#EndFGM: Researching to End FGM/C in a Generation

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200 million girls in 30 countries have undergone female genital mutilation/cutting (FGM/C) and 13 million girls under the age of 15 are at risk of undergoing FGM/C. Dr. Jacinta Muteshi-Strachan, FGM researcher with Population Council, sits down with us to discuss FGM/C, (which occurs in 30 countries across Africa, Asia and possibly South America), and the impacts surrounding this severe violation of the human rights of girls and women around the world.

FGM/C involves the total or partial removal of the external female genitalia for non-medical reasons. There are extreme physical impacts of this procedure, including but not limited to pain, trauma, bleeding, and heightened risk for complications related to pregnancy and delivery. There are also lasting psycho-sexual impacts of FGM/C.

The WHO has identified 4 types of cutting depending on the practicing cultural group. Reasons for FGM/C vary from community to community, but many include preparing young girls for marriage and adulthood, managing chastity or sexuality, or for beautification reasons. The most common age group to cut is between a few days after birth to 15 years old. While prevalence of the procedure seems to remain generally high, declines are evident in Kenya, Nigeria, Togo, and Benin.

FGM/C is a cultural and social norm and people who practice it do so because others in the community are practicing it. So in order to address FGM/C, we need to work to change those norms. It is vital to engage with those who have a cultural influence and to engage communities in dialogues and conversations around norms. Unfortunately, there is no ‘silver bullet’ when it comes to addressing FGM/C. It is a complex issue that can be very community specific and therefore many different responses will be needed. But, it is possible to highlight what is working in communities that have ended the practice and to offer alternatives to FGM/C.

In order to address FGM/C we must get a clearer picture and that means more research. We need to study the nature of interventions being taken to address FGM/C (what is working and why), look at the wider impacts of FGM/C (it’s relation to HIV/AIDS, child marriage, fistula, etc.), and analyze social norms more deeply.

While the picture still remains incomplete, it will be hard to accelerate the progress being made on ending FGM/C. To get a clearer picture, we need to invest more in research.

Links from this episode

Population Council on Facebook
Population Council on Twitter
Population  Council’s compendium of FGM/C data
Population Council's information of FGM/C

Transcript

Jennie: Welcome to rePROs Fight Back a podcast on all things repro. I'm your host Jennie Wetter. In each episode, I'll be taking you to the front lines of the escalating fight over our sexual and reproductive health and rights at home and abroad. Each episode, I will be speaking with leaders who are fighting to protect our reproductive health and rights to ensure that no one's reproductive health depends on where they live. It's time for repros to fight back.

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Jennie: Welcome to rePROs Fight Back. In this week's episode, we're going to tackle another human rights violation facing women and girls around the world. More than 200 million women and girls alive today have undergone FGM in 30 countries. Helping me dig into this topic I'm excited to have with me today, Dr. Jacinta Muteshi-Strachan from the Evidence to end FGM/C Research to Help Women and Girls Thrive Project at the Population Council. Welcome Jacinta, thanks for being here.

Jacinta: Thank you very much. A real pleasure to be here today.

Jennie: Um, so let's start at the beginning and tell us a little bit about where and when and why FGM is practiced.

Jacinta: That's a very big question.

Jennie: Yeah. And I guess I just, I already slipped and started right away with acronyms. We shouldn't do that. Uh, we can use it after this, but, um, FGM, what do we mean when we say that?

Jacinta: Okay. A FGM or FGMC means female genital mutilation cutting. It's a cultural practice, found across possibly now we think 30 countries in Africa, in Asia, and possibly even South America. And FGM/C is procedures that involve the removal either of partial or total external genitalia of females and for nonmedical reasons.

Jennie: Um, and there's a wide range of what happens, right? So, you know...

Jacinta: Yes, that's true. Um, WHO, which is the World Health Organization has identified four different types of cutting. They range from very extreme forms to forms that are sort of pricking, nicking, or cutting at, at at the least extreme form. So the forms therefore will also vary depending on the cultural group. Groups also, or communities that practice practice for a variety of reasons. They practice because it's how they prepare their girls for marriage. They practice because this is how they prepare young girls for womanhood or adulthood. They practice as a means of ensuring chastity or purity. Or they may also practice depending on the community because they consider to be beautifying of a woman's genitalia. And they're practicing it, and I say chastity, but sometimes it's also goes beyond that in the sense of managing women's sexuality. So those are the reasons it is practiced, but the reasons will vary from community to community. The other thing to note about it is that our current estimates show that um, something like 200 million girls in 29 countries have undergone FGMC and we also think that's 13 million girls will be at risk, 13 million girls under the age of 15. Uh, given our current estimates and research are at risk of also facing FGMC.

