Female Genital Mutilation and its effects over women s health

Female Genital Mutilation and its effects over women s health Authors Enu Anand 1, Jayakant Singh 2 Draft Paper for Presentation in the Session 285 at the 27th IUSSP Conference, 26-31 August 2013, Busan, South Korea -------------------------------------------------------------------------------------- 1 Senior Research Officer, Family Health and Wealth Study, International Institute for Population Sciences (IIPS), Govandi Station Road, Deonar, Mumbai, India. Email: enuanand@hotmail.com 2 Research Officer, Conditional Cash Transfer Schemes for Girl Child in India Project, International Institute for Population Sciences (IIPS), Govandi Station Road, Deonar, Mumbai, India. Email: singhjayakant.tiss@gmail.com

Introduction Female Genital Mutilation (FGM) according to WHO is partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons. More than 132 million women and girls are estimated to have had FGM worldwide and nearly two millions are added every year (WHO 1998). According to WHO, FGM is classified into four categories such as no FGM: no evidence of any genital mutilation, FGM I: excision of the prepuce, with or without excision of part or all of the clitoris, FGM II: excision of the clitoris with partial or total removal of the labiaminora and FGM III: excision of part or all of the external genitalia and stitching or narrowing of the vaginal opening (infibulations) (WHO, 1996). FGM III is the most severe and painful type of circumcision. This is a practice which results in excessive bleeding, shock, mental trauma for some girls and infection which can even lead to death. In 1999, a study done by Heidi Jones found that the more severe the cut, the more likely the health complication. Further a study from Edo State, Nigeria, examined the relationship between being circumcised and experiencing problems at childbirth found that circumcised women had higher risks of tearing and of stillbirths than those who were uncircumcised (Larsen & Okonofua, 2002). Most of such cases are reported from Africa. According to KDHS (Kenya Demographic Health Survey)-2008-09, the prevalence of circumcision among women is 27 percent. Majority of these circumcised women have reported that they had some flesh removed which also included removal of the clitoris, while 2 percent reported to have nicked with no flesh removed and 14 percent of circumcised women reported the most invasive form of the operation in which the labia are removed and sewn closed. These figures are alarming and clearly depict the magnitude of FGM practices in Kenya. Whether obstetric outcomes and infertility differ in relation to women who have and did not have undergone FGM is unclear due to limited studies and methodological limitations (Obermeyer, 2005; Almroth et. al., 2005; Essen et. al., 2002). Although these studies have been conducted to establish the relation between female genital mutilation and obstetric outcome, genital infections, in African scenario in general including Kenya, it lacks agreement in providing findings in a similar direction. As a result, examining these relations from a nationally representative sample is essential. In addition to that, FGM being a harmful and unlawful practice, why such a practice is widespread needs to be explored. Thus this study aims to examine the effect of different types of FGM on obstetric outcome and genital infections in Kenyan Women. Further it also attempts to find out the discriminant factors in

transmission of inter generational FGM (here mother to daughter). FGM and circumcision are referred interchangeably in this study. Methods & Materials The study uses Kenya Demographic Health Survey, 2008-09 data. The respondents consist of 8444 women in the age group of 15-49. Bi-variate and Multi-variate analysis have been carried out. Frequency is generated to provide a background of Female Circumcision in Kenya. Adjusted and Unadjusted Odds ratios are used to explain the effect of circumcision on women s obstetric and genital infections. The outcome variable used in logistic regression was circumcision status of women. The variables used to study the effect of circumcision on women s health were genital discharge, genital sore, sexually transmitted diseases and any terminated pregnancy. Two different models were used in logistic regression, the first one was to find out comparative effect between FGM and no FGM and second model was between FGM III and no FGM. Discriminant analysis was carried out to find the discriminating factors of FGM among daughters of the respondents. It is carried out between two groups of daughters, one group of daughters who have been circumcised and other who have not been circumcised. Discriminant analysis involves the determination of a linear equation like regression that will predict which group the case belongs to. The form of the equation or function is: D=v 1 X 1 + v 2 X 2 + v i X i + a Where, D = discriminate function v = the discriminant coefficient or weight for that variable X = respondent s score for that variable a = a constant i = the number of predictor variables The function is similar to a regression equation or function. The v s are unstandardized discriminant coefficients analogous to the b s in the regression equation. Standardized discriminant coefficients can also be used like beta weight in regression. Good predictors tend to have large weights. The number of discriminant function is one less the number of groups.

