ADOLESCENTS AND FEMALE GENITAL MUTILATION

Transcription

1 Africa Division Regional Division Sahel and Westafrica ADOLESCENTS AND FEMALE GENITAL MUTILATION Adolescence Adolescence defined by WHO as the generation of 10 and 19 year olds, is an important period of both opportunity and vulnerability. During adolescence, the world expands for boys and contracts for girls in the major parts of sub-saharan Africa. Boys gain autonomy, mobility, opportunity and power; girls are systematically deprived of these assets. Girls lives are often governed by harmful, culturally sanctioned gender rules and practices imposed by parents, males, and other elders and perpetuated at times by girls themselves. For biological and social reasons, adolescent girls are vulnerable to more reproductive health problems than boys - considering their risk of Female Genital Mutilation (FGM) related morbidity and mortality - and are more vulnerable to problems that affect both sexes, such as HIV infection and other sexually transmitted diseases. Girls are vulnerable because they often do not know about the risks that will do them irreparable harm like FGM or early pregnancies, the related consequences, or what they can do to protect themselves. While we know little about girls FGM experience, we do know it has a profound impact on the quality of their lives. And, this transition into womanhood signals a girl s entry into a world in which her value is largely determined by her sexual and reproductive functions. Among the critical consequences of FGM may be its direct effects on the said functions, effects on sexuality, on childbearing and delivery or the inability to bear a child as a result of immediate or long-term damage to the reproductive system. What they don t know can hurt them Initiation rites are practised in many traditional societies to conform maturity and entry into the adult community. They comprise traditional education on the role the adolescent girl will be expected to play, including aspects of sexuality and motherhood. FGM often is part of initiation. However, FGM is but part of a full range of concerns, resulting from social pressure deeply rooted in family systems and the social construction of gender, societal and familial forces. Justifications for the practice obfuscate the fact that girls suffer physically and psychologically, that their sexuality is controlled, and that they are denied their rights to, inter alia, health, bodily integrity, and freedom from violence. Adolescence is a critical time in the development of sexual identity and behaviour. Thus, the period of adolescence represents an opportune time to address sexual and reproductive issues. Education has the potential to empower adolescents with the knowledge and skills they need to care for themselves (s. fact sheet Basic Education). Research indicates that support for FGM among adolescent girls decreases with education and urban residence. Girls whose mothers attended school beyond the eighth grade and those who lived in urban areas were less likely to be circumcised. When interviewed, girls have also shown that they are more open to discussion, less committed to traditions and more willing to change and adopt new ways of thinking and acting than adults. Data indicate, that adolescent girls knowledge of reproductive biology and health is critical to their ability to protect themselves from unwanted reproductive outcomes. Therefore, knowledge about how the reproductive system functions, combined with accurate information on circumcision, will enable adolescents to make the linkages between FGM and reproductive health problems. Empowerment Adolescent sexual and reproductive behaviour cannot be modified without understanding the familial and societal forces and gender dynamics that shape this behaviour. Thus, approaches must challenge discriminatory familial and community norms, as well as male attitudes and behaviours that are damaging to girls - like the male attitude about the need to marry circumcised girls/ virgins. This again will allow girls and boys to grasp the dimensions and the impact of FGM as well as the implications for both sexes. Principles for successful empowerment strategies for adolescents include:

2 - Challenging prevalent gender stereotypes, attitudes and gender inequalities in relation to FGM - Life skills training which incorporates sexuality education in and out of school - Training and support for teachers/adults delivering FGM related education - Encouraging open communication among adolescents, and between adolescents and adults The Life Skills Approach The life skills approach promotes in adolescents the competencies necessary to make a healthy transition to adulthood, and adopt positive forms of behaviour that are protective to mental and physical health and wellbeing. It comprises social and interpersonal, cognitive and emotional coping skills. This comprehensive approach expands the adolescents skills in analysis, understanding consequences, decision-making, problem solving and negotiating, and enables them to define their needs and to identify innovative ways to create a safe passage into womanhood. It covers all aspects of becoming and being a sexual, gendered person. And, it includes biological, psychological, social, and cultural perspectives with the goal of making gender-based violence such as FGM unacceptable in the context of promoting protection of girls sexual and reproductive health and rights. Through interactive, participatory teaching methods such as role plays and open discussions. The life skills training can actively engage adolescents in their own development process. Innovative Approaches The Alternative Rites approach, initiation without mutilation, circumcision with words are strategies that have been developed in Kenya, in Uganda or the Gambia where excision is traditionally practiced as part of initiation. In the new rite of passage ceremony, the cutting is replaced by important health, religious, and human rights education, combined with other traditions and information that have been passed down to girls in the rite of passage ceremony for generations. Alternative rituals have