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.

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 prevalence and risk of Female Genital Mutilation/Cutting among migrant women and girls in the Netherlands: An extrapolation method.

OBJECTIVES: The aim of the study was (I) to estimate the prevalence of Female Genital Mutilation/Cutting (FGM/C) and distribution of types of FGM/C among migrant girls and women in the Netherlands, and (II) to estimate the number of migrant girls at risk of being cut in the immediate future. METHODS: National population-based survey data regarding FGM/C prevalence were applied to female migrants in the Netherlands who migrated from 29 countries with available nationally representative data on FGM/C. RESULTS: As of January 1st 2018, there were 95,588 female migrants residing in the Netherlands, originating from 29 countries with available nationally representative data on FGM/C. Our findings suggest that about 41,000 women had undergone FGM/C, of which 37% had Type III (infibulation). In total 4,190 girls are estimated to be at risk of FGM/C in the next 20 years, of whom 394 were first-generation girls. CONCLUSION: These findings show the urgency to develop appropriate strategies and policies to prevent FGM/C, to protect girls and women at risk of the practice, and to provide adequate services and support for those affected by FGM/C in the Netherlands.

Transforming social norms to end FGM in the EU: an evaluation of the REPLACE Approach.

BACKGROUND: Despite numerous campaigns and interventions to end female genital mutilation (FGM), the practice persists across the world, including the European Union (EU). Previous interventions have focused mainly on awareness raising and legislation aimed at criminalizing the practice. Limited evidence exists on the effectiveness of interventions due in part to the lack of systematic evaluation of projects. This paper presents an evaluation of the REPLACE Approach, which is a new methodology for tackling FGM based on community-based behaviour change and intervention evaluation. METHODS: We developed, trialed and evaluated the REPLACE Approach through extensive engagement with eight FGM affected African diaspora communities in five EU countries. We employed qualitative and quantitative tools to obtain data to inform the development, implementation and evaluation of the Approach. These included community-based participatory action research, questionnaires and community readiness assessments. The research took place between 2010 and 2016. RESULTS: Findings suggested that the Approach has the capability for building the capacities of FGM affected communities to overturn social norms that perpetuate the practice. We observed that community-based action research is a useful methodology for collecting data in FGM intervention settings as it allows for effective community engagement to identify, educate and motivate influential community members to challenge the practice, as well as obtaining useful information on the beliefs and norms that shape the practice. We also found that community readiness assessments, pre and post intervention, were useful for tailoring interventions appropriately and for evaluating changes in attitudes and behaviour that may have resulted from the interventions. CONCLUSION: This evaluation has demonstrated that the REPLACE Approach has the potential, over time, to bring about changes in norms and attitudes associated with FGM. Its strengths lay in the engagement with influential community members, in building the capacity and motivation of community members to undertake change, in recognising contextual differences in the barriers and enablers of FGM practice and in tailoring interventions to local community readiness to change, and then evaluating interventions to re-inform implementation. The next steps would therefore be to implement the Approach over a longer time frame to assess if it results in measurable change in behaviour.

Poverty, gender and reproductive justice. A qualitative study among adolescent girls in Western Uganda.

Low socio-economic status has been consistently identified as a primary risk factor for sexual and reproductive health violations affecting young women. This study shows how poverty interacts with gender power relations to impact upon adolescent girls' sexual and reproductive lives in Western Uganda. Qualitative research with 147 participants was undertaken. This comprised 59 in-depth interviews and 11 focus group discussions with groups of 12-14 year-old young women, teachers and parents. Data were analysed manually using open and axial coding, and conclusions were generated inductively. Findings reveal that young women are restricted in exercising their sexual and reproductive rights not only by poverty and unequal gender relations, but also by corruption and poor service provision. In contrast to interventions using liberal rights-based approaches, we advocate the use of a 'marketplace of options' since access to sexual and reproductive health services is very limited for poor girls and not evenly distributed. Moreover, while poverty and unequal gender relations render girls vulnerable to sexual coercion and violence, the criminal justice system is often weak, leaving victims powerless. Investment in appropriate resources and inclusive and affordable access to justice is essential to advance young women's sexual and reproductive health.