Jennie: Well, and I think that's important and we're talking about under 15 is that it usually happens on very young girls, right?

Jacinta: Yes. Generally in most communities, and given our, the evidence we now have, it tends to be between the ages of zero, zero meaning from a few days after birth to about 15 years of age. That's the most common age group it happens. It's very rarely happens on adult women except in some communities. Um, and also we, we, uh, we are seeing that when a woman has an or a girl hasn't been cut, that it can happen again or not happen again. It can happen later when she's getting married or when she is married or when she's giving birth to her first child. So this is communities for whom it is a cultural practice. Okay.

Jennie: Um, what are some of the biggest pieces of misinformation that are around FGMC?

Jacinta: One of the biggest ones actually is that, um, the is the tendency to think that people practice because it's a religious obligation. Uh, we now know and in fact from engaging with communities that have always practiced it because it's religious, but it is, it is not a religious decree that there is no basis in any religion, uh, to cut, um, or to practice FGMC. The, the other often sort of misinformation around this issue is that, um, and it goes in two ways that either it's a woman's issue or that it's women who practice and cut and are responsible. And we know that that is actually a rather simplistic explanation of it. Um, because women, yes, indeed do prepare their daughters for FGMC, but they're doing it because they live in communities where it is the norm, what you need to fit into your community. So it's, it's not that women make this decision because, and therefore the responsibility is entirely theirs. In some communities, yes, men are also involved in, in, um, sustaining the practice, but we also know increasingly given our data that there are increasing number of men who are not supportive of the practice. So I think those two things have to be understood more in the sense of the complexities around them. That its not a simple answer.

Jennie: Um, so, you know, we touched on this a little bit that a lot of people view FGMC as being rooted in social and cultural norms and so that there's no way to change that. Right. So what would you say to those people?

Jacinta: I think one of the biggest findings we now have is actually understanding that FGMC is a social norm. And that means that, it is a shared behavior, that people who practice it to do because they believe that others in the community are also practicing or cutting their daughters. And so one of the lessons we've learned over time is that one of the ways to begin to address social norms because you're so deeply rooted in communities or underpin many cultural practices, is to actually begin to engage with those who influence what we call cultural influences. So the kind of conversation can begin around the importance of these cultural practices. It's also meant, uh, the need to understand, um, how do you change a social norm, right? Uh, given the power of social norms and some of the current work we see where there's been some successes has been mainly because you're engaging communities in dialogue and conversations around norms so that you're understanding why it's important to them. Your understanding, therefore, what alternatives can be offered if the intent is the, the reasons I I highlighted earlier, right? How do you manage the chastity of young girls? How do you protect your young girls? So the, in the conversations you can begin to think about and understand some of the concerns that families have around their daughters and how can those be addressed beyond cutting their daughters.

Jennie: Addressing a social norm or changing cultural norms seems really complicated and that it would take a really long time. So how long do you think, you know, a tackling that would take?

Jacinta: That's actually a very difficult question in many ways because the work around social norms or using social norms change is relatively recent work, or at least the focus on it is relatively recent work. Uh, the are examples of projects, for example the Costan project that has used this for longer periods of time. And we're looking forward to actually learning how that works. Part of the constraint and challenge we faced in this work has been understanding what is it that people do? When I say people do, I mean those organizations, those advocates, when they seek to support abandonment. The challenge for many is that they're not often documenting in ways that help us understand the steps they've taken, the way the organize, how the particular interventions will work, what informs the selection of particular interventions that they have, and are they monitoring and evaluating the interventions that they have in sort of seeing the same thing in terms of what, what I'm raising here. because when we speak of social norms, it's important to understand the power of the norm. The fact that women and men are in relationship to each other. Societies have to think of and do figure out ways in which they manage those relationships and we know, yes, in many cultures and in many societies, women's positions tend to be sort of secondary or lower than those of males. So those conversations are therefore going to be actually speaking to or targeting what are very complicated issues and very challenging issues in communities. In some communities, we've heard it moves quite quickly that when these types of conversations begin to happen, people may begin to consider alternative ways of addressing the issue.