been successful when they revitalised positive traditional forms of teaching and harmonising them with modern life skills education. However, they should be elaborated in close collaboration with the communities concerned and should be accompanied by complementary strategic elements. Intergenerational Dialogue Initial evidence from Guinea indicates that communication between generations about FGM is well received. Intergenerational dialogues between adolescent girls and elderly women focus on women-specific values and traditions related to FGM, and the relevance of traditional education in a modern world. In a climate of mutual respect two generations of women create a culture of participation and listening. Together they discover how they can break the silence surrounding the practice of FGM. These dialogues offer a forum for learning, negotiating and mutual support, a process of discovery for everyone. Beyond that, they have the potential to initiate a process of understanding and conscientisation between the generations. Above that they allow to question social norms and values, which determine gender roles and sexual behaviour, and serve to perpetuate traditional practices, like FGM. The Positive Deviants Approach The Positive Deviants Approach pioneered in Egypt, places emphasis on working in local communities to create positive images of uncircumcised girls and women as a strategy for advocating for ending the practice. Women who resist to circumcise their daughters or adolescents who form committees to advocate against the practice, have deviated from the norm and are receiving positive reinforcement for their decision. Giving positive deviants the opportunity to take choices proofs itself to be an empowerment tool. It breaks the taboo and silence surrounding FGM and the fear of speaking out is removed. Thus, the so-called deviants have become powerful advocates within their own communities. Lessons learned from these experiences indicate that empowering adolescents is an essential first step, which can enable them to act as advocates and educators in their own society. FGM, however, is symptom of a larger social problem. Unless the surrounding community or network supports the decision to end FGM, girls continue to be at risk. Published by Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH Supra-regional project Promotion of initiatives to end Female Genital Mutilation (FGM) Dag Hammarskjöld-Weg 1-5 Tel. +49(0) , -1579, Eschborn Fax +49(0) kerstin.lisy@gtz.de Web

3 Africa Division Regional Division Sahel and Westafrica FEMALE GENITAL MUTILATION (FGM) AND THE RISK OF HIV TRANSMISSION Introduction In the context of the HIV/AIDS epidemic, the relationship between FGM and HIV transmission needs to be elucidated in order to determine whether HIV needs to be considered as another factor, that can further infringe on the physical and emotional well being of circumcised girls and women. The hypothesis that FGM increases the risk of HIV transmission stands; although, the evidence of that increased risk is not well documented. Geographically the HIV/AIDS epidemic covers regions where FGM is practiced; however, the countries that practice the most severe forms of FGM, e.g. Sudan and Somalia, have reported comparatively low rates of HIV infection. The highest HIV prevalence rates are reported from states where FGM is not practised. Although the World Health Organisation and the International Federation of Gynaecologists and Obstetricians assume that FGM is a risk factor for HIV infection due to women s biological and socio-economic vulnerability, there is no conclusive evidence on the linkage between FGM and HIV transmission; however, the theoretical assumptions underlying the hypothesis are strong and will be presented in the following paragraphs. Biological Vulnerability Women are more vulnerable to HIV infection than men because of their reproductive organs. The risk of becoming infected with HIV during unprotected vaginal intercourse is 2-4 times higher for women than for men because women have a larger surface area of mucosa (the thin lining of the vagina and the cervix) exposed to their partner s sexual secretions. In addition, men s semen contains a higher concentration of the HIV than women s sexual secretions. This explains why male-to-female HIV transmission is likelier than vice-versa. Girls, whose reproductive organs are still immature, have an even greater risk of acquiring HIV through sexual intercourse, especially if physical coercion is involved. Sex practices like dry sex (through the use of herbal and other drying agents) increase the risk of lesions and therefore the transmission of the virus. This biological vulnerability of women and girls may be increased through FGM for the following four reasons. - First, HIV may be transmitted when groups of girls are circumcised with the same non-sterilised instrument. As HIV can be transmitted via blood contact, the bloodstained cutting instrument used to circumcise one girl after the other can transmit the virus. - Second, the most common complication following FGM is haemorrhage. Thus, there is an increased need for blood transfusions when the girl is circumcised, at childbirth, or as a result of vaginal tearing during defibulation and/or sexual intercourse. The probability of HIV transmission may be increased because safe blood supplies are rare in sub-saharan Africa, especially outside major towns. - Third, coerced sex, which is itself a risk factor for HIV infection, causes trauma, tearing and bleeding, and increases the risk of tissue damage to the vulva and the vagina. The severity of the problem is probably related to the degree of mutilation and scar tissue formation, which depends on the type of circumcision. Types II and III are more likely to create a condition that would increase the likelihood of exposure to HIV. - Fourth, for many of the infibulated women, vaginal intercourse is difficult at best and is associated with repeated tissue damage and bleeding due to vaginal narrowing and occlusion; subsequently, many couples resort to anal intercourse, which, if unprotected, is known to increase the chances of HIV transmission. Social and Economic Vulnerability The social and economic factors, that increase women s and girls vulnerability to HIV, are well known. They include social norms of sexual ignorance and the high social value placed on virginity. Gendered power imbalances make it difficult for women to control their bodies or to negotiate the terms on which to have sex. Early and arranged marriages do not leave a choice for young