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.

Evaluation of a school based comprehensive sexuality education program among very young adolescents in rural Uganda.

BACKGROUND: Limited research has been conducted on the effectiveness of sexuality education for very young adolescents (VYAs) ages 10-14 years in Sub-Saharan Africa. Furthermore, evaluations of sexuality education programs often report outcomes of risky sexual practices, yet positive aspects of sexuality are hardly studied and rarely reported. This study evaluates the effectiveness of a Comprehensive Sexuality Education (CSE) intervention for VYAs in Uganda, analyzing both positive and negative outcome indicators. METHODS: We conducted a mixed methods study, incorporating a cluster randomized trial (NCT03669913) among pupils in 33 randomly selected primary schools in Mbarara district. This was followed by a qualitative evaluation of the intervention in 4 schools that included 14 in-depth interviews and 3 focus group discussions distributed among pupils, teachers and parents. Quantitative data were analyzed using ordered logistic regression to compare differences in the change from baseline to endline between the intervention and control arms. We conducted bivariate analysis and multiple regression analysis controlling for key covariates, including age, gender, school location (rural vs urban), truancy, and orphanhood. Qualitative data were analyzed by thematic approach using ATLAS TI. RESULTS: Between July 2016 and August 2017, 1096 pupils were recruited. Outcomes were studied among 380 pupils in the intervention arm and 484 pupils in the control arm. The proportion of pupils who ever had sex increased from 9 to 12.1% in intervention compared to 5.2 to 7.4% in the control group between baseline and endline, however the differences between groups were not statistically significant. We found greater improvements in sexual and reproductive health (SRH) knowledge among intervention schools (AOR: 2.18, 95% CI: 1.66-2.86) and no significant differences in self-esteem, body image or gender equitable norms. Qualitative evidence echoes perceived SRH knowledge acquisition, increased their perception of SRH related risks, and intentions to delay sexual intercourse to prevent unwanted pregnancy, HIV and other STIs. CONCLUSION: This study demonstrates that CSE can improve SRH knowledge and behavioral intentions among VYAs in Uganda. These results further emphasize the importance of initiating sexuality education before most adolescents have started engaging in sexual activity, enabling them to make informed decisions in the future. TRIAL REGISTRATION: NCT03669913 , registered retrospectively on September 13th, 2018.

Process evaluation of a comprehensive sexuality education intervention in primary schools in South Western Uganda.

BACKGROUND: We present findings of a process evaluation of a Comprehensive Sexuality Education (CSE) program for young adolescents in 15 schools in South-Western Uganda. METHODS: Using the Medical Research Council (UK) framework for process evaluation and the European Expert Group guidance on evaluation of sexuality education programs, we conducted a mixed methods study comprised of a review of relevant implementation documents, qualitative interviews(16), and focus group discussions(4) distributed among 50 participants including pupils, teachers, student educators and parents. RESULTS: Delivery of the anticipated 11 CSE lessons occurred in all target schools with moderate to high pupil attendance, however the duration of sessions was often shorter than planned. Facilitating factors for implementation included establishment of a community advisory board, use of multiple interactive delivery methods and high acceptance of the program by key stakeholders. Socio-cultural norms, geographical access, time constraints and school related factors were barriers. CONCLUSIONS: It was feasible to implement a contextually adapted CSE program for young adolescents in schools successfully with overall high acceptance by key stakeholders. Proper coordination of school activities with the program, ensuring linkages of the school based CSE program with community support systems for adolescent SRH and addressing socio-cultural impedances could be beneficial.

The practice of female genital mutilation across the world: Data availability and approaches to measurement.

While Female Genital Mutilation (FGM) has been in existence for centuries, the rigorous and systematic documentation of the extent of the practice is a recent undertaking. This paper discusses data availability related to the practice of FGM and reviews the methods used to generate prevalence estimates. The aim is to illustrate strengths and limitations of the available data. The review is organised around two main categories of countries: FGM countries of origin, where representative prevalence data exist, and countries of migration for women and girls who have undergone FGM, for which representative prevalence data are lacking. This second category also includes countries across the world where FGM is only found among small autochthonous populations.