We carried out discriminant analysis to explore the factors distinguishing the group of circumcised and non-circumcised daughters of the respondents. The analysis was carried out only for ever-married women who had any living daughter. Circumcision status of daughters is taken as a nominal variable which indicates whether the daughter is circumcised or not. The study variables used for discriminant analysis are education of women and partner, wealth in percentiles, age at marriage, children ever born, mother's circumcision status, women s working status, number of daughters and decision making score of women. Decision making score was constructed from the set of questions asked to women to know about their autonomy. The questions included final say on own health care, making large household purchases, making household purchases, decision regarding visit to family and friends, decision about food to cook. If the women responded she herself can take the decision she was given the score of 1 on each of the item otherwise 0. Finally all these variables were added to get the decision making score. Results More than one in four women in Kenya underwent circumcision. Prevalence of FGM by different background characteristics (table 1) reveals differences among each of the category. Educational level of the women comes out to be one of the important predictors of female circumcision. Women with no education are more likely to be circumcised as compared to women with any education. In an aggregate, more than 50 percent of women in the no education category are circumcised and out of that more than 20 percent of women had undergone most severe form of circumcision i.e. FGM III. As the level of education increases, prevalence of circumcision decreases. Circumcision by religion revealed that, 50 percent of Muslim women had undergone circumcision, followed by women from Christian religion. Furthermore, most severe forms i.e. type III FGM is highly (31 percent) prevalent among Muslim women. On the other hand, one fourth of Christian women were circumcised and among them only 1 percent had undergone most severe form of circumcision. Similarly, maximum circumcision was observed among women in the low standard of living index and among women in the rural area as compared to women from middle and high standard of living index and urban area respectively.

Table 1: Percentage of women circumcised by different background characteristics, KDHS 2008 Background Characteristics No FGM FGM I FGM II FGM III Total N Highest educational level No education 46.70 31.30 0.50 21.50 1242 Primary 72.80 24.20 0.80 2.20 4404 Secondary 79.30 18.90 0.40 1.40 2084 Higher 88.70 10.10 0.40 0.90 714 Standard of living index Low 64.70 28.80 0.60 5.90 2983 Medium 71.30 25.80 0.40 2.50 1455 High 80.50 16.30 0.70 2.50 4006 Religion Christian 75.60 22.50 0.50 1.40 6836 Muslim 49.60 17.40 1.60 31.40 1358 Others 94.20 5.30 0.00 0.40 57 Place of residence Urban 84.10 11.50 1.20 3.20 2615 Rural 69.70 26.10 0.40 3.80 5829 Total 73.40 22.40 0.60 3.60 8444 Table 2: Age of women at circumcision by background characteristics, KDHS 2008 Background Characteristics <10 10-14 15-19 >20 Total N Highest educational level No education 52.5 19.4 19.9 8.2 817 Primary 28.5 29.9 34.2 7.3 1228 Secondary 50.3 28.1 15.5 6.1 404 Higher 47.1 34.1 5.4 13.4 92 Religion Christian 31.7 30.6 30.3 7.4 1637 Muslim 80.0 11.4 0.8 7.8 837 Others 47.5 7.5 0.0 45.0 4 Standard of Living Low 40.2 23.1 29.3 7.4 1265 Medium 32.7 30.6 28.4 8.2 442 High 38.1 32.2 22.7 7.0 834 Place of residence Urban 54.5 28.0 10.4 7.1 499 Rural 34.9 27.8 29.9 7.5 2042 Total 37.9 27.8 26.8 7.4 2284 Around 90 percent of circumcision among Kenyan women took place befor the age of 20 (table 2). Among them majority (38 percent) of women were circumcised before the age of 10. A mere 7 percent of women were circumcised after the age 20. It may be due to the fact that the early a girl is circumcised, she will be eligible for marriage. Further analysis revealed that most of the women who had no education, belonged to Muslim religion, had a low standard of living index and belonged to urban area underwent circumcision before the age