4 women over whom to marry. Economic dependence and the fear of violence can effectively force women to consent to unprotected sex. The most pernicious inequality is poverty, which often traps women into their reproductive roles. In numerous studies on HIV, women report that they do not dare to insist on safe sex or object to painful sex for fear of being abandoned by their men and spiralling down into destitution. No wonder that studies show that the lower the women s status, the higher the prevalence of HIV. These social and economic factors regarding gender relations only exaggerate the already biological vulnerability of circumcised women and thus their susceptibility to acquiring HIV. Male Circumcision Although still controversial, there exists a body of research suggesting that male circumcision is associated with a reduced risk of HIV infection in sub-saharan Africa, implying that male circumcision is a preventive measure against sexually transmitted infections like HIV. Compared to male circumcision, data and discussions on FGM in the context of HIV are noticeably absent, despite the fact that FGM involves notable alteration to the genitalia, which goes further than male circumcision. In male circumcision only the foreskin is removed. From a biological viewpoint, the genital mutilations performed on females are the equivalent of the amputation of a part or the entire penis. The only form of FGM, which is anatomically comparable with the circumcision of boys, is that form of circumcision in which the clitoral prepuce is cut away; however, this form is rarely practiced. There is anecdotal evidence that in some population groups male circumcision is perceived as a protection against HIV infection. Male circumcision creates a false sense of security that leads to an increase in risky sexual behaviour. Men may use their circumcision status as a reason for not using condoms, while women may be less inclined to insist on condom use, if their male partners are circumcised, and they share the perception of being protected by the invisible condom (circumcision). Thus, an increase in risky sexual behaviour, including reductions in condom use, will likely continue to put women at risk. Conclusion FGM covers a complex web of biological, social, cultural and gender factors, which may affect women s risk of HIV infection and other STDs. There is little more than anecdotal evidence and theoretical assumptions on the increased vulnerability of HIV transmission through FGM. Equally, little is known about the sexual behaviours of circumcised women to ascertain the increased risk of HIV. However, there is some evidence and there are clear biological and socio-economic aspects that point to a potentially very dangerous synergy between FGM and HIV transmission. Especially gender aspects, such as women s and girls sexual roles and low bargaining powers in matters relating to their body, indicate that circumcised women and girls are highly vulnerable to HIV because the gender aspects that contribute greatly to the spread of HIV/AIDS among women around the world also apply to circumcised women and girls in Africa. Initiatives working to put an end to FGM should take these interrelated elements into account. Candid information about how discriminatory harmful cultural practices enhance the risk of HIV infection for women and girls, combined with clear prevention messages, may be the starting point for a dialogue about social norms and its related consequences. HIV/AIDS as well as FGM interventions can assist to promote a better understanding of sexuality and social relationships and foster attitudes and behaviour, which are less likely to result in disease. Published by Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH Supra-regional project Promotion of initiatives to end Female Genital Mutilation (FGM) Dag Hammarskjöld-Weg 1-5 Tel. +49(0) , -1579, Eschborn Fax +49(0) kerstin.lisy@gtz.de Web

5 Africa Division Regional Division Sahel and Westafrica BASIC EDUCATION AND FEMALE GENITAL MUTILATION (FGM) Basic Education Education and knowledge are the basis of individual and social development. Education not only directly increases people's capabilities and choices but also creates human capital, necessary for sustainable economic growth and poverty reduction. Education should be a lifelong process but it is basic e- ducation that conveys the essential skills of literacy and numeracy, the capacity to learn, to interpret information, and to adapt knowledge. During the last decades, much has been done to increase primary school enrolment, but especially in sub-saharan Africa the situation is still critical: A recent UNESCO report shows that four out of e- very ten primary-age children do not go to school. Out of those who do go to school only a small proportion reach a basic level of skills. The gross enrolment rate (GER) of girls lies 12 % under the GER of boys. Education and FGM In Sub-Saharan societies with traditions of FGM and where almost half of the girls in school-going age are still excluded from primary school education, girls are deprived in a double sense: on the one hand they do not receive basic education skills which could not only help them to increase family income, reduce infant and maternal mortality, increase nutrition, overall health, and life expectancy but which could also create awareness of the risks of the harmful practices of FGM to their health and future life and well being. On the other hand, even girls enrolled in school run the risk of dropping out before having finished their basic education due to the wide spread practice of FGM and its negative impact on the education of girls. Impact of FGM on Education Out of the still insufficient number of