Community Knowledge, Attitudes and Practices Related to Female Genital Cutting (FGC) in Kapchorwa District

Abstract

Whereas several campaigns intended to create awareness and prevent female genital cutting (FGC) have been undertaken in Kapchorwa since 1995, it is not known how much cultural change these interventions have caused in the Sabiny. Evaluative studies indicate that FGC began declining since 1992, but the recent head count of women/girls who were circumcised in 1998 suggests an increase in FGC. This raised concern as to whether the FGC is really declining in the Sabiny. This study therefore examined the etiology and status of FGC among Sabiny aged above 15, developments and community views regarding ongoing FGC preventive campaigns, and why the practice is still going on in spite of the eradication campaigns in Kapchorwa district. Methodology: Research Design - The study employed a cross-sectional survey research design, and applied qualitative and quantitative methods. A survey questionnaire (KAPS) was used to collect quantitative data, while interview and discussion guides were used to collect data from key informants and discussion groups. Study Coverage - The survey was conducted in all the three counties of Kapchorwa district covering two sub-counties per county, two parishes per sub-county, three villages per parish and twelve households per village. Therefore, a total of six sub-counties, 12 parishes, 36 villages and 432 households were involved in the survey. The sample - The sample size was 432. Of these, an equal number of subjects were drawn from each sub-county involved in the study, and half of these were males. The sample was structured to reflect the population structure for Kapchorwa district in terms of age and sex. The distribution of the sample was 38% for the age range 15 â 24, 23% for age range 25 â 34, 24% for age range 35 â 54, and 16% for the age group above 55. Sampling strategy - Selection of the sampling units was done systematically. A first list of sub-counties, parishes and villages was obtained and arranged in alphabetical order. A second list was developed after eliminating sub-counties and parishes that were inaccessible, insecure or with substantial non-Sabiny populations. From the list of sub-counties within each county, two sub-counties were randomly selected using systematic sampling. After selecting a random start, every second sub-county on the list was selected. The sampling interval was 2. The same technique was used for selection of 2 parishes from each selected sub-county, and 3 villages from each parish, and 12 households from each village. In selecting the households, a random start was selected and then every second household thereafter was visited and included if it had subjects falling within the desired age and sex categories. This was maintained until the required sample of 12 subjects per village was obtained. Only one subject was selected from each sampled household. Instruments - The KAPS was developed to collect quantitative data on community knowledge, attitudes and practices related to FGC, and desired changes in the ongoing campaigns against FGC. It comprised of questions related to etiology, incidence, nature, information/skills, major actors, rituals and values/benefits, effects (before, during and after initiation) and eradication measures of FGC. The KAPS was pilot tested, reviewed and finalized before administering it to subjects. The completed KAPS were then coded, checked, entered and cleaned. Univariate and bivariate analyses were then performed to establish the distribution of subjectâ s responses against the study variables. The discussion and interview guides comprised of questions for the specific groups and key-informants targeted for the survey. Discussion and interview sessions explored the etiological basis and desired preventive measures of FGC among the Sabiny. Altogether, nine FGD sessions were separately conducted for each of the following subgroups: in-school male discussants aged 15â 24, in-school female aged 15â 24, out-of-school male aged 15â 24, out-of-school female aged 15â 24, uncircumcised women married by 1996, circumcised women, elders, mentors, and Sabiny opposed to eradication of FGC). Each FGD session comprised of six to eight discussants. Meanwhile, key informant interviews were conducted with a circumcisor, circumcision aides, in-charge of community health unit, midwife, TBA, district departmental heads (director of health services, education officer, chief administrative officer, probation and welfare officer) and politicians (vice chairman LC-5 and secretary for women affairs). Data accruing from these sessions were thematically summarized, analyzed and synchronized with quantitative data. Key Findings: Norms and taboos of FGC - It was established that several norms that discriminate against married women who are uncircumcised have been institutionalized in Sabiny culture with the view of regulating discipline and respect for the individual, family and community. These include denying them dignified roles in the family such as addressing gatherings or even taking up positions of responsibility in the community, climbing into the food granary to remove or store grain, stepping into the kraal to collect cow-dung for smearing houses, milking