A total of 221 adults (over 16 years) participated in the study. Thirty-five people (29 women and six men) were interviewed face-to-face and 186 (142 women and 44 men) participated in the 19 FGDs. Information about the number of KIIs and FGDs conducted in each study district and the participants are summarised in Table 1.
Table 1
Number of KIIs and FGDs across selected study sites
|
KIIs
|
FGD
|
Study
District
|
Participants
|
No.
|
Age (years)
|
Sex
|
Participants
|
No.
|
Age (years)
|
Sex
|
Ampara
|
Moulaviya
Moulvi
Osthi Mami
|
2
3
2
|
30, 60
32, 35, 42
60
|
F
M
F
|
Professionals, un/married, Muslim
Un/ married, Muslim
Married housewives, Muslim
Un/ Married, Muslim
|
12
10
12
12
|
22–37
19–30
35–60
18–60
|
F
F
F
M
|
Colombo
|
Doctor
Lawyer
Civil Servant
Researcher
Professional
|
2
3
1
1
1
|
25, 37
58, n/a, 56
61
25
22
|
F, M
M, M, F
F
F
F
|
Professionals, un/married Muslim
Married housewives, Muslim
Professionals, un/married, Muslim
|
13
9
10
|
> 35
35–60
25–50
|
F
F
M
|
Kalutara
|
Nursing Sister
|
2
|
< 45
|
F
|
Professionals, married, Muslim
|
3
|
36, 39, 60
|
F
|
Mannar
|
Activist
Pre-school teacher
Moulaviya
Nurse Matron
Post Master
Osthi Mami
|
2
1
2
1
1
1
|
36, 50
35
28, 34
60
45
70
|
F
F
F
F
F
F
|
Moulvis & business men, married Muslim
Doctor, 2 midwives, Tamil, married
Midwives, married, Muslim
Professionals, housewives married, Muslim
Professionals, un/married, Muslim
Professionals, un/married, Muslim
Married housewives, Muslim
|
10
3
3
11
9
9
10
|
30–55
30–55
30–55
35–70
25–35
25–35
18–35
|
M
M, F, F
F
F
F
F
F
|
Puttalam
|
Islamic teacher
Midwife
Nurse
Osthi Mami
|
1
4
2
3
|
55
< 50
32, 54
50, 60, 75
|
F
F
F
F
|
Professionals, married un married, Muslim
Un/married, Muslim
Un/married, Muslim
Married housewives, Muslim
Moulvis & business men, un/married Muslim
|
9
8
10
12
11
|
18–35
18–35
18–35
35–65
25–55
|
F
F
F
F
M
|
Total
|
|
35
|
|
|
|
186
|
|
|
The participants included Osthi Mamis (traditional practitioners of FGM/C), Moulvi (male) and Moulaviya (female), Muslim religious scholars. We also interviewed an Islamic teacher working at a madrasah that provides teaching in the Koran and the Islamic faith for children 7–12 years. All KII participants were Muslim except for the Buddhist nursing sisters from Kalutara and a Doctor from Colombo and a Catholic nurse from Mannar.
The findings are described below according to the main themes from the template analysis.
Providers, procedures and associated rituals
Older women known as Osthi Mami were described as the main providers of FGM/C. Six Osthi Mamis across three sites described receiving training from their mothers or sister.
I was trained by my mother-in-law. She taught me when I was 17. Now I am 75 years old and continue to provide khatna. I have four girls. I have taught one of my girls to do this (Osthi Mami 1, Puttalam).
Some doctors were also reported to provide FGM/C. “Doctors are also doing it secretly. They do not abide by the law; some of them do it for money.”(Ampara FGD men). However, one nurse stated, “many the doctors don’t wish to do it”. (Nurse, Mannar)
Participants described ranges of procedures.
There are ladies who do this on the clitoris. Some make a tiny incision, some cut it off, some scratch it with the nail, and some just pinch it slightly and later put medicine on it (Nurse, Mannar).
Type IV practices such as cutting, nicking, pricking, scraping and scarring were described by most Osthi Mamis, and male and female participants.
I do not cut and chop …in the secret part of the women's body there is a piece above the urinating hole, I just take that slightly. Keep the knife like this [demonstrating] – keep thumb and index fingertips together and pinch and scrape. Slightly, like a piece like a fish scale it would come and bleed slightly (Osthi Mami 2, Puttalam).