Jacinta: A good example would be what we see, what we see in Kenya and it's called the alternative rights of passage. So here there was the understanding that um, for this particular community that circumcised or cut their girls in preparation for womanhood, were doing it for those very reasons. So the girls would go through particular ceremonies, particular, particular rights of understanding what does it mean to be a woman? What does it mean to be a mother? What does it mean to become an adult? How do you fit into the society in which you were born? So the question then became, can those things still be done without cutting your daughter's? So an alternative rite of passage was developed in, in consultation and in communication with those communities. And what we've seen now over time, because this has been in practice over time, is that those communities be moved to alternative rites of passage. It's one of the interventions that we've seen as being successful. So, and when we have evaluated them, we've seen there is change in attitudes. So I think the work going forward will be to actually seek to understand did the behavior remain sustainable? We think it has because when you look at the same communities that I'm speaking about that have alternative rites of passage, we see that prevalence rates have dropped or have been on the decline over time. So what that points to us or raises as a key way of looking at this work is the need to understand always, when you speak about FGM, when you seek to address issues around FGM, that you understand the specific cultural practices of communities that there is no one blanket response. It's about understanding why communities are cutting their daughters. Uh, and what would encourage them to abandon the practice and therefore what types of responses you would need to put in place. And those responses would be diverse and would be varied because, uh, FGMC is very ethnic based in the way it's, um, determined in the way in which communities respond as well.

Jennie: I think that's really important because so many times advocates are looking for, you know, the so-called silver bullet, the one thing we can tell people to do that's going to fix x problem and it's really important to see that it's, it's really complex and you need to look at a whole range of things.

Jacinta: Yes, you, you, you certainly do. And we look at the work as it has evolved over time. You'll find they've been so many different types of approaches put in, put in place, right? There are approaches in some communities that focus on health approaches, and there are communities where you do alternative rites of passage like I've just mentioned, there are communities where social change, particularly social change through community dialogue have become the mode that in which you engage communities. We also now have, um, countries where the implementation of policies and law has been one of the ways in which those interventions are allowed. And because we are studying what is happening with all of these interventions, we also need to highlight that they've been inconsistencies in the way those interventions are implemented. They're not always implemented in the same way. So there's need to really understand what were people doing, cause they'll often call them the same thing. So you may have people saying we've had in our community, um, even alternative rights of passage when you look closely, but it's actually not necessarily implemented in the same way, right? People say they have community dialogue conversations, you look closely, but they're not actually the same. Countries will implement laws and you look at the content of the law, they're not the same across countries. So the results are going to be different. So I think the biggest contribution we will be making as Population Council is to begin to understand what exactly has been happening around interventions. How have nation states responded, particularly those with high prevalence. Um, and where we've seen trends change, what have they been doing right? Where we've seen communities stopped the practice, what does that look like and how did that happen? So that is the work of research and that's the evidence that over the next few years we hope to be generating and sharing more widely.

Jennie: Oh good. So this leads perfectly into, do you want to tell me a little bit more about, uh, the work that you are focused on?

Jacinta: So beginning in 2015, uh, we were in receipt of um, a grant from different, that is UK aid, uh, to undertake research around FGMC to address the gaps that persist around our understanding of FGMC. Uh, and it's important to note actually that many years had passed before um, there was interest again in the looking at the gaps and providing resources to support research. That that hadn't been there since, um, sort of the previous commitments actually from, from USAID, which led the foundational work of looking at FGMC per Population Council that is. And so this recent commitment of resources to address those gaps has been a very positive step forward. And so we have primarily four broad areas of research we are looking at, uh, but within these four broad areas, there is, um, a multitude of research projects.

Jacinta: Uh, the first broadthematic area of our work is called building the picture and building the picture is to keep deepening and broadening our understanding around the practice that FGMC. Uh, because there are countries where we have very little data or information or knowledge about the practices, the practices of where and when and why and if there's any change happening, uh, we don't have enough information. So as I said earlier, we currently have, for example, national prevalence data for 30 nations or 30 countries. But there are countries where we know that there is FGMC and there is no national data available such as India, Sri Lanka, Iran, Malaysia and Pakistan to name some. And also we don't have prevalence data for the United States either. So, um, this is part of building that picture. Granted our work, our research work is focusing on seven African countries. Uh, those seven are representative of countries where there's still high prevalence and universal prevalence. And then countries where we're seeing, yes there was high prevalence but it's beginning to change in positive ways and countries where there has been significant changes in the practice. So that's building that picture and we're even bringing new tools with regards to how you make sense of um, a survey data, which is the main means of collecting much of the prevalence data that we have. Uh, and what that is doing is for example, is we are saying it's all very well and good to have national prevalence data because it's how we even begin discussions about where FGMC is. But for purposes of policy, for purposes of strategic investment, for purposes of targeting interventions, you need to be able to identify what we are calling currently the hotspots, which means you have to move to subnational data. So we have begun, our first example is Kenya. That's where we have began the work. And this year we are expanding it to Nigeria and Senegal and hope to expand it to the other countries if resources allow. So that's the main big theme about understanding what the picture looks like. Um, and it may be interesting to add here that one of our early findings also around building the picture is increasing medicalization, uh, with regards to FGMC. So the percentages don't seem so high then 27, 28%, but those percentages represent, uh, several million young girls. And so that is something that's pointing us in the direction. That's what the evidence is doing. Pointing us in the direction of where we need to be working.

