Opinion of Women in Kafr El-Sheikh Governorate Regarding Prohibition and Criminalization of Female Genital Cutting

ABESTRACT: The study aimed to identify the opinion of women regarding prohibition and criminalization of female genital cutting (FGC). It was conducted at the five medical health centers located in at Kafr El-Sheikh governorate. A total of 250 women attending these centers were selected. Fifty women were selected from each center. An interview schedule was designed and used to collect data. It consists of three parts: the first part included socio-demographic characteristics, the second part entailed the women's knowledge about FGC, and third part contains the details of knowledge about and opinion of women regarding the law that prohibits and criminalizes FGC. The main findings of the study revealed that more than one half (51.2 %) of the study sample were against prohibition and criminalization of FGC and only 27.2 % agreed that it should be prohibited and criminalized, while 3.6 % were uncertain. Mass media was the main source of information about the law, yet, at certain times mass media messages were ambiguous. As a result only one fifth of the sample changed their opinion about FGC during the previous year.


INTRODUCTION
Throughout the last two decades women's health, their status and the respect of their human rights became a major concern for the International society. (1,2)herefore, cooperation, and economic rights, to empower them, to insure equity and equality between men and women and to end all forms of violence against women including Female Genital Cutting (FGC). (3,4)C is a permanent physical damage done to the female genitalia.It is sometimes referred to as Female Circumcision (FC) or Female Genital Mutilation (FGM).It is a deeply rooted traditional practice which is unfortunately prevalent in most African countries, some Asian countries and among some immigrants in Europe and the USA.It is estimated that 135 million girls and women have undergone genital mutilation, and two million girls a year are at risk-approximately 6,000 per day.The procedure has severe deleterious consequences for girls and women. (5)FGC is usually performed on girls at an age that ranges between four and ten.
Sometimes it is performed on infants or at the age of marriage.It is usually performed under unsanitary conditions, by non medical traditional practitioners, using non sterile instruments and without the use of anesthesia.
In many instances it results in immediate & delayed serious complications.Thus the health and even the life of its victims are compromised. (6,7)ere is no clear cut understanding of where or why FGC came into existence.It predates both Islam and Christianity.One of the most common explanations for continuing it is local customs and traditions.
It is strange that women themselves are sometimes unwilling to give up the practice as they see it a long-standing tradition passed on from generation to generation . (8,9)C is a fundamental violation of human rights.It violates the rights to the highest attainable standard of health and to bodily integrity.Furthermore, it could be argued that girls under the age of 18 cannot be said to give informed consent to such potentially damaging practice. (10)Currently there is a strong universal opposition to FGC which is based on many dimensions.
Firstly the procedure is considered an infringement on the physical and psychosexual integrity of girls and women, secondly it is a form of violence against them and thirdly it violates their human rights. (11,12)llowing the International Conference This study is an attempt in this direction.

Aim of the study:
To explore the opinion of women attending medical health centers in Kafr El-

Sheikh governorate regarding prohibition
Bull High Inst Public Health Vol.40 No.1 [2010]   and criminalization of female genital cutting.

Research design
This study is an exploratory descriptive study

Setting
The

Part II:
'It also included items related women's knowledge about FGC such as its meaning, the reasons behind its performance, its types as well as their source of information, persons who perform this practice and the possible complications.
Women's experience with FGC was also explored.

Part III:
This section included the details of women's knowledge and opinion regarding the law that prohibits and criminalizes female genital cutting and their intention to stop or continue performing the procedure to their daughters.

Approvals:
An official permission clarifying the purpose of the study was obtained from the executive directors of health affairs department in Kafr El-Sheikh governorate and the concerned health centers to conduct the study and collect the necessary data.

Development of the tool
An interview schedule was developed by the researcher based on an extensive review of relevant and recent literature.It was tested for content validity by 5 juries, who are experts in the related field to reach consensus on the best form to be implemented.

Pilot study:
A pilot study was carried out on 30 women from the previously mentioned settings.These women were excluded from the study subjects.The purposes of the pilot study were to: ascertain the relevance and applicability of the tool, and to detect any problem peculiar to the statements such as phrasing, sequence and clarity, and to estimate the time needed to complete the tool.The pilot study revealed that, the tool was relevant and applicable but some words have been modified.The average time needed to complete the tool ranged between 10-15 minutes.The right of respondents to participate in the study was fully respected.Therefore, the purpose of the study was explained to each woman and an oral consent to participate in it was secured.

