Violence against women: Female genital cutting, a practice impossible to abandon?

Violence against women: Female genital cutting, a practice impossible to abandon? Natascha Wagner September 2011 Abstract Female Genital Cutting (FGC) remains a pervasive practice in many sub-saharan African countries. Using cross-sectional data from 13 African countries, the determinants of FGC as well as the social outcomes associated with this practice in terms of marriageability and health risks are studied. The novelty of this approach lies in grouping DHS surveys and thus taking a community-based sample, which yields results that are representative of the population at large. In a game-theoretic approach, I develop possible channels for FGC to work, namely by increasing reputation and strengthening identity while causing health problems. Employing conditional logistic regressions, I demonstrate that by far the main determinant of FGC is ethnic identity. Reputation and peer pressure as measured by ethnic density are not decisive factors, whereas adherence to Islam fosters the continuation of FGC. In addition, being cut increases marriage prospects by almost 50 %. Negative health consequences are often used as an argument against FGC. However, I do not find a general impairment or decreased fertility. Yet, cut women are more likely to have sexually transmitted diseases, vaginal discharge and/or genital ulcers/sores. Although cut women have up to 25 % increased odds of having an STD, the health impairments related to FGC seem too moderate to serve as single case for the abolition of a practice that defines ethnic identity to a considerable degree. The more recently advocated human rights based campaigning against FGC that includes aspects of ethnic identity seems a promising complement to the traditional health-related campaigning. Keywords: Female Genital Cutting (FGC), Ethnic Identity, Custom, Peer-Pressure. JEL: D70, I15, O12, Z13 International Economics Section. The Graduate Institute of International and Development Studies, Avenue de la Paix 11A, 1202 Genève, Switzerland. E-mail: natascha.wagner@graduateinstitute.ch, Tel.: + 41 22 908 59 30. 1

1 Introduction When talking about violence against women we almost always think about domestic violence in the context of husbands beating up their wives. However, domestic violence does not necessarily have to emanate from the husband. In most countries of sub-saharan Africa polygamy is an accepted form of marriage and domestic violence among co-wives can be a way of keeping junior wives subservient. Moreover, conflicts between in-laws who have to live together under the same roof can lead to further incidences of domestic violence. What I am concerned with here is yet another form of domestic violence: it s violence against the physical integrity of women because part of their genitalia are removed. While female genital cutting (FGC) is not a classical topic in development economics it is prone to be studied by economists for three reasons: First its study contributes to Sen s capabilities approach. Second the decision to have daughters cut relates to questions of household utility maximization and organization and third it allows to study the impact of social pressure and identity on decision making. Under the capabilities approach Sen offers a new gate to welfare economics that understands that both materialistic and non-materialistic elements are to be accounted for in the individual utility function (1992, 1993 and 1999). He defines capability as a person s ability to do valuable acts or reach valuable states of being (Sen, 1993). Hereby, the term valuable has an individualistic notion that is not necessarily resource-based. Nussbaum (1999) further links the capabilities approach to gender (in)equality. She emphasizes the need to guarantee that individuals can exercise what she calls central human functional capabilities. These central capabilities included the bodily health and integrity of women, especially in developing countries (Nussbaum 2000a, 2000b). Nussbaum (2005) explicates that the classical thinking about economics as fostering GDP growth does not do justice to the central human functional capabilities. Household economics and intra-household bargaining power are prevalent topics in development economics. In recent years the unitary household model was challenged as it assumes cooperative family units. Thereby it fails to accommodate the underprivileged position of wives in most developing countries and is incompatible with incidences of domestic violence (Rao, 1997; Morrison and Loreto Biehl, 1999; Koenig et al., 2003 and Srinivasan and Bedi, 2007). Consequently, the literature about female bargaining power and how the wives positions within the household influence household outcomes is steadily increasing. Using the natural experiment of the expansion of the South African pension system Duflo (2000) showed that the gender of the pension recipient is decisive for the money use. Beegle et al. (2001) study the importance of bargaining power for the use of prenatal and delivery care in Indonesia. Using Nepalese data Ray and Basu (2001) demonstrate that balanced gender relations in marriage reduce the likelihood of the children being engaged in child labour. While much has been written about household 2