children enrolled in Sub-Saharan Africa primary schools significantly less girls than boys finish the primary level. An important factor for girls' early dropping out is seen in FGM. Numerous girls suffer health problems, pain and trauma as a result. This leads to frequent absenteeism, poor attentiveness, low performance and loss of interest. In certain parts of Africa FGM is connected to monthlong anticipation and preparation of the ceremonies and rites, which makes it difficult for the girls to follow the lessons and keep pace. FGM increases the risk of HIV-infection through unhygienic "operations", as well as due to the gendered power relations of which FGM is an expression, which leaves girls vulnerable to the consequences of unsafe sexual relations. In settings where girls are circumcised in school age, like Kenya for example, once circumcised, they are often seen as grown-up and ready for marriage. They have to adapt to new roles and accept changing identities. Their unclear self-perception can lead to various negative effects in school and regarding their education: there are reports of girls behaving in a superior and disrespectful manner to uncircumcised female teachers and classmates, others being subservient to male teachers and peers, exposing them more to abuse. Many other girls lose interest in school since they and their families do not see how school could prepare them for their new roles as young female adults and future wives and mothers. At this stage girls often drop out of school. In other cases, parents are no longer willing or able to pay for their daughter's education in the wake of the expensive circumcision ceremony. But basic education of girls not only suffers from FGM but can itself be used to struggle against this harmful practice. Impact of Education on FGM Education offers knowledge, an increase in self-esteem and strengthens empowerment. In the context of school,

6 co-operation between school and community can provide a forum for discussion, information, and exchange and above all a possibility to speak out in public about FGM, its health hazards and dangers to the life and well-being of girls and women. But even if curricula, educational materials, capable (female) teachers and conducive learning environment are in place, school can only reach a certain percentage of the girls. Almost half of the age group does not attend schools and receives traditional instruction at home. In those cases, education must find alternative ways to address the community and especially the mothers and other females of the community in order to reach the girls. Since FGM not only concerns girls but also their mothers, families and communities, initiatives in education need to be integrated in a broader and even holistic approach. Curricula and Teaching Aids Activities inside the official school system are based on the commitment of the Government and legal positions to fight FGM. The Ministry of Education and its institutions develop and disseminate modules for lessons in school and teacher training, handouts for teachers and trainers. In Guinea, the struggle against FGM is declared policy of the Government: The National Institute for Research and Pedagogical Activities (INRAP) is working on modules to integrate FGM in the curricula of school and teacher training. A GTZ supported Basic Education project combines efforts to improve the quality of basic education, to increase access of girls to school and to reduce FGM by community based approaches. In Burkina Faso, the Directorate for Education of Population (DEMP) in the Ministry of Secondary School Education offers assistance and other services in education, micro-projects, documentation and materials development as well as administration and financing. DEMP is working successfully with the National Committee to Fight FGM on the development of materials for a teaching and sensitisation campaign. PATH, a Kenyan NGO supported by various international organisations, has developed a curriculum on FGM for teachers, youth and adult educators and trainers. Their curriculum that they share with other organisations is designed to assist adolescents in Africa to become more knowledgeable about the impact of FGM on reproductive health; to gain the skills needed to educate their peers, families, and communities; and to contribute to the eradication of this practice. Training of Teachers and Instructors Usually, those institutions or organisations working on curricula and materials also offer services in how to train teachers, instructors or other trainers in youth groups and adult education. Understanding how to address youth and adults, how to communicate with them, how to organise the learning conditions, is crucial to passing on the message and to initiating behavioural changes. Experience has shown that the newly trained educators ought to be continuously supported by external pedagogical personnel. Experienced trainers and educators should be further involved in the conceptualisation of material on FGM-related issues for adolescents, as well as in school-based peer education programmes. Innovative Learning Approaches Many organisations state that peer education leads to an increased level of awareness, and to attitude changes. Peer education can create a more open atmosphere of exchange and solidarity, but there is no proof yet that it really leads to a change in behaviour. The experience of the "Groupe pour l'etude et l'enseignement de la Population" in Senegal with sensitising pupils and educators on FGM in school clubs is proving successful. Integrated approaches offering knowledge on reproductive health, population, prevention of HIV, etc. seem to be more effective than unilateral ones. Traditional and new media offer additional information: theatre plays, radio programmes, videos, soaps, comics, etc. break the silence and provide information. All initiatives to end FGM must have in common that they draw and communicate the positive image of the uncircumcised girl and woman for health reasons and to defend human rights, a matter of concern for all projects Published by Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH Supra-regional project Promotion of initiatives to end Female Genital Mutilation (FGM) Dag Hammarskjöld-Weg 1-5 Tel. +49(0) , -1579, Eschborn Fax +49(0) kerstin.lisy@gtz.de Web