Sexual health of very young adolescents in South Western Uganda: a cross-sectional assessment of sexual knowledge and behavior.

BACKGROUND: In most Sub-Saharan African countries, little is known about young adolescents' sexual and reproductive health (SRH). Though some efforts have been made to understand and improve SRH of older adolescents, very young adolescents (VYAs) are often overlooked, and little is known about their sexual knowledge and behaviors. The goal of this study was to describe SRH knowledge, information-seeking, and sexual behavior of VYAs in Uganda. METHODS: A cross-sectional survey was administered in 33 primary schools in June and July of 2016. Trained interviewers administered surveys to adolescents ages 10-14 regarding SRH knowledge, information-seeking, sexual behavior, and relevant covariates. Continuous variables were summarized as means (SD) or medians (IQR) whereas categorical variables were summarized as proportions (percentages). RESULTS: A total of 1096 adolescents were included in this analysis, 81.8% of which were from rural areas, with a median age of 12. Regarding sexually transmitted infections (STIs) knowledge; 95% knew HIV while 37% knew other STIs apart from HIV. Although 47% knew at least one way in which HIV is acquired only 8% knew at least four ways. Regarding contraceptive knowledge, 56% mentioned at least one modern method of preventing pregnancy (condoms, pills, intrauterine devices, implants, or injections). The majority (85%) of VYAs reported accessing SRH information in the media with 35% reporting accessing media with sexual content while 10% vs 22% consulted their father or mother respectively and 31% a school source. At least 7.6% of VYAs had ever had sexual intercourse, 90% of which were not using any protection. CONCLUSION: Comprehensive SRH knowledge was low among VYAs in this study. Media remains an important source of information for SRH for this age group though it may be misused as some adolescents reported accessing sexual content that may be inappropriate. A large proportion of sexually active VYAs reported sexual risky behaviors. This study highlights the need for an accurate and more comprehensive SRH education approach for VYAs in Uganda at an opportune age before the majority engage in sexual behavior.

'Doing hymen reconstruction': an analysis of perceptions and experiences of Flemish gynaecologists.

BACKGROUND: Hymen reconstruction (HR) involves the restoration of the hymeneal membrane's gross anatomical integrity. Among the medical profession, hymen reconstruction receives particular attention and its necessity is debated because the surgery is not medically indicated, and often reveals conflicting social norms on virginity and marriageability between health professionals and their patients. The focus of this paper is not to address the many open questions that the ethics and politics around HR reveal, but rather aims at contributing to the much-needed empirical evidence. It presents findings of a study conducted in Belgium (Flanders region), among gynaecologists that aimed at assessing their knowledge, views, and experiences on hymen reconstruction. METHODS: A digital self-administered questionnaire-based survey was sent to Flemish gynaecologists and trainees in Flanders registered with the Flemish Society of Obstetrics and Gynaecology (VVOG). RESULTS: Hundred-and-nine questionnaires were completed. The majority of the respondents (73%) had requests to perform HR. Knowledge and technical skills about HR were considered to be sufficient (69%), even though HR does not seem to be integrated in medical curricula or post-graduate training. Most respondents (72%) would favour the publication of a guideline by their professional organisation. Few respondents discuss alternative options with the patient (19%) and half of the respondents reject to perform HR (49%). The majority of our respondents are against reimbursement of the surgery (70%). Not even half of our respondents believes that a patient is at risk of further violence (47%). 7% of the respondents mentioned complications, but the majority was able to perform a follow up consultation. CONCLUSIONS: The responses of this survey cannot be generalised to the entire population of gynaecologists in Flanders, but do provide insights in how gynaecologists confronted with HR are approaching such requests, and thus contributes to the empirical evidence. Our paper showed that many Flemish gynaecologist are likely to encounter requests for hymenoplasty, but that a majority would not perform the surgery. There seems to be a lack of guidance and debate in Flanders on the social and moral dimensions of HR, and a number of complexities were revealed when gynaecologists address HR that need further research.