cows. Another aspect for which married uncircumcised women are discriminated against is serving food and beverages to elders or guests, and drinking local brew from a special pot, which is decorated with hides. Compliance to these norms is assured by attaching taboos to their contravention. For example, it is a taboo for married uncircumcised woman/girl to collect food from the granary because they are regarded as â girlsâ and wasteful, and as such they are likely to cause food shortage (famine) in the household if they did otherwise. Additionally, it is a taboo for a married uncircumcised women to milk cows because they are regarded as dirty or unclean, and as such they would contaminate the milk if this norm was contravened. There is a strong belief that if these taboos were contravened, the individual and household would encounter misfortunes and social disasters such as infertility and food shortage respectively. Although these norms and taboos are being abandoned, a number of community members especially the young males and females, they still provide a firm foundation for the continuation of FGC. Key players and benefits of FGC - The key players for this practice are the circumcisors, circumcisor's aides, mentors, parents, partners, in-laws, elders and the community as a whole. Each of these players benefits differently from FGC ceremonies. The benefits include money and physical items like chicken and local brew (for circumcisors and their aides), gifts and ceremonial attire (for candidates), lesu that candidates put on during the ceremony (for mentors), high dowry and respect (for parents and family members), and festivities (for elders and other community members). Discriminative norms do not apply to girls who are not yet married or circumcised. Such girls are allowed to collect food from the granary, cow dung from the kraal, serve elders and visitors and address gatherings (Comment given by a Sabiny elder aged 60). FGC related Discussions: Sabiny women/girls often discuss issues related to FGC with friends/peers (67%), parents (30%), family members (22%), partners/husbands (16%), social workers (16%), health workers including nurses and nursing aides (12%), elders (4%), teachers and circumcisors (3%). Peers and social workers includes the Sabiny who have been trained by FPAU and REACH as peers educators, community based counselors and key community members sensitized on the harmful aspects of FGC. During female initiation ceremonies, candidates are told never to reveal what they are told during the face-toface initiation so as to encourage uncircumcised women/girls to discover the unknown by undergoing the practice. They are also inducted with skills of resisting pain during circumcision, maintaining good hygiene,and marital relationship, avoiding extra-marital sex and responding when called upon or insulted by an elder or husband. Circumstances of undergoing FGC: The survey revealed that 94% of the circumcised women/girls braved circumcision voluntarily, implying that only 6% did so by force. Forced initiation was most prevalent among Christians (Catholic, Protestant and Saved), and those aged 25 â 34, who did not reach senior four and resident in Kaptanya, Binyiny and Bukwa sub counties. However, even some of those who reported having undergone FGC voluntarily did so with some form of pressure from peers, parents and family members (in-laws and partners) and for cultural identity. Of the circumcised women/girls involved in this study, only 21% reported that they had braved it due to personal conviction. Nature of genital excision: Results indicated that 33% of the circumcised women/girls reported that they had their clitoris removed, 38% had both the clitoris and labia minora removed, and 29% had the clitoris, labia minora and labia majora excised. Interview data further revealed that the clitoris is the genital part that every circumcisor in Kapchorwa is supposed to cut, but excision of the labia minora and majora often occurs accidentally. Excision of the clitoris was more common among women/girls resident Bukwa sub-county while excision of both the clitoris and labia minora was most prevalent among women/girls resident in Chesower, Binyiny, Kaproron and Kaptanya. Excision of the labia majora including the clitoris and labia minora was more common among women/girls resident in Kaserem sub-county. It is Because of the cultural belief that some persons use the genital parts that are cut to bewitch candidates, these parts are immediately collected by the â guardians/mentorsâ once circumcision is complete and kept in an undisclosed place. This is also intended to instill discipline and respect for the circumcisors, guardians and parents in the community. For example if a circumcised woman/girl degenerated in discipline and respect for elders, she would be reminded of the fact that someone is in possession of her genital parts that were cut to ensure that she behaves well and respects elders. Prevalence and Trends: Results indicated that FGC is often carried every even year mainly at age 18. However, some women/girls are initiated as early as age 11 and as late as age 28. This practice is most prevalent among women/girls who are or have ever been married, uneducated or educated but did not reach primary seven and resident