7 Africa Division Regional Division Sahel and Westafrica APPROACHES TO OVERCOME FEMALE GENITAL MUTILATION (FGM): BEHAVIOUR CHANGE After some twenty years of concerted efforts and experiences in the field of FGM, a large amount of information is available and can be evaluated in terms of impact, weaknesses and lessons learned. Many different approaches have been tested and applied over the past years. Those presented here mostly focus on interventions at the community level. The way the approaches have been structured is to some extent artificial, as most programmes have been using a combination of approaches. It serves the purpose though to present an overview. The comprehensive social development approach The FGM issue asks for a comprehensive approach addressing all aspects of development, including gender questions as well as the social, political, legal, health and economic development of a community. FGM is very often practised out of respect for a society s traditions and to preserve conformity. The decision to stop mutilating girls is therefore only partly an individual one, but primarily a question of social change. An individual person or family wanting to stop cutting their girls as long as the rest of the community is determined to go on with the practice will be confronted with sanctions. Parents and their girls may be stigmatised and not find a husband ready to marry them. Change can thus happen more easily where the whole community has taken up the issue and decided on a common basis following a process of conscientisation (this is a reference here to Paolo Freire s philosophy on adult education) to give up the tradition. Change at the level of society can only come about as the result of a process that actively involves the community in consensus-based learning and decision-making. Integrated learning means integrating the issue of FGM into a wider learning package. Enabling social rather than individual change is a very promising strategy. The success of this intervention nevertheless calls for a greater input of human resources. IEC and behaviour change campaigns Most programmes dealing with FGM have an important IEC (Information, Education, Communication) component. Traditional IEC campaigns focus on awareness raising by promoting, informing, motivating and teaching. Unfortunately, many of the strategies and messages used have not been developed on the basis of local research nor have they been properly tested in advance. A certain lack of message diversification in keeping with the various target audiences and a failure to deal with issues like women s sexuality, along with rumours spread on non-excised women are some of the weaknesses that were commonly observed in past campaigns. In looking at past experiences, it becomes rather clear that readymade messages have but a limited impact and, in certain cases, can even be counterproductive. Approaches that look at the context and motives behind the practice in collaboration with the target populations and which also deal with local myths and rumours have proven to be much more effective. When designing IEC programmes, a special focus has to be on youth as a priority target group. Examples of the strategies applied to reach the young include the integration of FGM into school curricula as part of family-life education, the development of out-of-school youth activities, the training of young girls and boys as peer educators and educating youth through radio and television programmes. Well-designed IEC programmes may raise awareness and change attitudes, but they are not usually sufficient to change behaviour. This involves behaviour-change communication and specific behaviour-change interventions, including skill-building (for example, how to resist being

8 pressured into having a daughter excised) as well as building community support to sustain the change. The religious approach The Christian approach definitely has an historic dimension. Different churches, with a bias more towards the Protestants than the Catholics, have taken FGM up in their missionary attempts. One example to be cited in this context are the Kikuyus in Kenya who once had a traditionally high prevalence. They have, however, almost abandoned the practice nowadays mainly due to numerous sermons and interventions by priests at the community level. The Seventh Day Adventist church has worked recently with PATH in Nyamira District in Kenya on the subject of FGM. In areas where the population is predominantly Muslim, religious motifs often present one of the strongest reasons why parents keep up the tradition of cutting their daughters. As Islam does not request FGM, reflected by the fact that some of the most pious countries do not practice it, it is essential to inform and involve Islamic religious leaders in any strategies aiming to change the population s FGM-related behaviour. In many African Muslim countries, religious leaders have engaged in the activities against this traditional and harmful practice. Representatives of religious organisations have a strong network at community level and are often willing to become involved in FGM interventions on a voluntary basis. As key people in the community, their opinion is a form of guidance for community members. Training and reconversion of traditional circumcisers Educating traditional circumcisers often health workers especially traditional birth attendants play a role as traditional or modernised circumcisers about the health risks associated with cutting and/or providing alternative means of income has been tried over the last five to ten years in various places. Most reported experiences have not produced the expected results. Experience shows that while such efforts may at best get a few individual practitioners to stop performing the procedure, they have no effect on demand. As a result, where such strategies are not accompanied by extensive awareness campaigns addressing the community as a whole, families seek other