Social Perspective of Female Genital Mutilation/Cutting in Khartoum State – Sudan

Background: Female genital cutting (FGC) comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female organs for non-medical reasons and it is considered as violation of human rights of girls and women. The overall objective of this study was to explore the social factors contributing in the persistence of this practice despite of the efforts for eradication in Khartoum State-Methods: This was a community based cross-sectional study conducted in Khartoum State- Sudan including the three localities. The study included 920 females within the reproductive age, sampled proportionate to size using multistage cluster sampling The data were collected using standardized administered questionnaire, Data were analyzed using statistical package for social science's version 21. Analysis was composed of descriptive data and Multinominal Regression Test to study the associations between variables of interest. : while the main reason for the conduct of female genital cutting ranked the second place in influence as the regression coefficient of this variable is .089. Conclusions : FGC is a cultural practice recognized as a violation of human rights. These findings support the social coordination norm model, and results indicate the widely prevailing misconceptions about FGC/M among the study participants especially among those participants supporting the continuation of FGC/M.


Background
Female genital mutilation (FGM) 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 (Mseddi et al., 2020). FGM is mostly carried out on young girls between infancy and age 15 and it is considered as violation of human rights of girls and women("Female Genital Mutilation/Cutting: A Statistical Overview and Exploration of the Dynamics of Change," 2013) .
More than 200 million girls and women alive today have been cut in 30 countries in Africa, the Middle East and Asia where FGM is concentrated (Wright, 1996) Inspire intensified efforts to reduce FGC/M in Sudan but the practice continues, the The eradication of FGC/M has been included within the national RH and other sectoral policies and strategies and the concerned bodies emanated interventional programs across the country but still the reduction in the prevalence is slow and lagging behind.
FGC is carried out for a range of social and cultural, traditional reasons, in some cultures, parents submit their daughters to FGC not as a means of punishment or abuse, but as deeply rooted beliefs, they think FGC will give them social acceptance. FGC is performed in order to prepare girls for adulthood and marriage; to ensure their virginity until marriage; to ensure their fidelity in marriage; in certain communities, it is thought to increase fertility and to enhance the sexual pleasure of men (Gruenbaum, 2005) . Men play a role by preferring to marry a woman who has undergone FGC, or by insisting that it be performed on their daughters.
The aim of this study is defining the identity of women in cultures where it is practiced, to explore the social factors that will help in generation of valuable information for the policy and decision-makers to upgrade the current policies and strategies to accomplish FGC/M eradication by the year 2030.

Methods:
This a community based cross-sectional study was conducted in Khartoum State; the capital of Sudan with an area of about 22.122 km 2 . The study included three localities; Khartoum North Locality, Sharq an-Nīl Locality and Umbadda Locality.
The study concerned with women in the reproductive age (15-49) and the total census of women at this age in Khartoum State, projection 2018 estimated as 2,014,382 (25.2%).
The sample size was estimated using the population formula n= N/1+ (N*d 2 ) and calculated as 920 participants considering the design effect of 2 and response rate at 15%.
The sample size was collected proportionate to size using multistage cluster sampling ,the data were collected using pre-coded, pretested administered questionnaire. Data were managed and Descriptive analysis was completed for background information and bi-variate analysis for cross-tabulation using Multinominal RegressionTest, we was performed to study the associations using The Social Program for Statistical Analysis (SPSS) version 21.         The "Wald test" was conducted to recognize the significance of the logistic regression coefficients in the model. The calculated value of Wald test was smaller than the value of the level of significance used and accordingly the alternative hypothesis that the regression coefficients are accepted is assumed. As shown in Table No. (6), the regression coefficients can be explained as follows:

Results
The variable "the risk encountered when girls are not subjected to female genital cutting" ranked the first place in influence as the regression coefficient of this variable is

68.779.
The variable "the main reason for the conduct of female genital cutting" ranked the second place in influence as the regression coefficient of this variable is .089.

Discussion
About 89% of the study participants were married and 48% of them got married for the first time at age less than 20 years. 99.8% of the study participants were Moslems and 77.5% were currently urban residents. 86% of the study participants have had daughters and 32% of them have two daughters. 32% of them have one daughter less than 14 years. The median of the total monthly income of the participants' families in Sudanese pounds was 5,000 while the mean was 5,937 with SD ±5.937. 88% of the participants' families practiced female genital cutting and the commonest age for such practice was 6-7 years as stated by about 48% of them. (Table 1) 53% of the study participants described girls who have never been subjected to FGC/M as Saleema while 28% described them as not circumcised and 18% as unclean (figure I).
The result indicates the positive attitudinal change of the participants towards girls who have never been subjected to FGC/M and this is due to delivery of effective IEC messages and awareness rising about FGC/M practice.
60% of the participants ever discussed female genital cutting with their husbands while 40% never discussed it as shown in figure (I1). 54% of the participants' husbands disagreed to female genital cutting while 43% of them agreed to it (table 2). The results reveal that the issue of FGC/M of daughters at the family level is still considered by a good proportion of the study participants as the responsibility of women rather men.
39% of the participants stated that they themselves influence the decision to subject their daughters to female genital cutting while 32% of them stated that the grandmothers influence such decision (table 3). The result revealed that the influence of the decision to subject daughters to FGC/M is shouldered mainly by the mothers and grandmothers. The results are comparable to a recent study in Sudan, where 38.8% of the respondents stated that mother's girls initiated the discussion on the need to conduct FGC/M and 37.6% of them identified the mother as the person involved in the decision of FGC/M (Eldin et al., 2018). Similar results were reported from Ethiopia, where the decision to have FGC/M was made by respondents' mothers, followed by grandmothers although the percentages were different (Gebremariam et al., 2016).
Another study from Somali Region, Eastern Ethiopia reported that 70.3% of the respondents stated that FGC/M was decided by mother and 28.4% of them stated that both mother and father made the FGC/M decision and none of the participants mentioned that only father could decide by himself to conduct FGC/M for daughters (Abdisa et al., 2017).
71% of the participants considered female genital cutting as a harmful traditional practice while 26% did not consider it as such ( figure I11). The result revealed that the perception of most participants is inclined towards framing FGC/M as health issue and even a quarter of them did not perceive it as such. Such perception may be related to the delivered IEC message that focused on FGC/M health effects rather than addressing right-based and gender-based violence approaches.
The results indicate that less percentage of the participants perceived FGC/M as a violation of their rights and a form of gender-based violence against women and girls.
Again, this might be related to the poor addressing of FGC/M as gender-based violence and violation of girls' and women's rights within the delivered IEC messages.   (Berg et al., 2014) .
The reaction of the participants in case her daughter is rejected by her husband as she has not been subjected to FGC/M) varied from no reaction (34%) to blaming the husband (28%) and support conduct of FGC/M. However, the reaction of the participants is different in case son married and his wife has not been subjected to husband (Gruenbaum, 2005).