in Bukwa sub county. FGC prevalence also tends to be high among the older generation, Catholics and Protestants. This is especially so because of the marginalization of married women who are uncircumcised and the big Sabiny population that is Protestant and Catholic. FGC began declining in 1990 and the highest drop rate was recorded between 1994 and 1996 due to increased advocacy, sensitization and mobilization of the community against the practice. Coital experience: Whereas FGC was previously used to regulate virginity and promiscuity of Sabiny girls, results indicated that it was no longer the case. Of the sexually active women/girls involved in this survey, 35% actually encountered first coitus before undergoing circumcision. This tends to weaken the position for the Sabiny who cherishes FGC on the grounds that â it preserves girlâ s virginityâ . Coitus with both circumcised and uncircumcised women/girls is also common among sexually active Sabiny males. Of the sexually active males who reported coital experience with both types of women/girls, the vast majority reported that uncircumcised females were more sexually pleasant and sensitive in the sense that they reached orgasm quickly. FGC attitudes: There is a strong negative attitude towards FGC among young males and females. Results indicated that 82% of the unmarried males favor marrying uncircumcised women/girls. Likewise, 85% of the females eligible for circumcision disfavor undergoing FGC. Moreover, at least 76% of the Sabiny would neither present their daughters nor recommend other women to undergo circumcision. These attitudes were stronger among the saved, highly educated and young Sabiny particularly for the residents of Chesower and Kaserem sub-counties. In addition, 68% of Sabiny wanted FGC to be eradicated, 11% wanted it modified, and only 29% wanted it maintained in its present form. The negative attitude towards FGC was attributed to the growing awareness and fear of the health risks and problems associated with the practice such as over bleeding, shock, trauma, lameness, HIV infection, sexual displeasure, birth complications and death. Health risks and problems FGC: Immediately after incision - The survey revealed that the Sabiny tend to be more aware of the short-term effects of FGC. These include over bleeding; HIV infection; difficulty in retaining/passing urine and walking; shock and fainting; increased pressure to get married; intermittent sickness; death and vagina constriction which often occurs when the genital wound is not well-treated. During pregnancy and delivery - The most encountered problems during pregnancy and delivery include uncontrolled vaginal discharge and intermittent sickness, painful birth, genital rupture, caesarian birth, over-bleeding. Others include stigmatization by the nurses due to the inelastic birth passage and Kelloids. They also encounter small painful septic wounds on the scar around the excised genital area caused when the excised genital area does not heal properly. In lifetime - Itching and pain in the urinary tract and vaginal lips when passing urine, and urine retention lapse most especially during old age; genital ulcers and painful scars during coitus and delivery; low sexual desire and ulcers around the genital area. The other common long term effect stigmatization by nurses and women who belong to tribes that do not practice female circumcision and fellow Sabiny who are uncircumcised. Some also tend to feel humiliated because they were not firm during initiation/circumcision, and often fail to control loud gassing and standing upright for long. Handling FGC complications: Most of the minor FGC complications are traditionally treated using herbs, by feeding candidate on cud of a ram, pouring cold water on the candidate in case of fainting, giving water and what remains at the bottom of the sauce pun after mingling millet, sorghum or posho to replenish energy. It was also established that the other form of treatment is tying a trouser of the husband around the waist of the candidate. However, severe complications are usually reported to health workers at the nearest health unit for specialized care or left to die specifically if there is no health worker in vicinity. The major caregivers for women/girls who encounter complications after circumcision are the mentors, family members, nurses/midwives and nursing aides. Persistence of FGC: It was established that as much as the FGC is declining among the Sabiny, it is unlikely to be completely wiped out in the near future. This is especially because society has cast a state of sacredness on FGC through: a) Attaching to it intangible benefits (values) such as using FGC as a means for preserving girlsâ virginity and regulating sexual desire and promiscuity, a measure of bravery/capability to defend Sabiny community and endure pain during birth, getting to know the relatives and interacting with elders and age-sets, bestowing dignity/respect for candidates and the family, and rejoicing as a community; b) Attaching tangible (material) benefits to FGC in a sense that it is a source of employment/income for circumcisors and circumcisorâ s aides, high dowry for parents/family and gateway to safe marriage for the candidate, and offers training opportunity for circumcisorâ s aides as