The medicalisation of female genital cutting in Kenya: a threefold exposition.

In Kenya, the prevalence of Female Genital Cutting (FGC) is slowly decreasing. Simultaneously, the practice is increasingly being performed by healthcare providers rather than traditional circumcisers, which may pose the risk of legitimising the practice. To date, the underlying mechanisms remain poorly understood. Using the 1998, 2008-09, and 2014 Kenyan Demographic Health Surveys, this study aims to enhance understanding by mapping both FGC prevalence and medicalisation rates across birth cohorts and ethnic groups. Additionally, the study delves into data from the Kisii community, where FGC medicalisation is particularly high, to examine the association between medicalisation and a mother's social position, as she is typically the primary decision-maker regarding the practice. Findings reveal that the coexisting trends of decreasing prevalence and increasing medicalisation exhibit significant ethnic variation. Among the Kisii, greater wealth is associated with higher odds of a medicalised cut compared to a traditional cut, while higher education and media use are linked to higher odds of not undergoing cutting at all compared to a medicalised cut. Our findings nuance the international community's premise that the medicalisation of FGC hinders the eradication of the practice.

Relationship between classic indicators of health behaviour and contraceptive choices in women in Flanders.

BACKGROUND: In this study we shed light on ongoing trends in contraceptive use in Flanders (Belgium). Building on the fundamental cause theory and social diffusion of innovation theory, we examine socio-economic gradients in contraceptive use and the relationship to health behaviours. METHODS: Using the unique and recently collected (2020) ISALA data, we used multinomial logistic regression to model the uptake of contraceptives and its association to educational level and health behaviour (N:4316 women). RESULTS: Higher educated women, and women with a healthy lifestyle especially, tend to use non-hormonal contraceptives or perceived lower-dosage hormonal contraceptives that are still trustworthy from a medical point of view. Moreover, we identified a potentially vulnerable group in terms of health as our results indicate that women who do not engage in preventive health behaviours are more likely to use no, or no modern, contraceptive method. DISCUSSION: The fact that higher educated women and women with a healthy lifestyle are less likely to use hormonal contraceptive methods is in line with patient empowerment, as women no longer necessarily follow recommendations by healthcare professionals, and there is a growing demand for naturalness in Western societies. CONCLUSION: The results of this study can therefore be used to inform policy makers and reproductive healthcare professionals, since up-to-date understanding of women's contraceptive choices is clearly needed in order to develop effective strategies to prevent sexually transmitted infections and unplanned pregnancies, and in which women can take control over their sexuality and fertility in a comfortable and pleasurable way.

Rethinking the Definition of Medicalized Female Genital Mutilation/Cutting.

In 2015, the international community agreed to end Female Genital Mutilation/Cutting (FGM/C) by 2030. However, the target is unlikely to be met as changes in practice, including medicalized female genital mutilation/cutting (mFGM/C), challenge abandonment strategies. This paper critically reviews the current World Health Organization (WHO) definition of mFGM/C to demonstrate that mFGM/C, as currently defined, lacks detail and clarity, and may serve as an obstacle to the collection of credible, reliable, and comparable data relevant to targeted FGM/C prevention policies and programs. The paper argues that it is necessary to initiate a discussion on the revision of the current WHO definition of mFGM/C, where different components (who-how-where-what) should be taken into account. This is argued by discussing different scenarios that compare the current WHO definition of mFGM/C with the actual practice of FGM/C on the ground. The cases discussed within these scenarios are based on existing published research and the research experience of the authors. The scenarios focus on countries where mFGM/C is prevalent among girls under 18 years, using data from Demographic Health Surveys and/or Multiple Indicator Cluster Surveys, and thus the focus is on the Global South. The paper places its arguments in relation to wider debates concerning female genital cosmetic surgery, male genital circumcision and consent. It calls for more research on these topics to ensure that definitions of FGM/C and mFGM/C reflect the real-world contexts and ensure that the human rights of girls and women are protected.

An international comparison of gender differences in mental health among higher-education students during the first wave of the COVID-19 pandemic: a multilevel design.