Two Osthi Mamis described the removal of flesh that may include the prepuce and clitoris that is in line with type 1 FGM/C.
There will be a little pain when it is cut and removed, and it will bleed. We should see the blood a little and cut and remove the nerve. There is a separate knife for that, called an operation knife (Osthi Mami 3, Puttalam).
It was reported that FGM/C is usually performed between seven and 40 days after birth alongside various rituals. One participant said: “they keep the child semi-submerged in the water, make the cuts and then bathe the child” (Female activist 2, Manner). Some associated shaving the baby’s hair with the practice:
On the seventh day a cow or a goat must be given as ‘akeeka’ [Islamic tradition of the sacrifice of an animal and distribute the meat on the occasion of a child's birth]. This is done for the girl child on that day. Yes, akeeka is given when they shave the hair (Moulaviya 1, Mannar).
Osthi Mamis described using a knife or blade for the procedure. “Yes, one blade to remove hair with and the other to do Khatna” (Osthi Mami, Mannar). Another participant described using “Maikkaththi [special knives] and shaving blades are brought from shop. Safety means, can do only for one or two cases. I should buy four or four. I should throw them after doing (Ampara Osthi Mami 2).
Two Osthi Mamis from Puttalam described applying cotton wool to the wound and other substances. “I apply eau de-cologne after bathing them, then it [the pain] will be reduced” (Osthi Mami 2 Puttalam). In Mannar, an Osthi Mami applied talcum powder to stop the bleeding.
The age and health status of the Osthi Mamis was seen as an issue by women and the Osthi Mamis themselves for fear that they may make a mistake and cause injury. One woman said “I was afraid as I saw her [the Osthi Mami] trembling” (FGD young women, Mannar). An Osthi Mami recalled that she “was asked not to do [FGM/C] if her hand was trembling” (Osthi Mami 2, Ampara). However, another Osthi Mami said, “There had been no such problems. Even though some say that, I have eye issue due to my age and diabetes. Most people say that even though I am old, I have never made a missed a cut, ever” (Osthi Mami, Mannar).
Demand and Decision-making
Some participants noted that FGM/C is an enduring yet clandestine practice “yes it is continuing. It is happening, though women treat it as a secret” (FGD men, Ampara). One participant recalled a recent event, “Only last week there was a new baby and she [Osthi Mami] was called in to do it.” (Older women, Colombo).
Participants spoke about the social pressure to practice FGM/C. “Educated people are against this but if their parents are culturally oriented people then they would force them to not stop this and under this pressure they would do it” (Female researcher, Colombo).
Family members were largely credited with suggesting that FGM/C be continued. This included mothers, grandmothers, mothers-in-law and sometimes men. Participant opinions varied regarding how the decision was made concerning the practice of FGM/C. For some participants this was a communal decision. “It usually a village decision. (Female activist 2, Mannar), “It is the decision of the mother and father to do this” (Nurse, Mannar). However, mothers-in-laws were reported to be very influential. “The Mother in law of my daughter was told it is compulsory.” (FGD older women, Puttalam).
Some participants noted a change in the prevalence of FGM/C: “It was 90% ten to fifteen years ago. It has been reduced due to awareness of fathers and the education level of mothers. It could be reduced to 15–20%” (Moulvi 2, Ampara). Osthi Mamis commented on the change in the demand for FGM/C and its impact on their livelihoods.
Some of them [Osthi Mamis] say that we are doing [FGM/C] for our survival. We are invited once every six months or once a year. We could be starving and lacking money until that time. We used to do [FGM/C] once a month. I am not going to accept it [the current situation] (Osthi Mami 1, Puttalam).