future circumcisors through apprenticeship. It is also a source of gifts and pride not only for the candidates (ceremonial attire) and parents but also the community. In addition, the community benefits through festivities such as eating, drinking and dancing; c) Institutionalizing FGC norms by not allowing uncircumcised women/girls to undertake certain dignified roles in the community such as to collect food from granary, step into the kraal or pick cow-dung or milk cows, serve brew or food to important people in the community, share a pot of local brew with circumcised women and other persons, address public gathering, represent Sabiny, and perform other dignified roles in the community such as defending the Sabiny in case of war; and d) Linking contravention of FGC norms to social disaster or loss of society benefits. For example, it is believed that: If an uncircumcised married woman climbed the granary, she would be wasteful and cause food shortage in the household; if a sabiny girl avoided circumcision, she would remain a â girlâ and may never bear children. e) There is also a strong belief that if uncircumcised woman/girl milked the cows or addressed a gathering, she would contaminate the milk because of being unclean and be heckled or shouted down upon respectively. It is worthy noting that while these norms and taboos were highly cherished long ago, a number of Sabiny are beginning to abandon them. In addition, in spite of the fact that ongoing interventions have significantly contributed to the current FGC decline a lot still remains to be done. For example, little has been done to address girls/women education and economic empowerment to be able to make independent decisions, and strengthened and alternative cultural activities that would ensure reproduction of the positive norms and minus minus FGC. They have also not effectively reached or involved the custodians of the Sabiny culture such as elders and age-sets, religious organizations and other NGOs, grass root communities (save for saved groups) and the community as a whole, and improved access to reproductive health services in remote areas of the district. The ongoing interventions have also encountered several constraints and challenges that seem to inhibit accelerated cultural transformation. These include perceived corruption and nepotism in the peer education program; few, shy and unrepresentative peer educators; and lack of FGC change agents at village levels; and lack of/inadequate sensitization and follow-up activities for circumcisors, circumcisors aides, mentors,elders, circumcised women/girls and other change agents. Apart from the poor reproductive health infrastructure, service provision and equipment logistics, there is also slow progress towards the construction of a health unit in Cheptuya parish and inadequate staffing of the functional health units. The rugged terrain and social instability due to cattle rustling by the neighboring Pokot and Karamajong have also hampered effective delivery of RH services. Members of the Sabiny Culture Association (SCA) also strongly feel that anti-FGC initiatives are a ploy by â outsidersâ to destroy the sabiny culture. Conclusion: These results indicate that there has been a positive change in knowledge, attitudes and practices related to FGC as is evidenced by the declining trends and prevalence in FGC particularly among the young Sabiny. The educated and unmarried, saved and young women/girls seemed less likely to undergo FGC. In addition, FGC prevalence is high particularly in the remote and inaccessible areas of the district such as Bukwa and Kaproron sub counties. Kaserem surfaced as one of the sub-county with high FGC prevalence because the study was confined to parishes that had a substantial Sabiny population. Therefore education, marital status, religion, age and place of residence bear significant influence on FGC. Despite the declining trends in FGC, the practice is still deeply entrenched and institutionalized in the Sabiny culture through norms and taboos that are often reproduced in the home and family. Marriage provides the social space through which women/girls are pressurized into FGC. Besides the cultural pride, circumcised peers, parents/relatives, in-laws, partners and elders, were the major sources of ostracism that drives girls into circumcision. FGC is strongly cherished and jealously guarded by the elders. A number of young individuals, particularly those who drop out school and marry early were practicing it for cultural identity and dignity irrespective of the health risks and problems associated with it. This is because Sabiny elders are the custodians of culture and wild a lot of respect and influence on the young women and boys. Finally, much as FGC has negative short term and long-term health, biological and psychosocial effects, it is also associated with provision of information and values that promote respect of elders, good hygiene, virginity and fidelity interaction and togetherness through the age-sets in the community. Therefore, the sabiny still cherish FGC because they do not think these values could be sustained without maintaining FGC. This implies that an accelerated cultural transformation regarding eradication of FGC is unattainable without creating socioeconomic and cultural