BACKGROUND: Mental health problems are a common phenomenon among higher-education students. How these mental health problems manifest themselves appears to differ between male and female students. While the latter group bears a greater risk of developing internalizing problems, with depression being particularly prevalent, these problems manifest themselves in male students mainly via externalizing disorders, with alcohol abuse being the most prevalent. Available cross-national research on students' mental health during the COVID-19 pandemic, to date, mainly focused on the prevalence of depressive symptoms, thereby ignoring a possible gendered impact of the pandemic. METHODS: The current study used the COVID-19 International Student Well-Being Study, which collected data on students' mental health during the first wave of the COVID-19 pandemic in 26 countries, and multilevel modeling was applied. RESULTS: It finds that, overall, female students reported more depressive feelings, and male students reported more excessive alcohol consumption. The strictness of the governmental containment measures explained a substantial amount of these gender differences in depressive feelings, but not in excessive alcohol consumption. CONCLUSIONS: Our study highlights that the COVID-19 pandemic had a gendered impact on students' mental health. Studies that ignore the gendered impact of the COVID-19 pandemic are therefore limited in scope.

Exploring the association between perceived male attitudes and female attitudes toward the discontinuation of Female Genital Mutilation/Cutting in Egypt.

Introduction: There are 200 million girls and women alive worldwide that have undergone the practice of Female Genital Mutilation/Cutting (FGM/C) and 4 million girls are at risk of undergoing the practice each year. FGM/C provides no known health benefits, while puts a plethora of medical, psychological, and sexual health risks into perspective. One of the countries where the prevalence of FGM/C is the highest in the World, even though local authorities legally banned the practice in 2008, is Egypt. Within the Egyptian context, there are several complex socioeconomic, religious, and cultural drivers that influence the familial decision making of the daughters being cut. Female attitudes hold great significance in the process, because mothers and female family members are typically the prime decision makers at the daughter's circumcision. However, whilst FGM/C is often performed to enhance marriageability and address male preferences, in practicing communities there is little to no open communication between men and women about the practice, making women rely on their perceptions on FGM/C related expectations of men. Even though the connection between female and perceived male attitudes toward the discontinuation was established almost 20 years ago, since then to our knowledge little is known about the further characteristics of this association. Therefore, this study aims to explore the association between female and perceived male attitudes within families of a younger cohort and moreover attempts to provide a more layered picture of it within different levels of education. Methods: To explore the relation between female and perceived male attitudes toward the discontinuation of FGM/C we conducted a 3-step binary logistic regression model. Results: Our results show that women are significantly less likely to favor a continuation of FGM/C if they think men are disapproving of the practice, compared to women that think men want it to continue. The strength of this association partially varies between the different levels of education as it is less pronounced at the level of secondary education, compared to the reference group. Discussion: In alignment with previous findings in the literature, women were more likely to support the discontinuation of FGM/C if they believed that men want the practice to discontinue as well and vice versa. At a higher level of secondary education however this association is less pronounced. This result concludes that the role of perceived male attitudes should be an important factor associated with female ones and studied further, and underlines the importance of education in women empowerment.

What interventions are effective to prevent or respond to female genital mutilation? A review of existing evidence from 2008-2020.

As the final decade of acceleration towards zero new cases of Female Genital Mutilation (FGM, SDG Target 5.3) by 2030 has begun, increasing the rigour, relevance, and utility of research for programming, policy development and resource allocation is critical. This study aimed to synthesize and assess the quality and strength of existing evidence on interventions designed to prevent or respond to FGM between 2008 and 2020.The study drew on a Rapid Evidence Assessment of the available literature on FGM interventions. The quality of studies was assessed using the 'How to Note: Assessing the Strength of Evidence' guidelines published by the Foreign, Commonwealth and Development Office (FCDO) and strength of evidence using a modified Gray scale developed by the What Works Association. Of the 7698 records retrieved, 115 studies met the inclusion criteria. Of the 115 studies, 106 were of high and moderate quality and were included in the final analysis. This review shows that at the system level, legislation-related interventions must be multifaceted to be effective. Whilst all levels would benefit from more research, for the service level especially more research is needed into how the health system can effectively prevent and respond to FGM. Community-level interventions are effective for changing attitudes towards FGM, but more must be done to innovate with these interventions so that they move beyond affecting attitudes alone to creating behaviour change. At the individual level, formal education is effective in reducing FGM prevalence among girls. However, the returns of formal education in ending FGM may take many years to be realized. Interventions targeting intermediate outcomes, such as improvement in knowledge and change in attitudes and beliefs towards FGM, are equally needed at the individual level.