providers. Traditional practitioners return to cutting within a short period of time, as excision is a lucrative business. It has also been noted that focusing on the excisors sometimes actually boosts their importance instead of exposing the profession as one that is harmful and needs to be counteracted. Establishing alternative rituals In a rather new approach, alternative rituals have been developed to substitute for the traditional cutting ceremonies. Initiation rites are practised in many traditional societies all over the world and usually confirm maturity and entry into the adult community. They comprise traditional education on the role the adolescent girl will be expected to play, including aspects of sexuality and motherhood. Girls may be secluded from the rest of the community for days or weeks and receive their education in sacred forests and other specially designated places. Such rites are usually the occasion for joyful festivities lasting for days and involving the community as a whole. It is much more productive to develop new activities to take the place of damaging customs than to prohibit outright what has been done traditionally. The alternative proposed here is to change the contents, stopping the mutilations while preserving the positive idea. In societies where accompanying sexual education and the passing on of traditional secrets of womanhood do not take place anymore, developing alternative rituals may not be a strategic priority. Revitalising positive, traditional forms of teaching and harmonising them with modern family-life education can, however, in all contexts raise the credibility of an anti-fgm programme. Alternative rituals have been successful when elaborated in close collaboration with the communities concerned and where accompanied by complementary strategic elements. Initial evidence indicates that alternative ceremonies are well received and impact positively by reducing the number of cuttings amongst girls initiated during their adolescent years. Still to be assessed are whether this initial effect can be sustained over time and what kinds of rituals work best. Published by Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH Supra-regional project Promotion of initiatives to end Female Genital Mutilation (FGM) Dag Hammarskjöld-Weg 1-5 Tel. +49(0) , -1579, Eschborn Fax +49(0) kerstin.lisy@gtz.de Web

9 Africa Division Regional Division Sahel and Westafrica APPROACHES TO OVERCOME FGM: HEALTH AND HUMAN RIGHTS After some twenty years of concerted efforts and experiences in the field of female genital mutilation (FGM), a large amount of information is available and can be evaluated in terms of impact, weaknesses and lessons learned. Many different approaches have been tested and applied over the past years. Those presented here mostly focus on interventions at the community level. The way the approaches have been structured is to some extent artificial, as most programmes have been using a combination of approaches. It serves the purpose though to present an overview. The human rights approach At international level, the discussion surrounding female genital mutilation is closely linked to the issue of human rights. In the United States and the European Union, discussions are underway as to whether women who flee Africa to escape both FGM and physical abuse may be eligible for asylum. The 1994 International Conference on Population and Development (ICPD) has done a great deal to make reproductive and sexual rights an issue on the international health agenda. FGM is today seen internationally as a violation of women s rights. Most programmes link sensitisation to FGM with the issue of human rights, and refer to international conventions as lobbying and advocacy tools. Non-governmental organisations include teaching on human rights, especially women s and children s rights, as an important topic in learning programmes. Raising women s awareness about their rights has been shown to have an empowering effect on them. It is a known fact that introducing the question of human rights in women s classes did not meet with any substantial opposition from the rest of the community, as the issue was only part of a larger package of information on health, hygiene and other topics dealt with in a sensitive and culturally adapted way. As much as human rights arguments may have their place in a larger pool of arguments against FGM, when used as a central and isolated focus of discussions, such efforts usually show little effect. Arguments that seem relevant from a European angle, may present a concept far too abstract for many of the people involved, if not translated to fit their realities. The legal approach Besides African countries, which have passed laws declaring FGM illegal, countries of the industrialised world have also legally banned the practice. In most European countries, FGM is a criminal offence subject to penalty in accordance with the respective stipulations regarding physical injury or child abuse. Passing anti-fgm legislation is one of the most controversial aspects of FGM elimination movements. One of its important advantages is that anti-fgm legislation provides an official legal platform for project activities, offering legal protection for women, and ultimately discouraging excisors and families fearing prosecution. It can also help health professionals justify their engagement in the anti-fgm struggle and give them an official reason for rejecting medicalisation of the practice or for refusing to comply with demands for restoring after delivery. On the other hand, laws cannot change traditions. Fears that criminal laws might push FGM into hiding, leading to it being practised secretly with complications going unnotified for fear of persecution, are justified by experience in many countries. Passing laws against a traditional practice in which many people believe is hugely controversial. In most African countries, enforcement of anti-fgm laws is poor. Finding the right balance between law enforcement, public education and dialogue is difficult and the risk of alienating communities by turning to the law to protect girls and women is a real one.

