Vol X: Female Genital Mutilation in Kenya: Impacts of Women’s Health Intervention Programs on FGM Prevalence

Alternative rites of passage

Some studies have shown that FGM can be effectively eliminated when the community is presented with an alternative rite of passage (ARP) that preserves culture and the health of women (10,11). ARPs are effective in that they incorporate cultural practices or celebrations that traditionally accompany FGM rituals (10). For example, if the girl is usually secluded from the group before and after FGM, then an alternative could be that girl leaves the community to go to an educational program. For this reason, ARPs have been shown to be most effective in communities with public celebrations, as the ARP can replace the cut, while the celebrations can be maintained (11). In communities where FGM is practiced in private or is not associated with a rite of passage, ARPs are less likely to be adopted. According to the WHO, it is also important for the community to play an integral role in planning and implementing the ARP, so that their cultural values respected, and the intervention is not an outside interference (10). The success of an ARP has been attributed to its flexibility to stress different components and celebrations in accordance with a specific community (10).

An ARP project in Meru, Kenya used organized events called “Ntanira na Mugamo” or “Circumcision Through Words.” These events involved a weeklong program of counselling, training, and education of young women, ending with a “coming of age” celebration with music, dancing and feasting like they normally would (10). Some topics addressed during the program include teaching of basic anatomy, sexual health, hygiene, development of self-esteem and how to deal with peer pressure. This project reportedly prevented over 1000 FGM procedures over eight years (10). The success of the intervention was linked to the inclusion of the entire community and family members, including males (10).

Another study looked at attitudes towards ARPs in the Kuria and Kisii communities of Kenya. It suggests that the successful implementation of an ARP is strongly linked to local understanding and acceptance, especially by decision makers such as parents and community leaders (11). Therefore, it is suggested that ARPs be embedded in programs with a larger scope involving education, empowerment, and collaboration between different stakeholders like schools, health providers and community leaders (11).

Human-rights & religious approach

In Kenya, the CARE Refugee Assistance Project partnered with the National Council of Churches of Kenya to expand on community level FGM intervention programs. The goal of this intervention was to understand how various community-based programs could affect the understanding of the effect of FGM, and furthermore encourage the abandonment of female genital cutting. The CARE program focused on two camps, the Ifo camp and the Hagadera camp. Before implementation, a pre-intervention baseline survey was done in order to understand the context of the practice (12). The project held community education and public discussion events to understand the way FGM was viewed as a human rights violation (12). Public messages were announced, emphasizing FGM as a human rights violation to women, as well as how the different forms of cutting were harmful to health. These messages were disclosed over a 21-month period in 2001 and 2002 through community volunteers, religious leaders and mass media activities (12). After the intervention, 62% of the respondents were still unaware that FGM had harmful effects and did not associate FGM with a violation of human rights (12). None of the respondents post-intervention recalled the messages that FGM was a violation of human rights (12). The most prominent message retained was that infibulation (type III FGM) was harmful to health and could have severe medical complications (12).

The most likely reason for this result was that religious leaders were not sufficiently implicated during the intervention and spread mixed messages over what is and is not a violation of human rights (12). This study demonstrated that although public messages on FGM being a human rights violation were prominent in community activities, without the involvement of religious leaders, this increase in knowledge would not translate into increased support of FGM abandonment as it had been hoped.

The importance of religious support is further demonstrated in a study carried out among the Maasai and Samburu communities in Kenya (13). This study was done to understand which approaches in these communities were most effective for the abandonment of FGM practices. It was found that when religious leaders spoke against the practice using a Christian, religious-based discourse, female genital cutting could be viewed as a sinful or unnatural practice (13). A Christian woman interviewed in this study responded to why she didn’t want to be cut with: “Why should I do this? I was born like that. God did very well. He gave me all parts of my body” (13). Maasai and Samburu people were told by their pastors that rather than fear the curse of their ancestors, they should fear the “wrath of God for continuing a practice that is performed against His will” (13).