Statistical analysis
Data analysis was carried out using SPSS program.The collected data was categorized, coded, computerized, tabulated and analyzed.Frequency and percentages were used for describing and summarizing categorical variables.family expenses for more than three-fourths of the sample (77.6%); it exceeds these expenses for 18.4%.Only 4.0% reported that their monthly income was insufficient.

Table
Approximately one fourth (24.0%) of them live in an extended family.Figure 4 presents the reasons for fathers' agreement to undertake FGC to their daughters.More than one-half (58.8%) state that they agree because it reduces the sexual desire, 46.0% state that it is a social habit and 39.6 % mention religious reasons.
Figure 5 illustrates the percent distribution of the study sample according to the reasons of fathers' disagreements to undertake FGC for their daughters.Fear from complications was reported by 31.3 % while only 6.8% reported that they disagree because it is against the law.believed that it should be continued whereas only 13.6 % believed it should be stopped.The rest (12.8%) were uncertain.

DISCUSSION
In 2008, Egypt issued a child protection law which include prohibition and criminalization of FGC.However, for a law to be effective, especially that it deals with a deeply rooted and widespread practice such as FGC, the community should be convinced by it.Accordingly, this study was conducted to assess the opinion of women in Kafr El Shiekh Governorate regarding the prohibition and criminalization of FGC. (19)e results revealed that the prevalence of FGC among the study sample exceeded 98%.This finding is higher than the national figure reported by the EDHS 2008.during earlier dates.Tawfik et al in (1994)   reported that 78.8% of their study sample were circumcised. (20)and Assaad (1979)   mentioned that at least 75% of Egyptian women and girls were circumcised. (21)It was also reported by the Ministry of Family and Population. (22)that the procedure no more exists in some governorates in Upper Egypt.This shows that Khafr El Skeikh lags behind other governorates in Egypt and more effort is needed to eradicate FGC there. (23,24)cordingly, the present study revealed The results of Billing et al. ( 2008) (22) revealed that the reasons for FGC were: method for birth control, guarantee of moral behaviors and faithfulness to the husband, protection of women from suspicions and disgrace, initiation ritual, symbol of femininity and beauty, hygienic, health and economic advantages.Nour.(2008) (23) reported that the reasons for undertaking 2003 (24,.25)showed that just less than three quarters of ever-married women reported that circumcision is an important part of religious traditions in Egypt.

It was reported by Martin. (2000) &
Assaad (2000) (26.27) that excision is part of a larger cultural ritual that marks a young girl's transition to womanhood and about two-thirds of women had the impression that the husband prefers his wife to be circumcised.According to EDHS (1995), (28) more than one-third of ever-married women cited cleanliness as a reason while a small number considered it a way to prevent promiscuity before marriage.In some communities, some families refuse to accept women who have not undergone FGC as marriage partners.Also Lamada (1998) (29) , Alaa El-Din and Mostafa (1996) (16) reported that the most common reasons given by women and husbands, who accepted FGC were to make young adult girls more pure, maintain their chastity and thereby preserves their virginity until marriage.
When the reasons for refusal of performing FGC for daughter were explored in the present study, it was found that most of women fear complications and only 10% refused it because they want to comply to the law.According to the EDHS (2003) (26) women who refused to undertake FGC to their daughters were either not convinced by it (61%), are afraid of the potential health complications (42%) or believed that it is against religion (20%).Other reasons included better marriage prospects (8%) and better sexual relations with their husbands (5%).
The results of the present study revealed that more than three quarters of FGC procedures were undertaken by traditional personnel such as TBA, barbers or gypsies.
A small proportion was undertaken by physicians or nurses.
Regarding the main decision makers about undertaking FGC, the present study revealed that fathers ranked first followed by mothers.One third of women specified physicians as the main decision maker.
Grand parents played the least role in this respect.Other studies such as Elbeih et al.
(1998) (34) , and Alaa El-Din (1998) (16) reported that the majority of their study samples specified mothers as the main decision maker about FGC.As for the knowledge of women constituting of the present study about the law that prohibits and criminalizes FGC, the results showed that almost three fourths are not informed about it.As expected, university graduates and workers were more likely to be better informed than the less educated and housewives.When the researcher told them about the law, more than a half stated that they are against such law and only one quarter endorsed it.
In fact, mass media was the major source of information about the law among the sample members of the present study.
One-half reported that mass media was their primary source of information.It is also important that such mass media be clear, specific, and unequivocal because quite a proportion of the sample stated that they got ambiguous messages from mass media.Rushwan.(1990) (42) , Mcauley et al.
Moreover, nearly two thirds of the sample believed that undertaking FGC is important and should continue.This is similar to the findings of Ekenze (30) et al. -All awareness creation activities should target both women and men. - coordination and partnership have been established between the United Nations, the International and National Non Governmental Organizations, the Civil Society and Governments.They worked to exchange information to get rid of the circumstances that deny women's social Bull High Inst Public Health Vol.40 No.1 [2010]

