Background: Female genital mutilation (FGM) or female circumcision is the removal of variable amounts of tissue from the female external genitalia. It is practised all over the world on very young girls. This study was conducted in Sudan where FGM is a criminal offence and not a religious dictate. We assessed the knowledge, attitudes, and perceptions of this practice among Khartoum university students and compared the differences between male and female student responses.
Methods: An anonymised detailed questionnaire was distributed among the university students. In addition to the participant’s age, marital status, course studying, details regarding their attitude, knowledge of the practice of FGM, and their own experiences were collected.
Results: Of the 500 questionnaires distributed, 414 (82.8%) were returned from 192 (46%) females and 222 (54%) males. 109 (56.8%) of the female respondents were themselves circumcised.18.8% of the male students and 9.4% of the female students thought FGM was recommended by their religion. Only 90 (46.9%) female students compared with 133 (59.9%) male students thought FGM was illegal. Though 16 (8.3%) female respondents thought FGM would increase their chances of marriage, the majority, 166 (74.8%), of the male students would prefer a non-circumcised female.
Conclusions: This study shows that 109 (56.8%) female university students who responded were circumcised. Confusing religious messages and ambiguous laws seem to be responsible for the continuation of this practice. The study highlights the partnership that needs to be established between religious leaders and educationalists to end this medieval practice.
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Female genital mutilation (FGM) or female circumcision is the removal of variable amounts of tissue from the female external genitalia. It is practised all over the world but mostly in Africa.1 It is usually performed on very young girls (3–8 years old) by non-medical people and often without anaesthesia. There are many reasons cited for its performance, among them chastity, increasing chances of marriage, religious decree, and tradition.2,3 Toubia4 has classified FGM into four main types depending on the amount of tissue removed. Type 1 represents the excision of a part of the clitoris or the whole organ (clitoridectomy). This is commonly known as sunna circumcision. Type II involves clitoridectomy and excision of parts of the labia minorae. Type III FGM (partial infibulation) represents clitoridectomy, removal of the labia minorae, excision of the labia majorae, and stitching of the anterior two thirds of the labia majorae leaving a small posterior opening. Type IV (total infibulation) involves the removal of the clitoris and labia minorae, excision of the labia majorae, and stitching of the whole raw area leaving a very small posterior opening for the passage of urine and menstrual blood. Since the operator is usually a layperson with limited knowledge of anatomy, the above description is arbitrary. The immediate complications of FGM are haemorrhage and infection which can be severe enough to threaten life. Long term sequelae such as sexual dysfunction, menstrual and fertility problems, difficulties with childbirth and psychological impairment are also reported.5,6 In many countries including the Sudan law forbids the practice of FGM. Previous studies have shown that FGM is performed on 85–89% of females in Sudan, especially in the northern part of the country and across all religious and social groups.7,8
This study was conducted at the University of Khartoum, which has students of all ethnic, religious, and social groups.
We aimed to assess the knowledge, attitude, and perception of the practice of female genital mutilation among Khartoum university students and compare the differences between male and female student responses.
Anonymous detailed questionnaires (see STI website) were distributed to the first 500 students who went through the doors of the main two campuses of the University of Khartoum (central and medical campus) over a 2 week period in July 2000 to male and female students by hand by one of the authors (EH). Questions were written in English and an Arabic translation was also provided. Demographic data collected included age, sex, marital status, religion, and the courses students were studying. The students were asked whether they favoured female circumcision and were asked to give reasons. Knowledge of female circumcision was sought, and whether students were aware of the complications of FGM. Students were asked whether they thought FGM was legal and whether it was recommended by their religion. Male students were asked about their preference for circumcised or uncircumcised females as future partners. Female students were asked if they themselves were circumcised and whether this would affect their chances of marriage. Circumcised females were asked to identify the person who they thought was responsible for the circumcision.
All students were asked whether this practice should continue and further comments were invited. Students were asked to return the questionnaires to a designated collection point.
Data were collected from the completed questionnaires in Microsoft Excel sheet and analysed by spss version 9. Parametric two sample t test was also used. A p value equal to or <0.05 was considered significant.
Of the 500 questionnaires distributed, 414 completed questionnaires were returned, a response rate of 82.8%. The respondents were from a wide range of faculties including arts 17.5%, law 16.4%, engineering 16.3%, medicine 15.1%, pharmacy 12%, economics 11.6%, dentistry 9.1%, and others 2%; 98.8% of the responders were Muslims; 222 (54%) were males and 192 (46%) were females. The mean age for males was 22.7 years (SD 2.1) and the mean age for females was 20.2 years (SD 1.9). Responses are shown in table 1. All male respondents were single but one, while there were three married and one widowed female student.
Fourteen per cent of the male respondents were in favour of female genital mutilation versus 5.2% of the females (p <0.01). Those who favoured FGM did so for various reasons; religious (males 77.4%/females 50%), social and cultural (males 10%/females 10%), sexual (males 2.6%/females 10%), and a combination of above factors (males 10%/females 30%). The five Christian students, three males and two females, were all against FGM.
Most students (males 91.4%, 94.2% females) were aware of the menstrual, sexual, fertility, and labour complications caused by FGM; 59.9% of the male respondents thought female genital mutilation was illegal compared to 46.9% (p=0.14) females, 17.6% of the males and 21.9% of the females thought FGM was legal. The remainder answered “don’t know” to this question.
Similar responses were obtained when the students were asked about the recommendation of circumcision by their religion: 48.6% of males and 55.2% of females thought it was not recommended while 18.8% of males and 9.4% of the females thought it was recommended and approximately one third of students again answered “don’t know” to this question.