organization and the negative externalities of imbalanced gender relations, female genital cutting (FGC) is hardly ever touched upon in the development economics literature. Notable exceptions are Mackie (1996), Chesnokova and Vaithianathan (2010) and Coyne and Mathers (2010) who take all a game theoretic approach. Last but not least the practice of FGC also relates to the emerging network literature (Watts, 2001; Jackson and Watts, 2002; Jackson, 2005 and Page and Wooders, 2009). If FGC can only be abandoned in a joint effort as it is often argued (WHO et al., 2008) concerns about network dynamics, peer-pressure (Kandel and Lazear, 1992) and reputation (Akerlof, 1980 and Cabral, 2005) also have to be tackled. Moreover, FGC also has the potential to serve as an identity marker that defines affinity and belonging (Akerlof and Kranton, 2000 and Coyne and Mathers, 2010). To the best of my knowledge this is the first large scale quantitative analysis of FGC that aims at testing whether (i) peer pressure and the reputation mechanism or (ii) identity gains or (iii) the lack of substantial health impairments are the driving forces for the continuance of this practice. I find that in the communities that practice of FGC it serves as identity marker as suggested by the theory of identity economics. However, peerpressure in the form of religious and/or ethnic density has no impact on FGC. Marriage prospects, in turn, are improved for cut women. the odds for cut women are almost 50 % higher indicating that the reputation mechanism is at work in the marriage market. In contrast, general health effects and increased chances of being infertile could not be found for cut women. There is some moderate indication that FGC increases the odds of having STDs, vaginal discharge and genital ulcers/sores by at least 15 %. The reminder of the paper is organized as follows. In section 2 the widely accepted understanding of FCG is recapitulated and the prevalence and the broad cultural context of FGC are discussed. Section 3 briefly describes the state of the health-related research about FGM and motivates why a new study of FGC is of use. A game-theoretic model of strategic decision-making when reputation and identity are valued is layed out in section 4. The dataset which stems from consolidated Demographic and Health Surveys (DHS) of 13 African countries is presented in section 5. Section 6 presents the empirical specification that compares cut to uncut women using a conditional logit model. The results are discussed in section 7 and section 8 concludes with a discussion of the findings and potential paths for intervention mechanisms. 2 Definition, Prevalence, Context 2.1 Definition Whether it is called female circumcision, female genital mutilation or female genital cutting, all terms refer to the medically unnecessary and painful practice of deliberately 3

damaging the female genitalia. While each culture and local context brings about its own way to talk over the mutilation of female genitalia for non-medical purposes, the academic community and the international agencies increasingly use the term female genital cutting (Yoder et al., 2004). The term female genital cutting, henceforth FGC, is considered value-neutral and will be used throughout this study. The accredited definition of FGC is given by the World Health Organization (WHO) that states FGC comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons. (WHO, 2010). More specifically four different types of FGC are specified by the WHO according to the severity of the surgical procedure: Clitoridectomy describes the partial or total removal of the clitoris and/or the prepuce. Excision refers to the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Infibulation is the most severe form of FGC where the vaginal opening is narrowed through the creation of a covering seal. All other harmful procedures to the female genitalia for non-therapeutic reasons are subsumed in a last general class. 1 Although the concrete occurrence of FGC varies from community to community (UNICEF, 2005), these classifications are accepted by the international agencies (WHO et al., 2008) and subsume the major tendencies in the practice of FGC. According to Yoder and Khan (2007) more than 8 million women between 15 and 49 years are infibulated which amounts to 10 % of the women who are circumcised. The majority of cut women, however, undergoes clitoridectomy or excision. 2.2 Prevalence The WHO (2011) lists 28 countries in which FGM is prevalent. 2 Prevalence of FGC is highest in Africa stretching from Mauritania in North-West Africa to Ghana and Cameroon, extending across the Central African Republic and finally reaching the East- African coast. According to WHO statistics Uganda has with 0.8 % the lowest prevalence rate among women and girls between 15 and 49, Somalia has the highest, namely 97.9 %. 12 of the 28 countries have prevalence rate over 50 % of which 5 countries have an FGC 1 For more detailed information see the WHO Fact sheet N 241, February 2010. 2 List of countries in which FGM is practiced: Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Côte d Ivoire, Djibouti, Egypt, Eritrea, Ethiopia, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, Somalia, Sudan (northern), Togo, Uganda, United Republic of Tanzania, Yemen 4

prevalence of at least 90 % among adult women. The data is derived from two sources, the Demographic and Health Survey (DHS) and the Multiple Cluster Indicator Surveys (MICS). The caveat of this information is that for some countries such as Sudan the data are more than 10 years old. For the majority of countries, however, the latest information is from the year 2006 and an end of the harmful and deliberately destructive practice is not in sight as long as countries such as Burkina Faso have prevalence rates as high as 72.5 %. In totals these prevalence rates amount to between 100 and 140 million girls and women worldwide who have been subjected to FGM. Alone in Africa an estimated 92 million girls aged 10 and above have been circumcised (WHO, 2010). The WHO further estimates that each year 3 million girls are at risk of being circumcised. National prevalence rates about FGC may be little informative about who has actually undergone FGC and who is in danger of being cut. Yoder et al. (2004) disaggregate country-level data and show that FGC varies by age, region, ethnicity, and religion. Descriptive statistics present evidence that, unsurprisingly, older women are more likely to be circumcised. However, there is no clear trend that FGC dies out. In 8 out of 12 surveys carried out in Northeastern and Northwestern Africa at least 70 % of the circumcised women support the practice. Moreover, mothers who are circumcised themselves are very likely to have their daughters undergo the same ritual. In 5 of 7 DHS surveys which Yoder et al. (2004) present at least 50 % of the eldest daughters are circumcised. Religion is often used as an ad-hoc explanation for the occurrence of FGC. Yet, it is not a stable predictor of FGC. Particular religious groups in one region seem to support the practice while the same religious groups in another area oppose it, though Muslims seem to practice FGC more widely than Christians (Johnson, 2000 and Yoder et al., 2004). The most important determinants of FGM, however, are regional differences and ethnic identities (Carr, 1997; Gruenbaum, 2001 and UNICEF, 2005). 2.3 Context As has been shown, that FGC is not a marginal phenomenon in terms of total numbers. The same holds for the cultural and cultic relevance of FGC, it is by no means a marginal event. Often the cutting is an initiation and/or coming-of-age ceremony or gender-identity ceremony which young girls undergo sometime between infancy and the age of 15 (Hernlund, 2003; Gruenbaum, 2001 and Johnson, 2007). For example in the Mandinga communities of Guinea-Bissau only a cut woman is considered a pure woman (Johnson, 2000). Therefore, in most cases mothers arrange the cutting ceremony of their daughters because it is considered a sign of good parenting. Together with good education and the choice of an adequate husband, FGM is one of the three important ingredients of raising a daughter in Central Guinea (Yoder et al., 1999). In most communities the cutting is carried out by traditional circumcisers (WHO, 5