10. Higher differential is observed in case of Muslim women. Four in five Muslim women reported to have undergone circumcision before the age 10. Table 3: FGM facts of Kenya Percentage of daughters circumcised 36.2 Percentage of women who intend to get their daughter circumcised 20.8 Who circumcised respondent Traditional 79.9 Health 20.1 Who circumcised daughter Traditional 58.3 Health 41.7 Perceived Benefits for circumcision Cleanliness/Hygiene 6.9 Social Acceptance 23.9 Better marriage prospects 8.9 Virginity/Prevent Pre marital sex 15.7 Religious approval 5.3 More sexual Pleasure for men 2.4 Reduce Sex drive 3.7 Perception about continuation of practice Continued 29 Discontinued 67.6 Most of the women got circumcised by a traditional circumciser. Only 20 percent of the circumcision was carried out by any health professional. On the other hand circumcision by health professional doubled in case of circumcision of daughters of the respondent. It is observed that, gradually there is a changing pattern of circumcision carried out by a health professional. Majority of the women who underwent circumcision (23.9 percent) thought that circumcision was beneficial for social acceptance. Around 16 percent of them perceived that circumcision was beneficial for maintaing virginity or avoid pre marital sex. Some other women thought that circumcision would help in better marriage prospects, (8.9 percent) cleanliness or hygiene (6.9 percent) etc. However, most of them (67.6 percent) perceived that the practice of female circumcision should be discontinued where as 29 percent of them perceived the practice should be continued.

Table 4: The adverse effects of FGM over women s health, KDHS 2008 Odds Ratios for circumcision status and obstetric outcome and genital infection among women, 2008 (KDHS) Model 1 Model 2 Any Circumcision FGM III (Infibulations) Unadjusted Adjusted Unadjusted Adjusted Sexually Transmitted Disease No Yes 2.454*** 2.596*** 1.02 1.168 Genital Sore No Yes 0.848* 0.748 1.345 0.726 Genital Discharge No Yes 0.484 *** 0.346*** 1.988* 3.218* Any Terminated Pregnancy No Yes 1.249*** 0.858 0.851 1.101 Reference Category Adjusted for Age, Region, number of children, education, socio-economic status, urban/rural residence, religion, age at first birth, contraceptive use and awareness about sexually transmitted infections. Separate models for FGM versus No FGM and FGM III (Infibulations) versus NO FGM. In table 4, unadjusted and adjusted effect of FGM on selected health problems of women are explained by logistic regression. Model one takes into consideration of any types of FGM and model two takes into consideration of FGM III alone. Sexually transmitted disease is significantly higher among women who had undergone any type of FGM both with adjusted and unadjusted effect. When the model is unadjusted STD is higher with OR=2.4, p<.001 and when adjusted with various socio-economic and demographic factors STD is higher with OR=2.5, p<.001. The result does not show statistical significance in case of FGM III category. Result of model 1 unadjusted effect on genital sore shows that, those women with any FGM are less likely to get genital sore with OR=0.84, p<.05. Similarly, in case of model II result did not show any statistical significance. Both adjusted and unadjusted effects of any FGM as well as FGM III on genital discharge are statistically significant. Genital discharge is less likely in case of any FGM with OR=0.48 (unadjusted) and OR=0.36 (adjusted) p<.001. In contrast with result of any FGM, genital discharge is more likely in case of FGM III with OR=1.9 when the effect is not adjusted and OR=3.2 when the effect is adjusted with p<.05. Furthermore, any terminated pregnancy is significantly higher among women who had undergone any FGM with OR=1.2, p<.001 when the model is not adjusted for the socioeconomic and demographic factors.