Health sector involvement in the management of female genital mutilation/cutting in 30 countries.

BACKGROUND: For the last decades, the international community has emphasised the importance of a multisectoral approach to tackle female genital mutilation (FGM/C). While considerable improvement concerning legislations and community involvement is reported, little is known about the involvement of the health sector. METHOD: A mixed methods approach was employed to map the involvement of the health sector in the management of FGM/C both in countries where FGM/C is a traditional practice (countries of origin), and countries where FGM/C is practiced mainly by migrant populations (countries of migration). Data was collected in 2016 using a pilot-tested questionnaire from 30 countries (11 countries of origin and 19 countries of migration). In 2017, interviews were conducted to check for data accuracy and to request relevant explanations. Qualitative data was used to elucidate the quantitative data. RESULTS: A total of 24 countries had a policy on FGM/C, of which 19 had assigned coordination bodies and 20 had partially or fully implemented the plans. Nevertheless, allocation of funding and incorporation of monitoring and evaluation systems was lacking in 11 and 13 of these countries respectively. The level of the health sectors' involvement varied considerably across and within countries. Systematic training of healthcare providers (HCP) was more prevalent in countries of origin, whereas involvement of HCP in the prevention of FGM/C was more prevalent in countries of migration. Most countries reported to forbid HCP from conducting FGM/C on both minors and adults, but not consistently forbidding re-infibulation. Availability of healthcare services for girls and women with FGM/C related complications also varied between countries dependent on the type of services. Deinfibulation was available in almost all countries, while clitoral reconstruction and psychological and sexual counselling were available predominantly in countries of migration and then in less than half the countries. Finally, systematic recording of FGM/C in medical records was completely lacking in countries of origin and very limited in countries of migration. CONCLUSION: Substantial progress has been made in the involvement of the health sector in both the treatment and prevention of FGM/C. Still, there are several areas in need for improvement, particularly monitoring and evaluation.

Adolescents' Sexual Wellbeing in Southwestern Uganda: A Cross-Sectional Assessment of Body Image, Self-Esteem and Gender Equitable Norms.

Measures of sexual wellbeing and positive aspects of sexuality in the World Health Organization definition for sexual health are rarely studied and remain poorly understood, especially among adolescents in Sub-Saharan Africa. The objective of this study was to assess sexual wellbeing in its broad sense-i.e., body image, self-esteem, and gender equitable norms-and associated factors in young adolescents in Uganda. A cross-sectional survey of adolescents ages 10-14 years in schools was carried out between June and July 2016. Among 1096 adolescents analyzed, the median age was 12 (Inter-Quartile Range (IQR): 11, 13) and 58% were female. Self-esteem and body image scores were high with median 24 (IQR: 22, 26, possible range: 7-28) and median 22 (IQR: 19, 24, possible range: 5-25) respectively. Gender equitable norms mean score was 28.1 (SD 5.2: possible range 11-44). We noted high scores for self-esteem and body image but moderate scores on gender equitable norms. Girls had higher scores compared to boys for all outcomes. A higher age and being sexually active were associated with lower scores on gender equitable norms. Gender equitable norms scores decreased with increasing age of adolescents. Comprehensive and timely sexuality education programs focusing on gender differences and norms are recommended.

Female genital mutilation/cutting in Italy: an enhanced estimation for first generation migrant women based on 2016 survey data.