on
Population and Development (ICPD) 1994 and the Fourth World Conference on Women (FWCW) 1995 governments were called upon to set strategic interventions to end FGC.In this respect they were asked to adopt clear national policies for the abolition of FGC, support and encourage media, women's groups, education and pressure groups to start open discussions of FGC which formerly was a taboo subject, organize information and education programmers to inform people of the harmful effects of FGC, increase research into aspects of FGC and when appropriate issue legislation that prohibits and criminalizes FGC. (13,14)The Human Rights Conference (HRC) 2006 declared FGC to be contrary to all religions and a practice that should be criminalized.Also the conference calls on judicial institutions to issue laws that prohibit and criminalize this habit. (15)In Egypt, although the prevalence of FGC is declining yet the Demographic and Health Survey (EDHS) 2008 (8) data shows that over 90% of ever married women have undergone the procedure.Egypt follows the aforementioned strategy and works hard towards the elimination of FGC.Lately the Convention on the Rights of the Child recommended passing a law that prohibits and criminalizes FGC and the law was passed in 2008. (16-18)In fact the effectiveness of any law depends, to a great extent, on the cooperation of the society and their readiness to abide by it.
study was conducted at Kafr El-Sheikh governorate.Data was collected from five medical Health centers affiliated to the Ministry of Health.The five centers are located in: Kafr el-Sheikh city, Beila, Balteem, Saiedy -Salim and Al Hamool.These settings were selected because they selected almost all districts at Kafr El-Sheikh governorate.In addition, the clients who attend these centers represent various socio-economic and cultural groups.Subjects A total sample of 250 women attending the above mentioned centers were selected for this study.Fifty women were selected from each of the previously mentioned centers.Data was collected on all working days until the required number was reached.The systematic random technique was followed in the selection of the study subjects.The third comer on the registration record was chosen among women who happened to attend the clinics at the time of data collection.Tool of data collection A structured interview schedule was specially designed by the researcher to collect the necessary data.It was tested for validity and reliability.It entailed three sections: This section included questions related to the socio demographic characteristics of the sample such as age, address, level of education, and occupation.
each subject was individually interviewed before or after her antenatal medical checkup.The duration of the interview ranged from 10-15 minutes.Data collection started by the end of November 2008 and continued until February 2009.

Figure 1 :Figure 1 :
Figure 1: presents the percent distribution of the study sample according to their personal experience with FGC.As shown in the figure, the majority of subjects (98.4%) had undergone FGC and only 1.6% had not.

Figure 2 :Figure 3 :Figure 4 :
Figure 2: Distribution of the Study Sample According to Complications Suffered after FGC

Figure 7
Figure 7 illustrates the distribution of the study sample according to their opinion about continuation of performing FGC.Less than two thirds of the sample (63.6 %) figure reported by the EDHS 2008. (25)and by figure reported by other studies undertaken in other places of the country that FGC was performed to the majority of women when their age was 10 to 15 years by a non medical person who used a non sterile instrument and local herbs on the wound.In addition quite a proportion reported that they suffered from some sort of complications.It was strange that inspite of this suffering still many of the study sample as well as their husbands still endorsed FGC and stated that they undertook the practice for their daughters and had the intention to undertake it in the future.The main reasons given for undertaking FGC in the current study include decreasing the sexual desire, complying to social norms and adhering to religious rules.The reasons given to justify FGC are numerous and similar in almost all studies done in this domain and over the years.

FGC
include: rite of passage, preserving chastity, ensuring marriageability, religion, hygiene, improving fertility, and enhancing sexual pleasure for men.This indicates how submissive the clients are in sex matters, they perceive themselves as sex objects that ought to satisfy their husband.The results obtained from the Demographic and Health Surveys in Egypt in 2000 and