2010). In recent years, however, the medicalization of FGC is observed which means that more and more trained doctors and nurses carry out the cutting (Shell-Duncan, 2001 and Njue and Askew, 2004). Traditional circumcisers and health providers continue cutting girls because they believe that it is an integral part of their culture. Althaus (1997) argues that in communities that practice FGC cultural and ethnic identity heavily rest upon this tradition. If daughters refuse to undergo FGC they are not only stigmatized but also ostracized by their peers (Thomas, 2000; Leonard, 2000; Hernlund, 2000 and Ahmadu, 2000). Consequently, young girls long to be cut because they know about the rewards from society and in many cultures they can also expect a ceremony and presents (UNICEF, 2005). Moreover, being cut is also the path to marriage and linked to marriage is the continuation of the family and honor within the local community. Mackie (1996) draws the link between FGC and the traditional footbinding in China. Both social customs have developed as elitist practices that finally became universal sings of marriageability in the practising communities. Furthermore, the roots of FGC are linked to gender imbalances and male power over females. Posner (1994) for instance argues that FCG is a cost-reducting mechanism that ensures virginity of unmarried girls and fidelity of wives. The underlying rational is that women with partly removed sexual organs have a reduced desire for sexual adventures and adultery. 3 FGC What do we really know? Traditionally it is the anthropological literature that is concerned with the social and cultural aspects of FGC and analyzes its continuance. Comprehensive reviews are found in the two collections of articles by Shell-Duncan and Hernlund (2000 and 2007). Anthropological research is complemented by medical research about the health consequences of FGC. However, the findings from medical research are inconclusive and/or the studies suffer from major flaws. For instance, the long-term reproductive health consequences of FGC in the Gambia are studied by Morison et al. (2001). They use a community-based survey of women of reproductive age and find that cut women are at a significantly higher risk to have bacterial vaginosis (small coefficient) and are considerable more prone to herpes simplex. However, this study cannot control for ethnicity independently of the FGC status and results may be driven by this confounding effect. Therefore and due to the lack of finding other impairments through FGC, the authors conclude that a clear detrimental effect of FGC on long-term reproductive health cannot be established. If there are no apparent long-term consequences of FGC, there might yet be FGCinduced problems upon first delivery. Slanger et al. (2002) carry out a hospital-based 6

study in Nigeria that shows no significant differences in first-delivery for cut versus un-cut women. In fact the differences that result from univariate anaylses are driven by omitted variable bias. Finally, circumcised women could be at risk to develop severe medical conditions such as obstetric fistulae. Yet again, in a study of 492 Ethiopian obstetric fistulae patients, women who had undergone FGC were not more likely to develop these complications from obstructed labor (Browning et al., 2010). Sexual pleasure of circumcised women is analyzed in a cross-sectional study of 1,836 women who attended one of three hospitals in Nigeria (Okonofu et al., 2002). The analysis rests on a comparison between circumcised and un-circumcised women and finds that sexual activity of cut women starts earlier and that they sense sexual orgasms as well. In addition, the results show that cut women have significantly more children. Thus, this study casts doubt on the argument that circumcised women are less sexually active and therefore more faithful. The drawback of the study is that it is hospital-based and not necessarily representative of the population at large. In a systematical review of FGC-related research between 1997 and 2005 Obermeyer (2005) criticizes that there is no comprehensive, large scale community-based study. She supports the general notion that evidence about the health consequences of FGC is inconclusive and many studies are methodologically weak. She argues that medical complications associated with FGC are in fact rare events and therefore difficult to detect in small samples. In addition, hospital-based sampling may introduce sampling bias. My study aims at directly addressing Obermeyer s critique. It s a community-based analysis that makes use of a large sample by pooling the latest Demographic and Health Surveys for 13 African countries. Thus, the precision of the estimated coefficients is high. By the means of the large sample I also introduce considerable variation in the FGC status and I avoid the risk of confounding ethnicity with the FGC status. 4 A Game-Theoretic Approach to FGM Existing rational choice models about FGC are built on the agency cost explanation. Posner (1994) argues that fathers and husbands incur lower supervision costs of their circumcised daughters and wives under the assumption that cut women have a reduced libido. Mackie (1996) views FGC as means to ensure paternal certainty and Chesnokova and Vaithianathan (2010) consider FGC as pre-marital investment that increases and improves marriage opportunities. The theoretical considerations that motivate this research draw from two seminal contributions by Akerlof. In his 1980 paper Akerlof forcefully demonstrates that the subscription to a social custom and the reputation derived from its obedience can result in a persistence of the norm despite its disadvantage for the individual. In the context of FGC, the cutting is considered the harmful social custom because the damaging of healthy 7