10 The health approach Having authoritative individuals (doctors, nurses and midwives, educators and other professionals) warn about the health risks associated with various forms of female genital cutting has been tried for the past 15 to 20 years. The main message of these campaigns was that FGM is dangerous and has to be stopped as soon as possible. It was thought that a health perspective could provide an easy entry point to address an issue as sensitive as FGM. In some countries (Egypt, Somalia) the focus of the approach was on presenting the subject of infibulation primarily as a health issue in a bid to remove the discussion from its religious and cultural connotations. The use of a simplistic health approach that focuses on complications alone has led to a number of problems. One of them is the increasing medicalisation of FGM (with the operation being performed by health professionals in health structures). Connected with this fact it is known that excision has become a source of income for health-care providers and hospital cleaners. The argument that a mild form performed by medically trained personnel would be a safer option is commonly heard in countries where FGM is widely practised. In countries where FGM is practised by a well-educated community and by people who have enough money at hand to pay a hospital visit, medicalisation has evolved to a high extent, for example in the Kisii community in Kenya with prevalence rates higher than 90%. GTZ subscribes to the WHO stance that medicalisation should never be considered as an option. Every campaign against FGM should include elements allowing basic understanding of the female genital anatomy and the changes brought about by the various forms of female genital cutting. This can then lead to discussions about the medical complications in the short, medium and long term. But confrontation with the medical and physical consequences of FGM should only be part of a more comprehensive IEC (Information, Education, Communication) strategy (see IEC and behaviour change-campaigns) that also deals with psychological and sexual disturbances and that takes a closer look at social, economic, cultural and historical aspects. Training health workers as change agents Health workers are confronted with the issue of FGM in various ways. - They may face a dilemma defending their professional duties while being part of a traditionalist society. - They play an important role in medicalisation (see health approach) and may be asked to re-infibulate women after delivery. - They have to deal with the complications of FGM, mostly at the time following the cutting procedure as well as during delivery. - High levels of complications are likely in any country practising FGM, especially those where the most severe forms are common. In the past, there was limited training on the clinical management of FGM complications. Health-care providers therefore often do not have the skills to treat and counsel women having undergone FGM. - Health professionals play an important role in counselling women and couples. - Health workers are well placed to counsel women suffering from psychological or sexual problems related to FGM. They should advise women and their husbands against re-infibulation after delivery and recommend that families do not seek FGM for their daughters. - Health professionals are opinion leaders. - As with other health-risk behaviours, health workers play an important role in any IEC and behaviour change campaign addressing the issue of FGM in communities. However, communication skills inadequate to the task of behaviour change, as well as a chronic work overload mean that health professionals, such as doctors and nurses, do not spend much time on health education at the community level. Despite these facts they can play an essential role in organising training and supervising health education activities for community health workers and everybody else involved in bringing anti-fgm messages to people living in remote areas and changing attitudes through repeated interpersonal contacts. In order to fulfil their role properly, health workers on all levels of the pyramid, including paramedical workers and volunteers, need appropriate training adapted to their s Published by Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH Supra-regional project Promotion of initiatives to end Female Genital Mutilation (FGM) Dag Hammarskjöld-Weg 1-5 Tel. +49(0) , -1579, Eschborn Fax +49(0) kerstin.lisy@gtz.de Web

11 Africa Division Regional Division Sahel and Westafrica FEMALE GENITAL MUTILATION AS HUMAN RIGHTS VIOLATION Introduction Female Genital Mutilation (FGM) tends to be justified among others by the following reasons: The apparent need to control women s sexuality and identity, an alleged hygienic or medical advantage of genital cutting, the belief that female circumcision constitutes a religious obligation, and/or the desire to adhere to customary traditions. However, in our view the more compelling arguments defy the practice, such as irrefutable evidence of its health hazards and its offence of human rights. Many African intellectuals and activists have been fighting the practice since the 1970s; today they constitute an integral part of, and are legitimised by the global discourse on women s human rights. Failing to frame the opposition to FGM as a human rights issue, the international community would risk becoming complicit in inflicting gender-based inequality, severe pain and permanent damage on women. Hence, we believe that it is just to interfere in the practice of FGM among others with reference to the human rights framework. Given that culture is a dynamic set of practices Article 5 of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) requires States Parties to modify the social and cultural patterns of conduct of men and women, with a view to achieving the elimination of [...] customary and all other practices which are based on the idea of the inferiority or superiority of either of the sexes or on stereotyped roles for men and women. The Human Rights Framework The human rights framework represents a powerful tool for affecting political processes at international and national levels. It rests on international agreements (mostly binding conventions) between nations on the protection of the fundamental rights of the human being. It obliges governments and the international community to assume their share of responsibility for the protection of the health and rights of women and girls. Based on these agreements, FGM offends various civil, political, social and cultural human rights, most importantly, the rights to