The role of religion
One religious scholar interviewed in this study identified three groups with different opinions on the matter of FGM/C; “one is, who has given a fatwa on this issue, another said it is not necessary for women and then there are ones who say ‘do it if you like’” (Moulvi 1, Ampara). Those participants who described FGM/C as a “compulsory” religious obligation (FGD young women 1 and 2, Puttalam, Moulaviya 2, Ampara) also linked it to a religious custom. One participant stated, “It is because it is a Sunnah [traditional Islamic custom and practice, both social and legal, based on the verbally transmitted record] and so must be done - Like how there is Khatna for men, there should also be Khatna for women.” (FGD older women, Colombo). Others said that is approved by the Prophet Muhammad, and therefore, “It should be done. There are Hadeez [a record of statement, or action or tacit approval of Prophet Muhammad] for that” (FGD men, Puttalam). Reference was made to the fatwa justifying FGM/C made by the All Ceylon Jamiyyathul Ulama. One male participant strongly suggested that Muslims were treated as outlaws for practicing their religious customs: “It is in Islam and it should be done for children as it is mentioned in Islam. It is outsiders who make this a huge issue and try to criminalize the Muslims” (FGD men, Puttalam). Some participants regarded circumcision as a religious obligation for males but not for females, “Islam doesn’t require women to do it, but has made it a must for men” (FGD professional women Mannar). However, a Moulvi from Ampara stated that new Islamic thought does not call for FGM/C because the “Hadeez are fake”. This Moulvi and FGD participants from Puttalam and Ampara pointed to the views of other religious and medically trained leaders who called for FGM/C not to be practiced.
While some participants were certain that FGM/C was a religious obligation, they could not recall or were not aware of the rationale for performing it. Even religious leaders could not point to the exact reason: “I am not aware of any proof, but yes it is part of Islam (Female Moulaviya 1, Mannar). Osthi Mamis were also unsure of the reason for the practice but that it had been undertaken for generations. However, they continued to practice FGM/C: “They said that this wasn’t part of Islam, but they say that it is. I still keep doing this around my usual circuit” (Osthi Mami, Mannar).
FGM/C was reported to be a requirement for women who wished to marry a Muslim man and convert to Islam. An Osthi Mami described:
I did this to a woman who had embraced Islam, after teaching her the Kalima [texts to memorize to learn the fundamentals of Islam] and bathing her. Similarly, there was a girl who eloped and I did it for her too after she embraced Islam. For older women, I usually take them to V.O.G [visiting obstetrician gynaecologist] and they would instruct me on how to do it. I would ask them to shave and clean themselves and then I come and do it [the FGM/C] (Osthi Mami, Mannar).
Anther Osthi Mami stated that she performed FGM/C to facilitate conversion to Islam alongside punishment that was handed down by religious leaders because a woman had sexual intercourse before marriage:
The mosque board would instruct me to do it. Then I would perform Khatna for them. If there other complications, such as sins, then the mosque would ask me to give the appropriate punishment-hundred and one beating- to the women while the mosque board would carry out that punishment for the men. Once that is done, I would perform Khatna and then bathe her, teach her to pray and all other things in Islam. Is she is a learned girl then I would advise her to be serious about this and to increase her knowledge by reading (Osthi Mami, Mannar).
Perceived benefits and adverse outcomes
The participants cited a number of health benefits that they believed to be associated with FGM/C. One nurse said that she had heard that FGM/C promotes sexual health and relationships saying, “They say they have good family life and sexual relationship” (Nurse 1, Puttalam). Several participants described the importance of FGM/C to moderate women’s sexual behaviour, safeguard monogamy and “prevent extramarital sex” (female Doctor, Colombo). A health professional said, “It is a ritual to keep women from not going astray; not to have affairs etc.” (FGD health professionals Mannar). An Osthi Mami stated that if FGM/C was not performed: “the child would become uncontrolled or with more sexual feeling if [the clitoris] is not taken off” (Osthi Mami 3, Puttalam).
Four participants described sexual problems, including difficulty with attaining pleasure and associated pain. One woman explained that one issue was “Taking a long time to climax and sometimes I am told women do not climax.” (Female activist, Mannar). A doctor stated that women could have “pain during sex due to exposure of nerves” (Female doctor, Colombo).
FGM/C was reported to promote cleanliness, prevent health issues that in some cases, was associated with religion. “Islam encourages this so as to avoid germs and remain healthy” (Female Moulaviya, Mannar), while others said that FGM/C “Removes some dirt which comes with us when we are born” (FGD young women, Puttalam). One woman explained that FGM/C “Can control some diseases and remove bad blood.” (Ampara FGD Professional women). An Osthi Mami stated that it “would prevent getting infected by cancer” (Osthi Mami 1, Ampara). FGM/C was also cited as “reducing all possibilities of having any urinary problems” (FGD young women, Mannar).