female genitalia has no health benefits rather it interferes with the natural functioning of the female body. Yet, the injurious practice persists due to peer-pressure and the gain in reputation derived from it. In light of the latest research endeavors in the area of identity economics, peer-pressure taken by itself seems an insufficient explanation for the continuation of FGC. Therefore, I also consider identity as part of the utility function as introduced by Akerlof and Kranton (2000). Coyne and Mathers (2010) have already interpreted the standard identity model in the context of FGC. I will extend their model by allowing for two forms of FGC: (i) the prevalent forms that involve partial or total removal of the clitoris (and the labia minora) and (ii) the severe and less frequently practiced form of infibulation. 4.1 Basic Setup of the Utility Function I consider the realization of FGC not an individual decision but rather a household decision. Given that girls undergo the procedure at very young an age it is more likely that the parents take the decision to circumcise the daughters than the daughters themselves. Therefore, I assume that a household either has all girls cut or no girl cut and write a household utility that includes four components: the utility derived from the consumption of a composite good C, health H, reputation within the community R and identity I. U = U i (C, H, R, I) = (1) = U i (C, H(a i, C ik ), R(a i, C ik, a i, C ik ), I(a i, C ik, a i, C ik, S i, P, ε i )) Each household i does not only receive utility from resource-based input factors but also from the health of its members, reputation within the community and identity. The composite health of household i depends on its action with respect to circumcision a i. This action is coded as a binary variable and takes on the value of 1 for households that have all the daughters circumcised. The utility derived from health will be modeled as loss that is experienced by those households that adhere to FGC. Households not engaging in FGC have a zero disutiliy. The amount of the disutility derived from subscribing to the FGC practice depends on the severity and type of the FGC procedure C k. The household has the possibility to carry out a moderate version of FGC, which will be denoted by C 1 or a more severe version C 2. The reputation a household gains from FGC depends on its own action a i and the type of circumcision C k and the actions of all the other households a i in the compound including their FGC type C ik. I assume that a fraction p of the households who engage in FGC opt for the severe version, the remaining 1 p households choose the moderate version. The reputation mechanism can also be interpreted as peer-pressure mechanism. 8

Household i can only increase its reputation if its action corresponds to the common practice in the community, else the household does not gain any reputation because the peers disregard the decision. Identity is based on the own action and the type of FGC carried out and on the actions and types of FGC of the other households in the community. Moreover, household i acts within a social category and also puts the other households in the community in social categories. This assignment is denoted by S i. Additionally, the appropriateness of the behavior of the different households within their categories is given by P. Finally, identity also depends on taste ε i and to what extend an household i s taste matches the social category household i is assigned to by the prescription P (Akerlof and Kranton, 2000). 4.2 Peer-pressure and reputation as causes for FGC? In a first step I will only focus on the reputation mechanism and leave identity out of the analysis. In the prototype model I consider a total population of N households of which N 1 households have already taken their decision with respect to their engagement in FGC and the remaining household A decides given the actions of all the other households. Figure 1 presents the game tree for household A with three possible options. Household A can engage in the moderate version of FGC and incur a health loss of H 0 and gain reputation R P j a j N 0, where the reputation depends on the constant R and the fraction of households in the community that adhere to FGC. If household A chooses the more severe from of FGC, C 2, it can expect a health loss of H H H 0 and a P j reputation gain of R a P j + Rp j a P j R j a j + 0. Thus C N N N 2 circumcision bears the risk of an additional health damage of H. However, it also comes along with an additional gain in reputation of Rp P j a j N. The extra reputation results from the added reputation shifter R and depends on the fraction of households in the community of FGC adherents that subscribe to the serve form of FGC. Finally, household A has the possibility to evade the practice of FGC which results in no health impairments but also no utility improvements from reputation gains within the community. Thus, as long as the losses to health are bigger than the reputation gains, no household engages in FGC. If, however the reverse is true, all households engage in FGC: H H H R j a j N R j a j N + Rp j a j N If ceteris paribus the additional health loss of undergoing the severe from of FGC H 0, then every household in the community subscribes to the severe from of FGC because of the additional mark-up in reputation R. If, in turn, the reputation mark-up R 0 every household in the community engages in the moderate form of FGC. (2) 9