Indeed, not using the power of religious leaders in their communities would drastically decrease the impacts an anti-FGM intervention could have (13). A country profile of FGM in Kenya by 28TooMany, a registered charity in England and Wales, had similar findings. They analyzed the religious-oriented approach done by the Frontiers in Reproductive Health Project for the Somali community, where religious leaders were encouraged to recount their opinions on FGM. Although the role of religion in FGM practice is complex due to a wide range of religions in Kenya, the highest percentage of women cut in Kenya are predominantly Muslim (51.1% of women) (14). Due to this high number, 28TooMany found that taking a religious-based approach in some communities is successful (7).

These studies demonstrate that although creating a human rights approach is important, without an integrative approach that includes religious leaders, they are less likely to have a positive impact on the abandonment of FGM. Creating a more holistic approach to anti-FGM interventions allows for a higher retention of messages and therefore lower rates of FGM.

Legal approach

In 2001 the Children’s Act was implemented in Kenya, making FGM an illegal practice for girls under 18 years old (7). The law was criticized because it did not include adult women and it did not lead to the expected decrease FGM as it was not accompanied by appropriate awareness-raising. It drove the practice underground and pushed families to conduct FGM in secrecy by fear of retaliation. Moreover, religious beliefs in Muslim areas were viewed as more important than man-made laws which also contributed to the maintained rates of FGM (7). Ten years later, in 2011, the Prohibition of Female Genital Mutilation Act was introduced. This law is more severe as it criminalized a broad list of actions surrounding FGM, including all forms of FGM performed on anyone failing to report the practice to the authorities. To increase capacity-building to better implement the new law, 800 police officers, probation officers, community leaders and others were trained (7). Legal efforts to reduce FGM may be beneficial as it provides a frame to protect girls and encourages health workers to reject the practice. On the other hand, it also has setbacks such as driving the practice underground, encouraging people to cross borders to perform FGM and preventing victims from seeking help when complications occur (7). It was also observed in surveys that the law seems to have pushed FGM to be executed on younger girls, at ages where girls are less aware of the implications of FGM and are less likely to object. Before the law, FGM was mostly performed on girls aged 12 to 18, girls are now being cut mostly between 7 and 12 years of age (7).

Promotion of girls’ education to oppose FGM

FGM views and prevalence strongly correlate with education: 53.7% of women with no education are cut and only 19% of women with secondary education are cut (7). Based on this knowledge, some organizations try to promote education for girls with the objective to decrease FGM prevalence in the long-term. The Forum for African Women Educationalists (FAWE) is an African NGO working to empower girls and women through education and has developed the Centre of Excellence (COE) model, which transforms already existing schools into gender-responsive schools that tackle different problems, including FGM. There are two schools in Kenya, AIC Girls’ Primary Kajiado and Athwana High School, and both have experienced an increase in the retention rates for girls at over 90% (7). However, this program is presently only implemented in two localized communities and does not reach a great number of girls. Thus, it may only have a small impact on FGM prevalence. The program requires more funding to help the increasing number of girls in the program that could benefit from the education and awareness (7).

Discussion

First and foremost, more research is needed on the interventions that are created to impact  FGM rates in Kenya and other countries (15). We found that very few studies monitored the outcome of their interventions, for example,  by comparing the progress to a control group. Measurements of effectiveness should be long-term and preferably include quantitative results in addition to qualitative results (4). Furthermore, data might be compromised as  people fear the consequences of admitting having undergone FGM (2). Additional data would help better manage FGM in different cultural contexts. However, we were able to draw some conclusions from the various interventions that were investigated, and the multiple surveys done on the Kenyan population on how FGM prevention should be approached.

Community-led interventions and building trust relationships

Successful elimination of FGM requires that local communities determine their own needs for interventions and that outsiders hand over control to facilitators from the community over time (10). It is essential for the community to be responsible for the change. It is also important to engage all stakeholders over a long period of time to develop trust, thus resulting in effective management of the practice and eventually appropriate policy (16). This can be done through partnership building, communication, establishing multidisciplinary teams, engagement, etc. (16).

To be effective, interventions need to involve community leaders that are trusted and influential. Hence, in the Kenyan context, interventions should include religious leaders as primary change agents and work with them to implement programs and encourage change (4, 12).