Corrigendum: Exploring the association between perceived male attitudes and female attitudes toward the discontinuation of Female Genital Mutilation/Cutting in Egypt.

[This corrects the article DOI: 10.3389/fsoc.2023.1183989.].

Mothers' perceptions of the medicalisation of female genital cutting among the Kisii population in Kenya.

While within the Kisii community in Kenya the prevalence of female genital cutting (FGC) is decreasing, the practice is increasingly being performed by health professionals. This study aims to analyse these changes by identifying mothers' motives to opt for medicalised FGC, and how this choice possibly relates to other changes in the practice. We conducted face-to-face semi-structured in-depth interviews with mothers who had daughters around the age of cutting (8-14 years old) in Kisii county, Kenya. Transcripts of the interviews were coded and analysed thematically, applying researcher triangulation. According to mothers' accounts, the main driver behind the choice to medicalise was the belief that medicalising FGC reduces health risks. There were suggestions that medicalised FGC may be becoming the new community norm or the only option. The shift to medicalisation was examined in relation to other changes in the practice of FGC signalling how medicalisation may provide a way to increase the practice's secrecy and decrease its visibility.

The medicalisation of female genital cutting: Harm reduction or social norm?

Today, female genital cutting is increasingly practised by trained healthcare providers. While opposition to medicalised female genital cutting (FGC) is strong, little is known about the underlying motivation for this medicalisation trend in practising communities. We formulated three hypotheses based on medicalisation theories. The medicalisation of FGC: (i) is stratified and functions as a status symbol, (ii) functions as a harm-reduction strategy to conform to social norms while reducing health risks and (iii) functions as a social norm itself. Conducting multilevel multinomial regressions using the 2005, 2008 and 2014 waves of the Egyptian Demographic Health Survey, we examined the relationship between the mother's social position, the normative context in which she lives and her decision to medicalise her daughter's cut, compared to the choice of a traditional or no cut. We found that an individual woman's social position, as well as the FGC prevalence and percentage of medicalisation at the governorate level, was associated with a mother's choice to medicalise her daughter's cut. Further research on factors involved in decision-making on the medicalisation of FGC is recommended, as an in-depth understanding of why the decision is made to medicalise the FGC procedure is relevant to both the scientific field and the broader policy debate.

Perceived group discrimination based on one's gender and the gender gap in depression in Europe.

BACKGROUND: Gender discrimination is one of the most significant psychosocial stressors. This study examined whether the relationship between perceived group discrimination against one's gender (PGD) and the gender gap depression varied by societal levels of gender inequality. METHODS: The current study used data from three waves (2006, 2012 and 2014) of the European Social Survey and applied multilevel linear regression methods. We assessed depressive feelings through the eight-item version of the Centre for Epidemiological Studies Depression Scale. The sample contained 71,419 respondents living in 22 countries. RESULTS: While only a small percentage of people were confronted with PGD, this group consistently reported more depressive feelings. PGD had a similar effect on the mental health of men and women, except for men in more gender-egalitarian societies. When confronted with PGD, the latter group reported more depressive feelings in comparison to men in more gender unequal societies. CONCLUSIONS: Our research found a strong association between PGD and depression. In addition, this relationship varied by societal levels of gender equality. More pronounced gender equality strengthened this relationship in men. Research that ignores this social context might, therefore, be limited in terms of generalization.

Debating medicalization of Female Genital Mutilation/Cutting (FGM/C): learning from (policy) experiences across countries.

