Female genital mutilation in Sierra Leone

Abstract: Background: The prevalence of female genital mutilation (FGM) in Sierra Leone is the seventh highest in Africa, yet little research has been done on its effects on girls and women. Objectives: This thesis aims to provide knowledge on the effects and experiences of girls and women, and the views of adolescent boys, about FGM which is performed within the initiation ceremony of the Bondo Society in Sierra Leone. Methods: The thesis is built around four articles (I to IV) analysing data collected in the Northern and Eastern Provinces of Sierra Leone as well as in the Western Urban Area of Freetown. Women and girls (n=1018) were recruited for articles I – III, and adolescent boys (n=75) for study IV. Results: Most of the decisions (65.1%) for FGM were made by females, with males deciding in 30.7% cases. Although the operation of FGM is performed mainly by traditional excisors, medicalization was reported in 13.2% of cases. FGM-related health complications were reported by 84.5% of the 258 respondents, the most common ones being bleeding, delay in or incomplete healing, and tenderness. Fever was reported by 46%, suggesting a more severe infection, but significantly more often among pre-pubertal girls. A total of 85.8% of those with FGM-related health complications sought treatment. A total of 47.6% received treatment from a traditional healer; 40.1% from a traditional excisor; and 8.6% from a nurse. Three forms of FGM were identified: type Ib (31.7%), type IIb (64.1%); and type IIc (4.2%). Results from logistic regression analysis for the outcome variable FGM showed that increasing number of previous pregnancies, rural residency, religion (Islam), being married and illiterate are factors associated with higher prevalence of FGM. There was a high level of agreement between reported and observed results for FGM status – 99%. However, respondents could not accurately describe the cutting extent, and we found that the DHS FGM module responses were not reliable for determining FGM type. Most adolescent boys (69.6%) considered Bondo a bad practice because of FGM, whilst some considered Bondo good because it is the culture and safeguards against stigmatization. A third of boys reported that girls face complications from FGM such as bleeding, fainting and death. The majority of boys (61.4%, n=43) would marry a non-Bondo member because they are viewed as more healthy and pleasant to have sex with. Qualitative analysis of the open ended responses from the boys identified three stages: “Becoming, Being and Belonging”. At “Becoming” – where FGM is performed, boys saw economic burdens for boys and health burdens for girls”. At “Being” a new status and respect was conferred on girls through public celebration. At “Belonging”, the boys lamented their lack of access to the Society, but were proud of new skills and value the girl now has. Interpretation: The results described in this thesis highlight the role men play in the decision making process for joining Bondo/FGM. The indication that FGM-related health complications are high is a cause for public health concern. That health professionals perform FGM is a serious cause for concern, as well as the lack of visibility of FGM-related health complications in the health care system. It may be possible within certain contexts in Sierra Leone to use self- reporting responses as a proxy measurement for FGM status, but not for form of FGM. Adolescent boys express ambivalence towards the practice, lamenting the potential harmful health effects of the FGM to the women and the economic burden the ceremony places on men, but also see the value of the Bondo initiation ceremony. Conclusion: This thesis suggests that the practice of FGM in Sierra Leone merits much more attention in research and policy in order to further identify and understand the effects that the practice has on girls and women.