4.3 FGC as identity marker Extending the above model to circumstances in which utility is also derived from identity, I derive a model in which non-adherents to the FGC practice incur an identity loss I S. In addition, their non-compliance with the practice also affects the identity of adhering households and reduces their identity by I O. In this setting we have two social categories, namely (i) FGC as norm and (ii) non-execution of FGC. Each household can decide whether it engages in the FGC procedure for its daughters or withstands. In case a household participates in the FGC ritual, there is still the decision about the magnitude of the cutting to be made. Again, I assume that the household can either decide to have the moderate or the more severe version of FGC performed. Following Akerlof and Kranton (2000) identity-based preferences are such that all households perceive FGC as a norm and the resulting behavioral prescription is that all household engage in FGC in one of the two forms possible. Otherwise they would reduce their utility by I S and the utility of the other households that subscribe to the norm by I O. The externality from the identity reduction by not engaging in FGC can be counteracted at a cost c which imposes a further loss on the household that does not follow the norm, which is denoted by L. To simplify the analysis I consider two households A and B and take the actions of all the other households as given. Household A is an absolute supporter of FGC, moves first and engages in one of the two types of the practice depending on the predominant form of cutting within the community. Household B does not want to execute FGC on its daughters and moves second. As household B does not have a taste for FGC, it experiences the usual health loss ( H H H) when it adheres to the practice. However, it does not perceive any reputation gain. The game tree is presented in figure 2. The possible outcomes are as follows: 1. If household A subscribes to the moderate version of FGC, C 1, because this type is the prevalent one in the community, household B never adheres to C 2. 2. If the identity loss from non-adherence is bigger than the health impairments from engaging in FGC, household B always practices FGC independently of household A s potential response: I S < H H H 3. Household A only responds to non-compliance with FGC if the response costs are outweighed by the identity externalities: I O < c 4. Whenever household B s health loss from subscribing to FGC is greater than the identity loss, three cases can result: 10

(a) The response costs are too high for household A and it withstands from a reaction which causes household B to refuse the adherence to FGC: H H H < I S (b) Household A responds but does not deter household B from rejecting FGC: H H H < I S L (c) Despite the health loss being bigger than the identity loss household B follows the norm and subscribes to FGC because of the additional loss L induced by the punishment mechanism of household A: I S L < H H H 5. If the health costs of the moderate version C 1 and the severe form C 2 of FGC differ widely, situations can arise in which it is optimal for household A to engage in FGC in its moderate version: H H < I S L < I S H. Household A only has to respond in such a situation and entail an additional loss L on household B if I S = H Unsurprisingly, the results I derive are similar to those by Akerlof and Kranton (2000) and Coyne and Mathers (2010). Yet, I have more possible subgame perfect outcomes because the previous papers do not allow for two possible ways of adhering to the norm that defines the identity of the households. 4.4 Hypotheses to be tested The theoretical considerations lead to three hypotheses that will be empirically testable. The first hypothesis is with respect to the health impairments induced by FGC. Hypothesis 1. The negative health consequences associated with FGM are economically significant and will cause the practice to die out. I measure these health consequences with a general measure of health, namely the Body Mass Index (BMI) and the incidences of Sexually Transmitted Diseases (STD), genital ulcers and vaginal discharge. Yet secondly, a competing hypothesis can be derived that is linked to reputation and peer pressure. Hypothesis 2. Peer-pressure and reputation gains are the driving forces for the continuation of FGC. Peer-pressure will be measured by the relative share of members of the same ethnicity or religion that live together in the same cluster. Possible reputation gains result from marriageability and a large number of offspring. Finally, I can state a hypothesis about the importance of ethnic and religious identity that is testable in the empirical specification by controlling for ethnicity and religion. Hypothesis 3. FGC is foremost a marker of ethnic and religious identity. 11