BACKGROUND: Migration flows of women from Female Genital Mutilation/Cutting practicing countries have generated a need for data on women potentially affected by Female Genital Mutilation/Cutting. This paper presents enhanced estimates for foreign-born women and asylum seekers in Italy in 2016, with the aim of supporting resource planning and policy making, and advancing the methodological debate on estimation methods. METHODS: The estimates build on the most recent methodological development in Female Genital Mutilation/Cutting direct and indirect estimation for Female Genital Mutilation/Cutting non-practicing countries. Direct estimation of prevalence was performed for 9 communities using the results of the survey FGM-Prev, held in Italy in 2016. Prevalence for communities not involved in the FGM-Prev survey was estimated using to the 'extrapolation-of-FGM/C countries prevalence data method' with corrections according to the selection hypothesis. RESULTS: It is estimated that 60 to 80 thousand foreign-born women aged 15 and over with Female Genital Mutilation/Cutting are present in Italy in 2016. We also estimated the presence of around 11 to 13 thousand cut women aged 15 and over among asylum seekers to Italy in 2014-2016. Due to the long established presence of female migrants from some practicing communities Female Genital Mutilation/Cutting is emerging as an issue also among women aged 60 and over from selected communities. Female Genital Mutilation/Cutting is an additional source of concern for slightly more than 60% of women seeking asylum. CONCLUSIONS: Reliable estimates on Female Genital Mutilation/Cutting at country level are important for evidence-based policy making and service planning. This study suggests that indirect estimations cannot fully replace direct estimations, even if corrections for migrant socioeconomic selection can be implemented to reduce the bias.

"Girls Have More Challenges; They Need to Be Locked Up": A Qualitative Study of Gender Norms and the Sexuality of Young Adolescents in Uganda.

Unequal power and gender norms expose adolescent girls to higher risks of HIV, early marriages, pregnancies and coerced sex. In Uganda, almost half of the girls below the age of 18 are already married or pregnant, which poses a danger to the lives of young girls. This study explores the social construction of gender norms from early childhood, and how it influences adolescents' agency. Contrary to the mainstream theory of agency, which focuses on the ability to make informed choices, adolescents' agency appears constrained by context-specific obstacles. This study adopted qualitative research approaches involving 132 participants. Of these, 44 were in-depth interviews and 11 were focus group discussions, parcelled out into separate groups of adolescents (12-14 years), teachers, and parents (n = 88), in Western Uganda. Data were analysed manually using open and axial codes, and conclusions were inductive. Results show that gender norms are established early in life, and have a very substantial impact on the agency of young adolescents. There were stereotypical gender norms depicting boys as sexually active and girls as restrained; girls' movements were restricted; their sexual agency constrained; and prevention of pregnancy was perceived as a girl's responsibility. Programs targeting behavioural change need to begin early in the lives of young children. They should target teachers and parents about the values of gender equality and strengthen the legal system to create an enabling environment to address the health and wellbeing of adolescents.

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.

Changing practices and shifting meanings of female genital cutting among the Maasai of Arusha and Manyara regions of Tanzania.

Using mixed methods that combined participant observation and semi-structured in-depth interviews, this study looked at changing practices and shifting meanings of female genital cutting among the Maasai people in Tanzania. The findings suggest that an increasing social pressure to abandon female genital cutting has inspired the hiding of the practice, causing the actual cutting to become detached from its traditional ceremonial connotations. This detaching of cutting from ceremony has created a shift in meanings: the ceremony still carries the meaning of passage into adulthood, while the cutting seems to function as a way of inscribing Maasai identity into the body. The detaching of genital cutting from ceremony offers those willing to continue the practice the opportunity to do so without being prosecuted, and those unwilling to undergo or perform the practice the opportunity to evade it by faking the cutting without being socially sanctioned for it. Findings also suggest changing attitudes towards the practice among the younger generation as the result of education. Maasai culture and the practice of female genital cutting are not static but actively challenged and reinterpreted from within the community, with formally schooled and women taking up leading roles in reshaping gender norms.

Estimates of first-generation women and girls with female genital mutilation in the European Union, Norway and Switzerland.

BACKGROUND: Female genital mutilation (FGM) is the practice of partial or total removal of female genitalia for non-medical reasons. The procedure has no known health benefits but can cause serious immediate and long-term obstetric, gynaecological and sexual health problems. Health workers in Europe are often unaware of the consequences of FGM and lack the knowledge to treat women adequately. OBJECTIVE: Our goal was to estimate the number of first-generation girls and women in the European Union, Norway and Switzerland who have undergone FGM. Before migration from FGM-practicing countries began, FGM was an unknown phenomenon in Europe. METHODS: Secondary analysis of data from the 2011 EU census and extrapolation from age-specific FGM prevalence rates in the immigrants' home countries to these data were used to provide our estimates. Estimates based on census and other demographic data were compared to our results for Belgium. RESULTS: In 2011 over half a million first-generation women and girls in the EU, Norway and Switzerland had undergone FGM before immigration. One in two was living in the UK or France, one in two was born in East-Africa. CONCLUSIONS: For the first time, scientific evidence gives a reliable estimate of the number of first-generation women and girls in Europe coming from countries where FGM is practiced. The use of census data proves reliable for policy makers to guide their actions, e.g., regarding training needs for health workers who might be confronted with women who have undergone FGM, or the need for reconstructive surgery.

