women, lie in the psycho-physical damage and risk to reproduction that the practice causes, the fear that the rite may be imposed also on couples of mixed marriages and the disbelief in the ‘positive’ values of the practice. For foreign women there is still a belief in the positive aspects linked to the tradition (namely, the socio-cultural significance of the rite, the sense of social inclusion, the preservation of female purity) and the justification of the practice in its original contexts. 

If we look at the specific aspects of Social representations of FGM we can observe the following divergences:

  • Knowledge area: 17.2% of the Italian women believe that the practice is imposed also to girls born in Italy from mixed marriages vs. 6.3% of immigrant women. 64.9% of Italian women identified more than one type of FGM vs. 32.5 of immigrant women and they recognized physical (82.5% vs. 41.3%), psychological (89.9% vs. 42.5%), sexual (75.4% vs. 62.5%) and relational damages (59% vs. 30%) caused by the practice. Foreign women (25% vs. 12.3% of Italian women) believe that the practice is also performed on Asian girls, and on girls between 12 and 18 years old (42.5% vs. 25.4%) ;

  • Emotions area: some of the foreign women (28.8%) consider themselves satisfied with the rite for having reached sexual maturity vs. the Italian women’s esteem (8.6%);

  • Behavioural area: Italian women (15.3% vs. 7.5% of immigrant women) believe that the practice could be imposed also to future generations of immigrant women;

  • Values area: foreign women (8.8% vs. 1.1% of Italian women) stated that the practice also embodies positive values, it preserves women’s purity and for these reasons it is justifiable in their countries of birthand in Italy (20% vs. 7.8%). Finally, Italian women (10.4% vs. 5% of immigrant women) believe that the practice represents religious commitments.

Concerning the objective on the role of health care services, from the therapeutic point of view, there is still a widespread demand for healthcare staff regarding specific professional training, the opportunity to compare experiences with peers, and the design of an operative protocol. Moreover, a positive evaluation has been recorded concerning the role of cultural mediation as a factor in improving patient/professional relationships. Under the prevention perspective, health care professionals underline the importance to sensitize foreign women during visits for abandoning the practice for their daughters and to protect younger girls through information and education interventions in schools. Finally, what emerged was the importance of both the health and social care system and of health education, in order to achieve the abandonment of the practice, through the
involvement of immigrant women and parents as agents of cultural change (Table 3).

Discussion
The phenomenon of FGM still needs to be investigated in its true scope, mode, cultural and social roots. Considering the impact of social representation on daily cultural traditions and practices, this might be a relevant target in the pursuit of abolishing FGM.
 
The change in social representations of FGM on the part of foreign women has an “immediate” effect on immigrant communities, but also a similar “distant” effect may be hypothesised on the cultural background of the country of origin. This aspect should be further investigated and demonstrated. Migration phenomena, constitute a “bridge”, crossed in both directions, for the passage of goods, services, information and also social representations.
 
The convergences area observed in this paper concerns mainly the area that condemns FGM (by immigrant women too), judged as a psychological and physical violent act and a violation of human rights. These convergences testify that – thanks to the dialogue and comparison with western contexts – it is possible to reach a change of social representations of FGM and this can be reached in one generation.
 
As reported in the present study, the direct contact of the immigrant population with Western culture is a factor of strong and rapid change in the social representation of FGM, as are other factors such as the role of mass media and social networks, the positions taken by the institutions and international agencies, and the action of social and health services.
In 2007, Unicef (16) supported this possibility of change, thanks to the study and understanding of social dynamics behind the rite. In this regard, it would be relevant to invest more and more on social and cultural strategies, as stressed by Unicef in 2005 (17), to support communities to abandon the tradition both in immigrant populations and provenience countries.
With reference to social and health care services, particularly those addressed to the protection of maternity and infancy (women’s health services, paediatricians, centres for immigrant women and children), the experience in the Emilia Romagna Region highlights that they constitute a particularly powerful asset for dealing with the problem of FGM. They can implement not only therapeutic and prevention skills, but also health promotion activities based on specific information, education,
empowerment of immigrant women, involvement of immigrants communities, networking with social, educational and judicial services, support for policy makers and institutions, promotion of cultural change, in accordance with the global affirmation of human rights and human development.
In conclusion, to overcome the FGM practice it is desirable to have a common strategy and action based on the implementation of the Child Rights Based approach, inspired by the Convention on the Rights of the Child, which recommends states to respect, protect and fulfill children’s right “to the enjoyment of the highest attainable standard of health” and to “be protected from all forms of violence” (18).
Acknowledgements
We would like to thank the following people for their contribution to the present research:
  • the members of the Scientific Committee: Maurizio  Bergamaschi, Andrea Bolognesi, Viviana Bussadori, Andrea Facchini, Cecilia Gallotti, Gianfranco Gori;
  • the group of national and international specialists: Simona Galbiati, Elise Ragnhild Johansen, Els Leye, Christine Loudes, Cristiana Scoppa;
  • the referees who made their contribution to the research: Daniela Bertani, Andrea Bolognesi, Paola Salvini;
  • the local facilitators: Alice Barbieri, Francesca Beraldo, Francesca Baldoni, Elena Francia, Francesca
  • Gatti, Giovanni Marozza, Giorgia Morini, Francesca Ferrari, Andrea Foracchia;
  • the cultural mediators: Queen Erivo, Mery Ndukuba;
And finally a warm thank you to Monica Minelli, Pamela Preti, Vivian Barnekow Rasmussen; Beatrice Mezzogori, the Health care operators of the Local Health Authorities of Bologna, Forlì, Parma and Reggio Emilia, the Italian and foreign women who participated in surveys and focus groups.
Contribution details:
Conception and design: IS
Coordination and work planning of the study: IS
Acquisition of data: AB, FB
Analysis and interpretation of data: IS
Drafting the article: IS
Revising the article critically for important intellectual content: FS
Final approval of the version to be published: IS, AB, FB, FS
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