Discriminant Analysis The group statistics and Tests of Equality of Group Means tables provide the information on any significant differences between groups on each of the independent variables using group means and ANOVA results. Mean differences between wealth status and circumcision status of women depicted in table below suggest that these may be good discriminators as the separations are large. Test of equality of group means provides strong statistical evidence of significant differences between means of circumcised daughters and non-circumcised daughters. The pooled within group Matrices also supports use of these independent variables since their inter correlations were low. Table 5: Group Statistics Daughter's Circumcision Status Mean Std. Deviation Non Circumcised daughter Women's Education 5.598 2.25627 Partner's Education 5.2417 2.22493 Wealth Status 50.7159 26.73763 Age at first marriage 19.2129 3.71543 Children ever born 3.9192 2.164 Circumcision status of women 0.2816 0.44987 No of daughters 2.0176 1.19945 Currently working women 0.6679 0.47105 Decision-making score 3.9466 1.38338 Circumcised Daughter Women's Education 4.5904 2.30573 Partner's Education 4.9738 2.03321 Wealth Status 38.5722 20.03384 Age at first marriage 18.0992 4.43104 Children ever born 5.6829 2.39706 Circumcision status of women 0.9803 0.1394 No of daughters 2.648 1.41238 Currently working women 0.819 0.38603 Decision-making score 3.4348 1.3777 Total Women's Education 5.5364 2.2718 Partner's Education 5.2253 2.2143 Wealth Status 49.9736 26.53416 Age at first marriage 19.1448 3.77169 Children ever born 4.027 2.21913 Circumcision status of women 0.3243 0.4682 No of daughters 2.0562 1.22264 Currently working women 0.6771 0.46765 Decision-making score 3.9153 1.38823

Table 6: Tests of Equality of Group Means Wilks' Lambda F df1 df2 Sig. Women's Education 0.989 34.541 1 3024 0.000 Partner's Education 0.999 2.543 1 3024 0.111 Wealth Status 0.988 36.806 1 3024 0.000 Age at first marriage 0.995 15.214 1 3024 0.000 Children ever born 0.964 113.79 1 3024 0.000 Circumcision status of women 0.872 443.242 1 3024 0.000 No of daughters 0.985 46.87 1 3024 0.000 Currently working women 0.994 18.246 1 3024 0.000 Decision-making score 0.992 23.783 1 3024 0.000 Eigen values table: This table provides an idea of overall model fit which is being the proportion of variance explained (R 2 ). In our analysis the value of canonical correlation is 0.407 which suggests the model explains only 16 percent of the variation in the grouping variable. Table 7: Eigen-values Function Eigen value % of Variance Cumulative % Canonical Correlation 1.199a 100 100 0.408 The standardized canonical discriminant function coefficients table: This table provides an index of the importance of each predictor like the standardized regression coefficients (beta's) do in multiple regressions. The sign indicates the direction of relationship. Circumcision status of women is the strongest discriminating factors, while education status and decision-making power of women are some of the major discriminating factors. These three variables with large coefficients stand out as those that strongly predict circumcision or non- circumcision status of the daughters. Table 8: Standardized Canonical Discriminant Function Coefficients Function Women's Education -0.305 Partner's Education -0.042 Wealth Status -0.091 Age at first marriage -0.07 Children ever born 0.35 Circumcision status of women 0.821 No of daughters -0.098 Currently working women 0.124 Decision-making score -0.189