(
2005). (22)revealed that trained medical personnel undertook almost three-quarters of the procedure for its sample.Such discrepancy might be due to increased awareness of families of the complication of FGC as result of the widespread discussion in mass media of cases who died due to hemorrhage following FGC and the campaigns carried out by NGOs and MOH.The present study revealed that two thirds of FGC procedures were undertaken without the use of anesthesia.This could explain why more than one third of the sample still remember that they suffered from severe pain and shock after the operation.As to the substances applied to the wound after the procedure, the present study revealed that antiseptics such as mercurochrome, alcohol and betadine were used for only 44.8%.Other nonpharmacological substances were used for the rest of the sample.These later substances included oven dust, salt and water, oil, yellow alluvium and cigarette heels.Similar findings were reported by Laumanann et al. (1997).(33)This explains the occurrence of wound infection for quite a proportion of the sample of the present study.Regarding the place where FGC was done, the current study revealed that nearly 90% of all FGC were undertaken at homes, 9.2% in health institutions and 1.6% in the barber shops.This is similar to what Alaa El Din and Mostafa reported in Assiut (1996).(16)As to the instruments used for undertaking FGC, the current study revealed that traditional instruments such as razor blades, scissors and knives were mostly used.Surgical blades were used for a limited proportion.The use of these instruments coupled with the non use of anesthesia and the lack of knowledge of traditional healers who performed most of FGC procedures about the anatomy and physiology of the external female genitalia could explain the wide spread of bleeding, infection, severe pain and shock among the study sample (figure2).
least one quarter of infibulated girls suffer from one or more of the immediate complications of FGC.These include bleeding, wound infections, sepsis, shock, micturition problems and fractures.Girls are also at a greater risk for serious infections such as HIV and hepatitis B & C. At later stages of there lives, women may suffer from delayed complications such as anemia, infection of the urinary tract, incontinence, infertility, menstrual problems and dyspareunia.They may also suffer from perineal cysts and haematocolpos, during pregnancy and delivery, examinations and vaginal application of medicine are more difficult and prolonged delivery and wound infections are common.FGC also predisposes women for postpartum bleeding and perineal tears.Moreover, newborns of infibulated women may need resuscitation and their lives are compromised.Mental consequences of Fathers and grandparents played a lesser role.The difference between the results of the present study and the other ones might be due to the sites where the studies were done.The present study was done at a governorate where most of the population resides in rural areas.Fathers take the lead in decision making about family affairs including FGC in rural areas than urban ones.Moreover, when women in the present study were asked whether or not fathers agree to undertake FGC to their daughters in the future, more than two thirds gave a positive response.It is therefore important to target men in all awareness creation activities whether related to the harmful consequences of FGC or the law that prohibits it.

(-
2007).Positively, the findings of the EDHS during the years 2005, 2000 and 1995 revealed that the proportion of women who supported FGC and of those who believed that men prefer circumcised girls dropped over the years.(24, 25, 28,) Regrettably, mothers who undergone genital cutting during their childhood endorse the practice for religious and socio-cultural reasons.Although Islam is free of any practice that inflicts harm, still some people undertake such practices under the pretext of Islam.As to the opinion about FGC, the current study revealed that more than one half of the study sample were against prohibition and criminalization of FGC and only 27.2 % agreed that it should be prohibited and criminalized This is consistent with the results of the, EDHS (2005) (19) , which show that there has been some change over time Bull High Inst Public Health Vol.40 No.1 [2010] in women's attitude about FGC.However, these results reflect that more efforts should be put forth in order to eradicate FGC completely.CONCLUSION In spite of both governmental and nongovernmental efforts against FGC, its prevalence among the study sample is higher than the national figure recorded by EDHS 2008.FGC procedures were more likely to be performed at homes, by traditional practitioners and without the use of anesthesia so that the majority of the sample suffered from at least one of the immediate complications of FGC.A sizable proportion of women endorse FGC.Their main reasons were: to decrease the sexual desire of the girl, comply to social norms, create better marriage opportunities and insure cleanliness.Mass media was the main source of information about the law yet, at certain times mass media messages were ambiguous.As a result only one fifth of the sample changed their opinion about FGC during the previous year.RECOMMENDATIONS Based on the findings of the present study, the following recommendations are suggested: Governmental and non governmental organizations as well as the civil society associations involved in the eradication of FGC are required to pay special attention to Khafr El Shiekh governorate.

Table ( 1): Distribution of the Sample According To Their General Characteristics
old and 4.0 % got married at the age of 30 years or more.About one half of the study sample (48.4%) was married for 15 years or more and 11.2% was married for less than 5 years.Regarding the educational level, only 6.0% of the study sample had university education, 25.6% finished preparatory and or secondary education, 41.6 % were just able to read and write and 26.8 % were illiterate More than one half (55.2%) of the study sample were housewives, and 44.8% were working.

Distribution of the Study Sample According to Their Opinion about Continuation of FGC.
Mass media should intensify clear,