5 Data The data to test the above hypotheses come from the consolidation of 13 African Demographic and Health Surveys. I take only phases 4 (1997-2003) and 5 (2003 - present) surveys of countries that report FGC. All countries except one have the surveys conducted between 2003 and 2008-09. I have to exclude Egypt, Liberia and Tanzania from the analysis although they have recent DHS surveys because they do not report ethnicity. The 13 countries, their shares of the overall sample and the FGC prevalence are presented in table 1. If the sample was equally split across the 13 countries the observations of each country would make up for 7.69 %. The actual distribution is spread around this number. The FGC prevalence across countries varies between 3.67 % in Cameroon and 96.82 % in Guinea. The high prevalence rates do not result from adult women only, 45.42 % of the daughters in the sample are circumcised (Table 2). As socio-economic control variables at the level of the individual woman I consider age, education, and marriage status (Table 2). The sample is restricted to women between 15 and 49 years. On average the women are almost 29 years old, however variation is considerable. Their education level is low: While on average the women have slightly less than 3.5 years of education, this figure is misleading because all the single years of education are summed up and the education distribution is highly skewed. Roughly half of the sampled women have no education at all. I consider that every year at school is valuable, regardless whether the year is passed or not. Even women who retake the same year several times, can profit from new material and/or teaching methods. 3 Marriage and family are important variables of social status: 60.33 % of the women are married and they have on average 3.98 children. In addition, more than two out of three women have lost a child and 19.44 % of the women have experienced a pregnancy that did not end in a live birth. The women s partner s are significantly older, namely 42.24 years on average. There level of schooling is higher although the actual numbers reported are lower. However, male schooling is measured in terms of the highest year of education. Using the same metric of measuring education for women does not alter the results significantly. Household level information include household size, wealth, religion and ethnicity. The average household consist of 7.39 members. Slightly more than a third of the households are classified poor or very poor. In contrast 27.35 % of the households are categorized as rich. More than half of the households are Muslim. Christians of Catholic, Protestant, Orthodox and Pentecostal denominations make up for 38.59 %, the remaining households are Animists, have other religious views or adhere to no religion. I also built a religious density indicator. For an individual i that lives in cluster c it gives the proportion of households that share the same religion. On average religious diversity within clusters is 3 Replacing this variable by completed years of education does not affect the results. 12

limited. The proportion of households that share the same religion is 76.32 %. Previous research as well as the theoretical model show that identity is an important determinant of FGC. Next to religious identity I also include ethnic identity in the analysis. Across the 13 countries I have 165 ethnicities and ethnic groups. Most countries report between 7 and 14 different ethnicities. Cameroon and Ghana, however, give detailed accounts of all subgroups. Similar to the religious density indicator I also construct an ethnic density indicator. Unsurprisingly, people with the same ethnic background live together and deal with each other on a daily basis. The proportion of households that have the same ethnicity within a cluster is roughly lower than the average religious density but ranges still at 70.80 % The outcome variables I consider are mainly related to reproductive health and are almost universally coded as binary variables. Both cut and uncut women are equally likely to have menstruated in the course of the last six weeks, and they are also equally likely of being amenorrheic. The occurrence of a sexually transmitted disease (STD) in the last 12 months is reported in 10.88 % of the cases, vaginal discharge is declared by 15.69 % of the women, and 10.81 % of the respondents had an ulcer or a genital sore. Cesarean sections are very rare events (5.36 %). In addition to measures of reproductive health I also consider the Body Mass Index (BMI) as general health indicator. The women in the sample are on average of normal weight with no significant differences between cut and uncut women. 6 Econometric Specification I apply the logistic regression model because my response variables y such as the FGC treatment status or the occurrence of an STD are binary variables. Thus, the conditional distribution of the outcome variable is not normal but follows the binomial distribution. The conditional mean model is expressed as a conditional probability model and looks as follows: π(y X ) = exp(β 1x 1 + β 2 x 2 +... + β K x K ) 1 + exp(β 1 x 1 + β 2 x 2 +... + β K x K ) (3) where the matrix X = (x 1, x 2,..., x K ) contains the K control variables such as the age and the education level. The associated coefficients are collected in the vector β = (β 1, β 2,..., β K ). Applying the logistic transformation to π(y X ) I get a model that is linear in its parameters: ( ) π(y X ) g(y X ) = ln = β 1 x 1 + β 2 x 2 +... + β k x k = β X (4) 1 π(y X ) In the case at hand I match each cut woman i to a number of uncut women (M i ) 13

within the same cluster. The total of all cut women is I. The number of uncut women per cluster M i is allowed to vary across clusters. I further denote the matrix of covariates for each cut woman as X i1 = (x i11,..., x i1k ) and the covariate matrix for the j uncut women as X ij = (x ij1,..., x ijk ). Then, the conditional likelihood is given by: L(β) = I i=1 exp( K k=1 β kx i1k ) Mi j=0 exp( K k=1 β kx ijk ) = I i=1 1 1 + ( M i j=1 exp K ) (5) k=1 β k(x ijk X i0k ) The conditional model is estimated because I have data clusters and I focus the analysis on the within-cluster comparison. The cross-cluster heterogeneity is addressed by conditioning out the cluster-specific intercepts. Consequently, if any of the covariates in X take the same value for the cut and all the uncut women in the cluster, they drop out and the corresponding β s cannot be estimated. In addition, I adjust the standard errors for intragroup correlation to obtain robust variance-covariance estimates. This empirical approach allows me to test the theoretical hypotheses established in section 4.4 by analyzing the determinants of FGC, as well as quantifying the impact of genital cutting on a number of binary outcome variables. 7 Results There are two possible ways of discussing the results: First, I can interpret the results in a conservative manner as merely associations. Second, if I consider circumcision an exogenous event that lies back in the past but despite the difference in FGC status the two comparison groups are equal, I can interpret the relationship between FGC and the health outcome variables as causal. As I control for observables at the individual level such as age and education, household observables such as wealth and cluster-fixed effects, a causal interpretation seems valid and will be employed. I consider conditional odds ratios in interpreting the results. In the case of two binary variables the outcome and the explanatory variable the conditional odds ratio is simply the exponential of the estimated coefficient (OR = exp(β k ), where k = 1, 2,..., K) given the other explanatory variables are fixed. Then, for instance an odds ratio of 2.93 for members of the Bariba ethnictity (Benin) can be interpreted as follows: The odds for Baribas being circumcised is 193 % higher than the odds for non-baribas. 7.1 Determinants of FGC In a first step the determinants of FGC are identified. Therefore, I restrict the sample to those women who have been living at the current side of residence for at least 35 years. This allows me to retrieve results that are not biased by migration. In table 3 column 1 I 14