The health benefits were also questioned by religious leaders “I don’t think there is a benefit. There is nothing like hygiene in Khatna for women. No benefit in the hygiene and sexual satisfaction” (Moulvi 2, Ampara).
Some participants were concerned about the infections that FGM/C exposed women and babies to, “the only problem that may come is the child being infected.” (Nurse, Mannar). This, according to one woman, was due to the Osthi Mami “using unclean instruments with no training”, (FGD older women, Ampara). Two nurses from Kalutara and two midwives from Puttalam said that they had never seen any infections or obstetric issues associated with this practice. One midwife stated, “It is not a problem, there are bigger issues, like children of one group of Muslim women are not immunized because they are against it, and having home deliveries” (Midwife 3, Puttalam).
Despite this, one participant described issues with Type 1 FGM/C: “Some people take off a large part (of the clitoris) and have faced a lot health related problems and complications.” (FGD older women, Colombo). Problems were noted by another participant who said, “I recently heard of something going wrong because of an inexperienced lady doctor doing this to a girl baby” (Female researcher, Colombo).
A number of FGD participants stated that they did not believe that there were any harmful effects of FGM/C: “there is nothing to fear as it doesn’t have any negative effects” (FGD young women, Mannar).
Ways forward for prevention
Many participants supported the prevention of FGM/C and that it should be abandoned in the future. They highlighted the importance of involving community figures and organizations in the communication of FGM/C prevention messages and inspiring change.
We should bring social change through socially accepted persons. These ideologies should be spread to the community. It would be easier for the next step. I feel that we [religious leaders] should make the first effort. We should empower like-minded people, such as Moulavis, doctors, social civil organizations, and village-level committees and spread the message through them. I think these efforts have to be made (Moulvi 2, Ampara).
Raising awareness for prevention, particularly “bottom-up” approaches were seen as a key priority: “We can stop this if we create awareness and do activities related to this, we can do it” (FGD Professional women, Ampara). Parents, students, and men were identified as important groups that should be involved in awareness-raising activities. School and workplaces were regarded as important sites for awareness-raising and the use of the Media as well as social media to transmit messages.
One nurse described the importance of women as change agents:
If Muslim women were to be made aware and decided to end [FGM/C], then it could be stopped. There are Muslim women of a higher level who should come together and raise awareness towards this matter. This is an issue for women. They can even come together with women from other communities to raise awareness about this. The women’s organizations could reach out for more support from other women and men. The support of men is important to stop this (Nurse Mannar).
Education was described as important. Several health professionals spoke about the usefulness of in-service education on FGM/C that she had received (Nurse 1, Kalutara) and one FGD participant said that they would like to receive education and a certificate on FGM/C (FGD old women, Ampara).
The need to involve religious and political leaders was noted by a number of participants because “to date no religious, political or community leaders have said FGM/C needs to be eradicated” (Female activist, Mannar). Participants cited the need for policy change as well as awareness activities: “you need to make policy decisions as well as awareness interventions from the policy level to the community level. Government involvement is not enough" (Female doctor, Colombo). A doctor said, “We need to get a few experts’ ideas and get some unbiased male religious people to say that it [FGM/C] is not required. Then it will be easy for uneducated people to justify not doing it” (Female doctor, Colombo). One Moulivaya said, “If they [the government] were to prohibit it, we should provide evidence from the Quran and Hadiths so that they [community people] can’t continue this anymore” (Female Moulivaya, Mannar).
The establishment of laws to prevent and eliminate FGM/C was also discussed. “We should we try to ban this by law” (Moulvi 2, Ampara). However, participants spoke of the need for a diplomatic and systematic approach to achieving this. One Muslim doctor said,
I think it is possible, but only with tactful measures. Bold measures such as criminalising the practise without understanding the concerns of the community could prove to be counterproductive and attract more people to this practice, which is, in fact, diminishing in my community (Male doctor 1, Colombo).
Participants also identified the need to be cognisant of the sensitivity of this subject matter and the risks taken by those who speak out against FGM/C: “A few of us who spoke against it were attacked, shamed and threatened including a few women rights activists, a couple of women politicians and a few educated men” (Female activist, Mannar).