security and personal liberty, to life and bodily integrity, and to health and reproductive health. Various documents prescribe that those cultural practices that violate women s rights be eradicated. However, to achieve this, it is vital to understand and respect the deeply felt beliefs of the people who practice FGM, and to retain positive aspects of such cultural practices. While all countries in the world are signatory to one or the other of the general and specific international conventions applicable to FGM in order to be effective these must also be incorporated into domestic law through national legislation and judicial application, as has been the case in some countries. In addition, effective enforcement mechanisms must be put into place, such as legal personnel trained and sensitised. Further, international and national legislation must be translated into customary law, and implemented at grassroots level. Finally, the human rights framework has to be accompanied by programmes that address the cultural environment to counter the various justifications of FGM and by comprehensive and intensive programmes of formal and non-formal education, awareness raising, and training to empower women. Then, it can serve as a moral backing for national as well as local action to end FGM. Limitations of the Human Rights Approach Though the human rights approach is a powerful moral and legal tool, it also has its limitations in addressing the practice of FGM: Above all, most people in developing countries are unaware of the human rights of women and girls. Anyway, they tend to perpetuate FGM in the assumed best interest of the child, the highest principle of the Convention on the Rights of the Child a fact that renders liability ambiguous. Moreover, people often feel modern laws to be remote from their every day life experiences, and hence do not have a moral or legal impetus to comply with them. Other limitations include that many people do not have the resources to file an official complaint, lack access and proximity to legal infrastructure, and require socio-psychological mechanisms of support in case of ostracism. Furthermore, the human rights

12 approach alone leaves the underlying structures of domination within society untouched. Hence, parallel programmes; structures of support, and alternative choices must be put in place. We support the translation of human rights into laws that prohibit FGM, and thereby function as a positive normative framework to fighting FGM. In contrast, in our view, legal measures that criminalise the practice are problematic: Firstly, criminal sanctions for those who inflict FGM may have adverse effects on the girls affected, for instance if their parents remain absent due to long prison terms. Secondly, taking legal action against one s own relatives or community members may cause grave social and economic repercussions for the person filing a complaint. Most crucially, criminalisation tends to push the practice underground, thereby preventing women with FGM-related health problems to seek professional medical help, and impeding education and awareness raising campaigns. Thus, laws must be introduced sensitively and timely. International and Regional Instruments There are three main international human rights protections, which the practice of FGM typically seems to transgress: firstly the right to corporal and sexual integrity; secondly the right to the highest attainable standard of physical and mental health; and thirdly the condemnation of discrimination against women. In this regard, numerous international instruments are applicable to FGM: from the Universal Declaration of Human Rights (UDHR) in 1948 to the Fourth World Conference on Women Declaration and Programme of Action in UDHR Articles applicable to FGM: 3: Everyone has the right to life, liberty and security of person. 5: No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment. 25: Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family. The 1981 African Charter on Human and Peoples Rights (the Banjul Charter), which is ratified by most countries in the region, provides some protection against FGM, but makes no explicit mention of it. In order to strengthen the fairly weak formulation of women s rights in this document, the Maputo Protocol, an official Protocol on the Rights of Women in Africa was adopted in July Article 5 of the Protocol recognises harmful practices such as FGM as a violation of human rights and outlines the state s duties to support and protect women through legislation, public awareness programmes, and the provision of basic support services. The African Charter on the Rights and Welfare of the Child has also been ratified by most African countries, though neither by Ethiopia nor Kenya. Like the CRC, it explicitly attempts to protect children from traditional practices prejudicial to their health. Reference to regional documents is an underestimated yet useful tool in the protection from FGM, because they are more culturally sensitive, and potentially more accepted and owned by the people than international documents, often rejected as Western imposition. African Charter on the Rights and Welfare of the Child: States Parties [...] shall take all appropriate measures to eliminate harmful social and cultural practices affecting the welfare, dignity, normal growth and development of the child and in particular (a) those customs and practices prejudicial to the health or life of the child; and (b) those customs and practices discriminatory to the child on the grounds of sex or other status. National Instruments All the countries affected by the practice of FGM are signatory to some or all the international and regional human rights conventions applicable to FGM. In addition, their national laws incorporate and develop human rights principles. Governments are required to ensure that rights are equally enjoyed in their jurisdictions, and may thus be held responsible for failing to take steps to prevent or redress FGM. No country has enacted a constitutional provision explicitly addressing FGM, whereas a number of countries (15 African and 10 elsewhere) have passed laws criminalising FGM. Although the number of prosecutions drawing on these legislative provisions is low, prosecutions and arrests relating to FGM have been reported in several countries African countries such as Burkina Faso, Egypt and Sierra Leone. Published by Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH Supra-regional project Promotion of initiatives to end Female Genital Mutilation (FGM) Dag Hammarskjöld-Weg 1-5 Tel. +49(0) , -1579, Eschborn Fax +49(0) kerstin.lisy@gtz.de Web