alternatives that would ensure what community members currently benefit from FGC is maintained as the practice is eliminated. Recommendations: Therefore, in order to accelerate cultural transformation regarding the eradication of FGC, it recommended that: 1. Community sensitization, advocacy and education seminars on the harmful aspects and women rights associated with FGC should be intensified and specifically target elders, women, youth, surgeons and the entire community particularly at the grassroots through village seminars/meetings and functional adult literacy campaigns. In so doing, local councils and elders at parish and sub-parish levels should be involved more in the ongoing FGC campaigns. This will go a long way to further increase advocacy for the eradication of FGC and legitimize change at community level; 2. Circumcisors and circumcision aides should be supported to start up alternative sources of income and livelihood; 3. Positive cultural values should be maintained by increasing advocacy for the elimination of the act of cutting female genitalia and maintenance of the positive aspects of female initiation. By so doing, the elders and leaders of age sets should be targeted and encouraged to innovate alternative ways of preserving the Sabiny culture not necessarily through circumcision of women/girls. 4. Family and individual counseling should be strengthened for women/girls who have been traumatized and stigmatized as a result of undergoing FGC; 5. Health service providers should be equipped with skills of counseling, detection and documentation of complications associated with FGC through continuous sensitization seminars and refresher training workshops. They should also be equipped with the minimum health care kits and adequate means of transportation to facilitate quick delivery of emergency RH services; 6. Apart from completing construction and renovation of the health units in each sub-county and some parishes, they should be provided with qualified health personnel and equipment with surgical tools to be able to handle minor surgical operations before patient are referred to the main district hospital; 7. Peer education should be intensified and expanded throughout the district. In so doing, recruitment, training and deployment of peer educators should put into consideration the social, economic and demographic diversity of the community such as sex, age, education level, marital and circumcision status, religious denomination and geographical location; 8. Religious organizations (the Saved, Catholic, Protestant and Muslim leaders) should be involved more in the campaigns against FGC. They should be encouraged only to teach community members about good morals but also about the harmful aspects associated with FGC. This would not only ensure cost-effectiveness in the approaches and strategies adopted to eradicate FGC, but also increase impact in the community; 9. Given that the current school infrastructure in Kapchorwa district is inadequate to cope with the demand for education, it is essential to establish secondary schools that give special preference for girlâ s education in each county. In the meantime, policy-makers, politicians, women and religious groups, human rights organizations and donor agencies should appeal for financial support in and outside Uganda to subsidize education for girls in Kapchorwa district; 10. UNFPA and other concerned agencies should facilitate the formation of an East African Association on FGC. This would go a long way not only in addressing intertribal and interregional dimension of this practice and promoting information sharing and regional coordination of activities intended to eradicate FGC, but also sustaining the positive social change regarding FGC; 11. It was assumed that the minimum age at which Sabiny females undergo circumcision is 15. Therefore,this survey did not include in the sample persons aged below 15. Results however indicated that some Sabiny girls undergo circumcision as early as age 11, thus suggesting that contrary to our assumption, individual considerations about whether to brave FGC begins earlier than the minimum age of the sample for the current survey. Therefore, there in need for further research to establish knowledge, attitudes and prevalence of FGC among Sabiny females aged 9â 14. 12. This survey also used scenarios and descriptions to determine the actual genital parts that are cut. The results on the nature of excision accruing from the current survey are therefore inconclusive. In order to effectively determine the extent of genital excision, FGC sentinel surveillance points should be established in all the maternity units of Kapchorwa district. This would enable health personnel to examine the genital area of all pregnant women who report for delivery and determine the actual parts that were excised and the resultant complications. 13. In addition, the results of this survey provide baseline information that is useful for determining whether ongoing and new interventions bear a positive influence on FGC knowledge, attitudes and prevalence. It is therefore recommended that similar surveys should be conducted after every circumcision season to keep track of the prevalence and social change being caused by the ongoing FGC eradication campaigns.