BACKGROUND: Although Female Genital Mutilation/Cutting (FGM/C) is internationally considered a harmful practice, it is increasingly being medicalized allegedly to reduce its negative health effects, and is thus suggested as a harm reduction strategy in response to these perceived health risks. In many countries where FGM/C is traditionally practiced, the prevalence rates of medicalization are increasing, and in countries of migration, such as the United Kingdom, the United States of America or Sweden, court cases or the repeated issuing of statements in favor of presumed minimal forms of FGM/C to replace more invasive forms, has raised the debate between the medical harm reduction arguments and the human rights approach. MAIN BODY: The purpose of this paper is to discuss the arguments associated with the medicalization of FGM/C, a trend that could undermine the achievement of Sustainable Development Goal 5.3. The paper uses four country case studies, Egypt, Indonesia, Kenya and UK, to discuss the reasons for engaging in medicalized forms of FGM/C, or not, and explores the ongoing public discourse in those countries concerning harm reduction versus human rights, and the contradiction between medical ethics, national criminal justice systems and international conventions. The discussion is structured around four key hotly contested ethical dilemmas. Firstly, that the WHO definition of medicalized FGM/C is too narrow allowing medicalized FGM to be justified by many healthcare professionals as a form of harm reduction which contradicts the medical oath of do no harm. Secondly, that medicalized FGM/C is a human rights abuse with lifelong consequences, no matter who performs it. Thirdly, that health care professionals who perform medicalized FGM/C are sustaining cultural norms that they themselves support and are also gaining financially. Fourthly, the contradiction between protecting traditional cultural rights in legal constitutions versus human rights legislation, which criminalizes FGM/C. CONCLUSION: More research needs to be done in order to understand the complexities that are facilitating the medicalization of FGM/C as well as how policy strategies can be strengthened to have a greater de-medicalization impact. Tackling medicalization of FGM/C will accelerate the achievement of the Sustainable Development Goal of ending FGM by 2030.

Characteristics of Women Who Present for Abortion Beyond the Legal Limit in Flanders, Belgium.

CONTEXT: Women who seek abortion care beyond the first trimester of gestation are often in a vulnerable socioeconomic position with limited social support, and in Belgium, the details of their circumstances are insufficiently understood. A better understanding of this group is essential to a critical evaluation of Belgian abortion policy, which restricts abortions on request after the first trimester. METHODS: Anonymized patient records were collected between 2013 and 2016 from LUNA centers, which are non-hospital-based abortion clinics in Flanders. Logistic regression analyses were used to identify associations between women's characteristics and whether they presented within or beyond the legal limit, which was 13 weeks and 1 day at the time of the study. RESULTS: A total of 28,741 women requested an abortion, and 972 individuals (3.4%) presented beyond the legal limit; 29% of these latter women were unable to receive abortion care as a result of the mandatory six-day waiting period. Characteristics positively associated with presenting beyond the limit, instead of beforehand, were being younger than 20, as opposed to 20-24 (odds ratio, 1.7); receiving a primary, lower secondary, upper secondary or special-needs education, rather than a higher education (1.8-3.1); being unemployed, rather than employed (1.3); and holding Belgian rather than a foreign nationality (0.8). Being accompanied by someone to the LUNA center (0.8), having irregularly (0.6) or regularly used contraceptives (0.7), and having ever had an abortion (0.8) were negatively associated with presenting beyond, rather than before, the limit. CONCLUSIONS: A fuller consideration of patients' characteristics when evaluating Belgian abortion policy is needed to ensure that the needs and rights of socioeconomically vulnerable women are addressed.

The Association Between Women's Social Position and the Medicalization of Female Genital Cutting in Egypt.

CONTEXT: Medicalization of female genital cutting (i.e., having the procedure done by a medical professional) has increased in Egypt in recent years. The relationship between a woman's social position and the decision to use a trained health professional to perform genital cutting is not well understood. METHODS: Data from the 2005, 2008 and 2014 Egypt Demographic Health Surveys on 11,455 women whose daughter had undergone female genital cutting were used to examine relationships between mothers' social position and medicalization. Logistic regression models were used to identify associations between measures of social position and the decision to have genital cutting done by a trained provider. RESULTS: Seventy-nine percent of women had had their daughter cut by a trained health professional. The odds of medicalization were greater among women who had a primary education (odds ratio, 1.2) or a secondary or higher education (1.8) rather than no education; who lived in wealthier households rather than in the poorest ones (1.4-2.6); and who shared decision making on large household purchases rather than had no say in such decisions (1.2). In addition, working for pay and the magnitude of the age difference between women and their husband were negatively associated with medicalization (0.99 and 0.9, respectively). CONCLUSIONS: A woman's social position in Egypt is associated with medicalization of her daughter's genital cutting. Research is needed to explore the social meaning attributed to medicalized genital cutting, which may inform campaigns that could decrease the prevalence of the procedure.