consider only the relationship between circumcision and the following covariates: religion, ethnicity, peer-pressure, age and the number of female siblings. The excluded religious category is Muslim. Results indicate that except for Pentecostal christians, all other Christian groups adhere less to FGC than Muslims. Members of traditional religions are neither more nor less likely to carry out FGC. Peer-pressure from members of similar beliefs increases the odds to be circumcised by 25.71 %. However, this results only obtains with a p-value of 9.7 %. While there is some indication that Muslim communities are more supportive of FGC, the effects are moderate. Similarly for age and the number of female siblings. The older women in the community are more likely to be circumcised, however the odds ratio of 1.07 is small indicating that FGC is more than an outdated tradition. Larger families tend to carry out the tradition more eagerly. Yet again, the effect is small: the odds ratio is only 1.05. Thus, if neither religion, nor pressure from religious peers, nor age or family structure are socially important determinants of FGC, ethnicity seems to play an important role. The Bissa of Burkina Faso have an odds of being circumcised that is 202 % higher than the odds for non-bissa. The Ethiopian Gurarie group have 6.07 the odds of being circumcised. For some ethnicities such as the Ethiopian Oromo or the Ghanaian Soussou (almost) all women in the sample are cut. However, ethnic pressure, as measured by the proportion of equals within the cluster, does not appear to induce people to adhere to FGC. Thus, this first analysis indicates that it is not peer-pressure that determines the continuation of FGC, but rather the practice serves as identity marker strongly along the ethnic dimension, in a more moderate fashion concerning religion. I do not have wealth information about the family of origin for the adult women. However, it is very likely that the family of origin is similar in terms of income and wealth to the family in law. A similar argument applies for the education level of the women in the study. It cannot be argued that the women s education level influences their FGC status, because the majority of the women are cut during infancy. Yet, the women s education is a good proxy for the education of other, (older) females in their family of origin. Including wealth and education in the regression of the determinants of FGC replicates the previous results (Table 3 column 2). In addition, it shows that FGC is practiced across all economic strata and that higher education significantly reduces the odds of being circumcised. However, the effect is small on a social level. In order to assess the effect of parental wealth and education more precisely, I also estimate a regression of the probability of daughters being circumcised. It is shown in table 3 column 3. Maternal education shows to have a dampening effect on the FGC status of the daughters. Paternal education, in contrast, has no effect. Older parents are more likely to have their daughters circumcised, yet again the effect is economically only marginal especially for fathers. If anything, we can deduce that decisions over the cutting of the daughters are rather taken by the mothers. Religious or ethnic pressure has no influence at all for the daughters FGC status. The previously gained picture that Muslim 15

communities are more in favor of FGC is reinforced and again the ethnic component is the most dominant determinant of FGC. Neither rich, nor poor people tend to be stronger advocates of the practice however households with more children have higher odds of circumcising their daughters (1.18). In short, it is not only older women who are circumcised. Thus, FGC does not die out automatically. Second, the poor and the rich men have their daughters circumcised. Third, peer-pressure, measured as the proportion of the local population of similar belief or ethnicity, is negligible as determinant of FGC, however, ethnic identity per se induces individuals to continue the practice. Thus, while I find counter-evidence for hypothesis 2, hypothesis 3 is firmly supported for ethnicity and moderately for religious beliefs. 7.2 Social and cultural aspects of FGC In a second step I look at the social and cultural aspects of FGC. I want to figure out what cut women can gain relative to their uncut counterparts. Table 4 presents the results. Here I will consider the reputation effect, as spelled out in the theory, not merely as resulting from immediate peer-pressure but as leading to gains of respect and honor within the local community. In Table 4 column 1 I consider marriageability. Being circumcised increases the odds of being married by 46.93 %. Considering the social and economic context of marriage, it is not surprising that the FGC practice persistently continues in the absence of social security systems for single women. Moreover, column 2 of table 4 presents evidence that circumcised women have more children. In light of the fact that circumcision is also interpreted as protection against promiscuity and adultery, the children from circumcised women are very likely to be fathered in an official marriage union. Despite controlling for the marriage status of the women, which has a significant and positive effect on the number of children, the circumcision status increases the overall number of offspring. Yet again, the effect is small; being cut explains only 5.44 % of the standard deviation in the number of children. Unsurprisingly, other covariates have more explanatory power than the circumcision status. For instance, older parents have more children and Christians of all denominations tend to have smaller families. Hence, while marriage prospects significantly increase for circumcised women, these women tend to have only little more children compared to uncircumcised women. Could it be the case that circumcised women have more complications during pregnancy and giving birth? Column 3 of table 4 shows that the likelihood of having a Cesarean section does not significantly increase for cut women. But this result is not surprising because only 5.36 % of the women who have children ever had a Cesarean section. Consequently, this result rather highlights a supply side problem than representing the 16