The canonical discriminant function coefficient table: The discriminant function coefficients b or unstandardized form beta both indicate the partial contribution of each variable to the discriminate function controlling for all other variables in the equation coefficients. The circumcision status of mother as an individual is coming out as the most contributing predictor variable followed by working status of women and her education. Table 9: Canonical Discriminant function coefficients Function Women's Education -.135 Partner's Education -.019 Wealth Status -.003 Age at first marriage -.019 Children ever born.161 Circumcision status of women 1.878 No of daughters -.081 Currently working women.266 Decision-making score -.136 Unstandardized coefficients. Discussion and conclusion Some of the findings highlight that circumcison of the women or girl begun at an early age. Most of the circumcision (38 percent) was done before the age 10. Moreover, more than 80 percent of women belonging to Muslim religion were circumcised before the age 10. There is a possibility that the early circumcision is intended to marry off the girl soon. When a girl is married early, the chances of dropouts from the school is also high. Furthermore, the prevalence of most severe forms of FGM is higher among Muslim, women with no education and women in the low standard of living index. This finding is in agreement with a study done by WHO study group on FGM and obstetric outcome. Sexually transmitted disease is significanly associated with female genital mutilation. However, FGM research focus has been mostly on infertility and obstretic outcome (Almroth et. al., 2005; WHO study group on FGM and obstetric outcome, 2006). There is a need to carry out systematic study on relation between STD and FGM as well. The current study also attempted to find out relation between infertility and FGM as well as some of the obstetric outcome but the data used did not provide much scope to carry out a detailed analysis. Genital discharge is significantly higher among women with most severe form of FGM (type III). Furthermore, any terminated pregnancy is significantly higher among cirumcised women.

Positive value that are predominant among the women tends to make them continue the traditon of genital mutilation. Social acceptance, increased prospect of marriage, the value of being a virgin are some of the perceived benefits culturally interlinked with this traditional practice (Almroth et. al., 2001). Nevertheless, majority of the women (68 percent) wanted the practice of FGM to be discontinued. Sadly, more than 30 percent of the women still think FGM should be continued. In addition to that, 36 percent of daughters of the circumcised mother have already been circumcised and more than 20 percent of the circumcised mother intend to circumcise their daughters. Result from discriminant analysis clearly stated that the circumcision status of the mother as the important discriminating factors in circumcizing their daughters followed by education and decision making power. Therefore, circumcised mothers need to be educated to prevent this transmission to their daughters. DHS data does not clinically examine the women whether they are circumcised or not, further the classification may be incorrect at times. Also the data on STD and other obstretic outcomes are self reported. In spite of the limitation of data, analysis throws some light on the situation prevalent in Kenya. FGM is not only illegal and calls for the attention of Human Right activists but also is a health problem that needs attention from the public health professionals. There is much that needs to be done to prevent from adverse health outcome. Together with treating the women with FGM, further practice of circucison must be halted to affect the future generation. References: Almroth, L., Almroth, B.V., Hassanein, O.M., et.al. (2001) A community based study on the change of practice of female genital mutilation in a Sudanese village, International Journal of Gynaecologic Obstetric, 74: 179-85. Almroth, L. et.al., (2005) Primary infertility after genital mutilation in girlhood in Sudan: a case-control study, Lancet, 366:385-91. Essen et. al., (2002) Is there an association between female circumcision and perinatal death? Bulletin of the World Health Organization, 80(8):629-32. Jones, H. et.al. (1999) Female genital cutting practices in Burkina Faso and Mali and their negative health outcomes, Studies in family planning, 30:219-30.

Kenya National Bureau of Statistics (KNBS) and ICF Macro (2010) Kenya Demographic and Health, Survey 2008-09, Calverton, Maryland: KNBS and ICF Macro Larsen & Okonofua, (2002) Female circumcision and obstetric complications, International Journal of Gynaecologic Obstetric, 77:255-65. Obermeyer, (2005) The consequences of female circumcision for health and sexuality: an update on the evidence, Culture, Health and Sexuality, 7(5):443-61. WHO (1996) Report of a WHO Technical Working Group, Female genital mutilation, Geneva, World Health Organization. WHO (1998) Female genital mutilation an overview, Geneva, World Health Organization. WHO study group on FGM and obstetric outcome (2006) Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries, Lancet, 367:1835-41.