Intimate partner violence in early adolescence: The role of gender, socioeconomic factors and the school.

BACKGROUND: Intimate partner violence (IPV) among adolescents is common worldwide, but our understanding of perpetration, gender differences and the role of social-ecological factors remains limited. OBJECTIVES: To explore the prevalence of physical and sexual IPV perpetration and victimisation by gender, and associated risk and protective factors. METHODS: Young adolescents (N=2 839) from 41 randomly selected public high schools in the Western Cape region of South Africa (SA), participating in the PREPARE study, completed a self-administered questionnaire. RESULTS: The participants' mean age was 13.65 years (standard deviation 1.01), with 19.1% (541/2 839) reporting being victims/survivors of IPV and 13.0% (370/2 839) reporting perpetrating IPV. Girls were less likely to report being a victim/survivor of physical IPV (odds ratio (OR) 0.72; 95% confidence interval (CI) 0.57 - 0.92) and less likely to be a perpetrator of sexual IPV than boys (OR 0.33; 95% CI 0.21 - 0.52). Factors associated with perpetration of physical and sexual IPV were similar and included being a victim/survivor (physical IPV: OR 12.42; 95% CI 8.89 - 17.36, sexual IPV: OR 20.76; 95% CI 11.67 - 36.93), being older (physical IPV: OR 1.26; 95% CI 1.08 - 1.47, sexual IPV: OR 1.36; 95% CI 1.14 - 1.62 ), having lower scores on school connectedness (physical IPV: OR 0.59; 95% CI 0.46 - 0.75, sexual IPV: OR 0.56; 95% CI 0.42 - 0.76) and scoring lower on feelings of school safety (physical IPV: OR 0.66; 95% CI 0.57 - 0.77, sexual IPV: OR 0.50; 95% CI 0.40 - 0.62). CONCLUSIONS: Physical and sexual IPV was commonly reported among young adolescents in SA. Further qualitative exploration of the role of reciprocal violence by gender is needed, and the role of 'school climate'-related factors should be taken into account when developing preventive interventions.

A multidisciplinary approach to clitoral reconstruction after female genital mutilation: the crucial role of counselling.

OBJECTIVES: Female genital mutilation (FGM) is becoming more widely seen in the West, due to immigration and population movement. Health services are being confronted with the need to provide care for women with FGM. One of the more recent trends is the provision of clitoral reconstruction. It remains unclear, however, what constitutes good practice with regard to this type of surgery. METHODS: Based on a keynote presentation about reconstructive clitoral surgery, we briefly discuss the possible consequences of FGM and the findings from recent publications on clitoral reconstruction. Recognising individual differences in women, we suggest a multidisciplinary counselling model to provide appropriate care for women requesting clitoral reconstruction. RESULTS: The literature shows that FGM influences physical, mental and sexual health. Clitoral reconstructive surgery can lead to an increase in sexual satisfaction and orgasm in some, but not all, women. A multidisciplinary approach would enable a more satisfactory and individually tailored approach to care. The multidisciplinary team should consist of a midwife, a gynaecological surgeon, a psychologist-psychotherapist, a sexologist and a social worker. Comprehensive health counselling should be the common thread in this model of care. Our proposed care pathway starts with taking a thorough history, followed by medical, psychological and sexological consultations. CONCLUSIONS: Women with FGM requesting clitoral reconstruction might primarily be looking to improve their sexual life, to recover their identity and to reduce pain. Surgery may not always be the right answer. Thorough counselling that includes medical, psychological and sexual advice is therefore necessary as part of a multidisciplinary approach.