(potential) demand for obstetric assistance. Terminated pregnancies that did not result in live birth are reported by almost one fifth of the women and the multivariate analysis shows that circumcised women have an odds that is 13.76 % higher. This finding is supported when looking at the number of dead children. Employing a Poisson regression to account for the count data nature, I find that circumcised women have 1.07 the odds of having lost children as compared to uncircumcised women. This finding supports the notion of the international agencies that babies born to cut women are at higher risk during obstetric labor (WHO, 2010 and WHO et al., 2008). However, in terms of birth weight and thus readiness for survival after birth, children from circumcised mothers are not worse off as compared to their counterparts from uncircumcised mothers (Table 4 column 6). As a result, I find convincing evidence for the reputation mechanism to work with respect to marriageability. Thus if marriageability is considered directly and not ethnic or religious peer-pressure I find evidence in favor of a reputation mechanism at work (hypothesis 2). However, cut women derive disutility from terminated pregnancies. Nevertheless, they have slightly more surviving children than their uncut counterparts which is another indication for the reputation mechanism at work. If, in contrast, the quality of surviving off-spring enters the utility function directly, I cannot detect any differences in the health of surviving newborns from cut and uncut women. 7.3 Health consequences of FGC Last but not least, it is also often argued that FGC has severe long-term health consequences such as for example sores, ulcers, and vaginal discharge (WHO et al., 2008). In table 5 column 1 I consider the most general and most simple measure of health, the BMI. I do not detect any significant differences in the BMI of cut versus uncut women. However, this result might be completely spurious because the BMI is a ratio taking the individual s weight in the numerator and the squared height in the denominator. If any given woman A is cut as a child and consequently her development is affect, she might remain smaller and more lightweight than her uncut twin B. Calculating the BMIs of the two one might end up with similar BMI values for the unequal twins. Therefore, I consider the BMI results with caution. To assess whether infertility is more likely among women who have undergone FGC, I further study whether cut women are more likely to be postpartum amenorrheic. This is not the case (Table 5 column 2). Approaching fertility from another angle and asking whether the women have menstruated in the last six week does not yield any indication that cut women are more likely to be infertile, either (Table 5 column 3). Finally, I also look at the occurrence of STDs, vaginal discharge and genital ulcers/sores. This allows me to address hypothesis 1 that the health consequences associ- 17

ated with FGC are statistically and economically significant. Table 6 column 1 presents the results for STDs. The odds of having an STD are 24.66 % higher for cut women. Moreover, cut women have 1.15 times the odds as compared to uncut women to have a vaginal discharge (Table 6 column 2) and genital ulcers/sores are also more likely for women who were subjected to FGC. Circumcised women have 1.25 times more genital ulcers/sores than their uncircumcised counterparts (Table 6 column 3). Thus, circumcised women are significantly more prone to genital infections and impairments. However, infertility does not result. Despite the increased chance for cut women to contract STDs and/or develop ulcers, the health risks resulting from FGC seem too moderate to cause the practice to be abondoned. Traditionally, the international agangies and many local NGOs used the painful and injurious health consequences as the main argument against FGC. The analysis at hand shows that it is not an invalid argument but it has to be used with the necessary prudence. The more recently advocated human rights approach to the combat of FGC is worth getting increased attention in light of the results presented. 7.4 Caveats There are a number of caveats with the analysis at hand. First of all the FGC variable itself has to be considered with caution because it is a self-declared status that has not been verified by doctors. Thus, one might argue that there is considerable underreporting of FGC due to traumata induced by the procedure and consequent neglect. However, Elmusharaf et al. (2006) show that women are well aware of the fact that they are genitally cut. In their study all women who reported to have undergone FGM had this verified, as well as all those who declared that they had not undergone FGM. No single women had mis-declared her status. However, when it comes to the extend of FGM the reliability of self-reported types according to the WHO classification is low. As this study does not distinguish between the different types of FGM, I can consider the reporting about the treatment status as candid. Further support comes from the Egyptian Fertility Care Society et al. (1996) who validate the findings of the DHS survey concerning FGC prevalence rates in Egypt. Similar caution applies for the recall of birth weight and the STDs. Recall errors are likely, however a priori they are not systematic and as these variables are outcome variables, the results should not be impaired. Moreover, I consider only the birth weight from the last born child and the recall period for STDs is limited to twelve months. The exogeneity of the circumcision status may also be challenged. It is arguable that omitted variables bias the results. There could be unobservables that influence the decision to be circumcised as well as subsequent outcomes. A valid instrument remains still to be found in order to verify the existing findings 18