RESUMEN Contexto: En años recientes, la medicalización de la mutilación genital femenina (es decir, la aplicación del procedimiento por un profesional de la medicina) ha aumentado en Egipto. La relación entre la posición social de una mujer y la decisión de utilizar un profesional de la salud capacitado para realizar la mutilación genital no está bien comprendida. Métodos: Se utilizaron datos de las Encuestas Demográficas y de Salud de 2005, 2008 y 2014 de Egipto referentes a 11,455 mujeres cuyas hijas se habían sometido a la mutilación genital femenina, con el fin de examinar las relaciones entre la posición social de las madres y la medicalización. Se utilizaron modelos de regresión logística para identificar asociaciones entre los indicadores de posición social y la decisión de que un proveedor capacitado realizara el corte genital. Resultados: Las hijas del setenta y nueve por cierto de las mujeres habían sido mutiladas por un profesional de la salud capacitado. Las probabilidades de medicalización fueron mayores entre las mujeres que tenían escolaridad primaria (cociente de probabilidades, 1.2) o una educación secundaria o superior (1.8) que entre las que no tenían ninguna escolaridad; también fue mayor entre las que vivían en hogares con mayores recursos que las que vivían en hogares pobres (1.4­2.6); y quienes compartían la toma de decisiones en la grandes adquisiciones familiares que quienes no tomaban parte de tales decisiones (1.2). Además, el trabajo remunerado y la magnitud de la diferencia de edades entre las mujeres y sus maridos se asoció negativamente con la medicalización (0.99 y 0.9, respectivamente). Conclusiones: La posición social de una mujer en Egipto está asociada con la medicalización de la mutilación genital de su hija. Es necesaria más investigación para explorar el significado social atribuido a la medicalización de la mutilación genital, lo cual puede dar sustento a campañas que podrían disminuir la prevalencia del procedimiento.

RÉSUMÉ Contexte: La médicalisation de l'excision (c'est-à-dire sa pratique par un professionnel de la santé) est en hausse depuis quelques années en Égypte. La relation entre la position sociale d'une femme et la décision de recourir, pour l'excision, à un professionnel de la santé qualifié n'est pas bien comprise. Méthodes: Les données des Enquêtes démographiques et de santé égyptiennes de 2005, 2008 et 2014, concernant 11,455 femmes dont la fille avait subi l'excision, ont permis d'examiner les rapports entre la position sociale de la mère et la médicalisation de la procédure. Des modèles de régression logistique ont servi à identifier les associations entre les mesures de position sociale et la décision de s'adresser pour l'excision à un prestataire qualifié. Résultats: Soixante-dix-neuf pour cent des femmes avaient fait exciser leur fille par un professionnel de la santé qualifié. Les chances de médicalisation étaient supérieures parmi les femmes instruites au niveau primaire (RC, 1,2) ou au niveau secondaire ou supérieur (1,8) par rapport à celles non instruites; parmi celles dont le ménage était mieux loti par rapport à celles vivant dans les ménages les plus pauvres (1,4­2,6); et parmi celles qui participaient à la prise de décision concernant les achats importants du ménage par rapport à celles non incluses dans cette décision (1,2). De plus, l'emploi rémunéré et l'importance de la différence d'âge entre les femmes et leur mari présentaient une association négative avec la médicalisation (0,99 et 0,9, respectivement). Conclusions: La position sociale d'une femme en Égypte est associée à la médicalisation de l'excision de sa fille. Il convient d'examiner plus avant la signification sociale attribuée à l'excision médicalisée, dans le but potentiel d'éclairer les campagnes aptes à réduire la prévalence de la procédure.