Although 56.8% of the female respondents had undergone FGM, most of them (78.1%) were unsure as to whether this would affect their chances of marriage; 8.3% thought it would improve their chances, 9.4% thought it would reduce their chances, and 4.2% felt it would have no effect.
This study showed that 74.8% of the male respondents preferred non-circumcised females for their future partnership and only 11.7% indicated a preference for circumcised females, while 13.5% didn’t think circumcision would influence their decision.
Of the circumcised females 65% said their mothers were responsible in taking the decision, while the grandmothers and fathers were responsible in 52% and 21% of cases, respectively.
When the students were asked whether the practice of FGM should continue 78.8% of the males and 88.1% of females thought this practice should be abolished (p=0.13). A small group of students (15.3% of the males and 4.6% of the females) wanted the practice to continue (p<0.01).
Previous studies have reported that FGM is performed on 89% of females in northern Sudan and in about 98% of Somali females.6,7 Allam et al9 reported that 95% of Egyptian females were mutilated to some degree. Our study reports a lower prevalence of FGM among female university students (56.8%), a finding that may indicate a decline in this practice. However, the population studied here may be different from those of previous studies.
Our study showed that the majority of the students were aware of the complications caused by female genital mutilation (91.4% males v 94.2% females). This awareness, however, didn’t translate into refusal of the practice because 17.3% of the males and 15.7% of the females still either favoured FGM or were not sure about it. This could mean that the pressure from religious, cultural, and social beliefs to continue this tradition is stronger than any perception of danger caused by the practice of FGM.
The students who favour the practice believe that it is a religious dictate (77.4% of males and 50% of the females), especially the Muslim students, many of whom mentioned in their comments that “sunna” circumcision (type I FGM) is recommended by the prophet Mohammed. The word sunna is misleading as its literal meaning in Arabic is “following the prophet’s acts.” In local Sudanese Arabic when pronounced sinna it means “a small piece of something” which could be the clitoris in the case of FGM. One is tempted to deduce that the word has been misunderstood and hence the practice. Although there is no explicit mention to female circumcision in the Koran, the Koran forbids causing harm to other Muslims.
The law of the Sudan10 (volume 9, 1974–1975) reads in provision 284A: “Whoever voluntarily causes hurt to the external genital organs of a woman is said, save as hereinafter expected, to commit unlawful circumcision. Whoever commits unlawful circumcision shall be punished with imprisonment for a term not exceeding five years or with fine, or with both.” The same provision then goes on to exempt those who merely remove the free and projecting part of the clitoris as if the clitoris is not an external genital organ. We think this is a very confusing message and probably, because of this ambiguity, there are no reported cases of successful prosecution against people who commit this crime. The students’ response to the question of relation between the FGM and the law and FGM and religion reflects this confusion.
Unless the religious leaders, government, and educationalists work together to clarify these matters, young girls will continue to be genitally mutilated in the Sudan under the wrong perception that this is a legal procedure recommended by religion—for example, Islam.
The traditional argument that circumcised females are more likely to get married when compared to their uncircumcised counterparts is clearly refuted by this study: 74.8% of the male university students would prefer a non-circumcised female and the females themselves do not believe that circumcision would increase their chances of marriage (only 8.3% thought it would do so).
Interestingly, 9.4% of the circumcised females thought being circumcised would reduce their chances of marriage. In our study this finding represents a change in attitude and perception of females to their mutilation,1 as FGM is viewed as an encumbrance to marriage rather than being an asset. We speculate that knowledge of the complications of this practice has psychologically disabled these women towards marriage. Female genital mutilation causes psychological impact as has been previously reported.7
The practice of female circumcision continues with over half of the university students still being mutilated.
We observed that conflicting religious messages and an ambiguous law might contribute to the perpetration of this practice.
As the majority of male students expressed a preference for an uncircumcised female; the traditional belief of female circumcision increasing women’s marital chances is refuted.
This study was conducted in an educational environment of upcoming professionals, probably from higher social strata. A decline in the prevalence of FGM in this study may not be a true reflection of the practice across the country. However, we hope that an increasing awareness of the complications caused by FGM and that increasing literacy may bring about a change in the practice.
The role of women in ensuring that the practice continues was highlighted in our study (mothers and grandmothers were responsible for the majority of the decisions, mothers 65% grandmothers 52%, while the fathers were the decision takers in 21%). This is difficult to explain, when we consider that women are the main, if not the only, ones who suffer the consequences of FGM. Would women’s empowerment bring about a difference as Ladjali et al suggest?11 We believe it would as is evident from our data—that is, the majority of the educated university students would not want this practice to continue.
We are aware that if this survey was performed in a different setting in the Sudan, figures of support and the number of those who are circumcised may be much higher. Conducting a study among illiterate people however would mean direct interviews which will only jeopardise the validity and reliability of many answers.
This study showed a promising attitude as the majority of the students would want to see the practice abolished (88.1% of the females and 78.8% of the males).
Despite the lack of support by religion or law females are still genitally mutilated in the Sudan. We believe that confusing religious messages and ambiguous laws are responsible for the continuation of this cruel tradition. The government, educationalists, and religious leaders have moral obligations to explain these issues and ensure that FGM is abolished. The students’ awareness of the complications caused by FGM should be utilised to fight the existence of this medieval practice.
Both authors worked together in writing the questionnaire, collecting and analysing the data and writing up the manuscript.
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