Jennie: And do you maybe want to stop for a second and talk about what, what medicalization is. I know what you're talking about, but I feel like it's a lot of our listeners might not know.

Jacinta: That's actually a very good question. Uh, what that means is that, um, as we look at communities now, our studies are now, we are noting that, uh, communities are moving away from, um, increasingly moving away, not all, but many communities are moving towards the using, uh, health care providers. In other words, health professionals, like doctors, like midwives, like nurses to provide the service. Uh, and, and even that in itself is interesting because in Egypt it will tend to be medical doctors, right? While you look at Sudan and Somalia, you will find it's mostly midwives and, and nurses. And in some contexts you will find, um, for example, Nigeria and Kenya that it will be some doctors as well and nurses, but primarily medical doctors will be, has been Egypt. That's what the evidence currently shows. So that's what medicalization means.

Jennie: Right. Good. Perfect. Yeah, no, thank you.

Jacinta: And so that's the first thing and we will probably come back to medicalization cause there are some interesting things to talk about.

Jennie: Okay, good.

Jacinta: Uh, and then, uh, the second, uh, broad thematic area, again with several research projects underneath is the one where we are asking the question, uh, what is the nature of interventions? Are they working? Why are they working? where are they working? Well, what have people have been doing to respond to FGMC? Of particular interest of course, cause people want to learn what will work. Um, this is early work yet, but the, the, the, the evidence should be coming in very shortly. Um, and I've shared some of the types of interventions such as health approaches such as alternative rites of passage, community dialogue. Those are some of the interventions that, uh, that exist. What is important to, again, maybe reiterate here, which like I said a little earlier is the absence, when you look at interventions, the absence of adequate documentation to help us understand, uh, why people or why those who intervene have intervened in the way that they have. That's sort of the limitation, but we're still going to try to make sense of it because our research is retrospective. We're looking at interventions that have already been undertaken so we can learn from them, uh, moving forward. And one of the things that is also emerging and is important piece of evidence is that when the, as we move forward, we may need to be investing more in, um, supporting the ability of, um, those who program and intervene, uh, to be able to monitor and evaluate. It's often the missing piece in this work. Um, and, and I can understand why what people want to do is respond immediately to an issue that they're facing an issue that is challenged as for a long time. Uh, but those other pieces with regards to why are you doing what you're doing, you know, why are you implementing this particular type of intervention remains a very, very important.

Jacinta: Um, another point to raise here just with regards to an intervention I'd mentioned earlier that law is a form of intervention. Um, the work of advocates over the last several years have seen many governments now create policies and create laws. Um, but what the evidence is telling us is that what laws have done to date is to depress reporting essentially. Meaning people may not tell you if they've been cut because essentially the law has criminalized the practice. So it'll go underground. And so that means how would we then really understand what is happening. But this is not a comment against law. You, you do need laws. You need laws because they create the environment for us to do the work we need to do. Because it shows that, uh, the state is supportive on the intervention. So it's a very important piece of policy. What is missing is the aligning of the necessary resources or the necessary understanding of what you need to support the implementation of law. So we have a study, which is, we've just developed a protocol now, so it's about to be implemented, but we'll try to answer that question. The question being when and why do people obey law. And those insights...And we're looking at communities where, of course FGMC is prevalent, uh, might begin to give us some insights into a possible way forward. What is it that we have not done well? What is it that's missing when we, you know, uh, create laws and policies, important as they are. So, um, that is an important current evidence out of looking at law as, as an intervention.

Jacinta: And then the third, um, and I'm just highlighting one example of an intervention. I mean, the interventions are so many. Uh, we also looked at with a third theme, which is what are the wider impacts of FGMC. Uh, these particular research projects will we begin, and we have just completed that work, looking at what are the possible associations between FGMC and early child, uh, which is a great interest to many people. Uh, what are associations with HIV AIDS? Currently, we don't see strong correlations. Um, what are the associations with Fistula? So the beginning baseline work is really, and it's actually available to the public, it's up on our website and can be looked at. But what's key about those studies is that in the history of this work, there's been mostly sort of an anecdotal evidence that there is associations, right, so what we've done is actually produced the evidence that currently this is what the evidence shows and that, but this evidence says to us that we may need to dig deeper to understand actually where the, the, there are associations that we were not evident when we first started looking at the issues. Um, so for example, when you look at, uh, FGMC and early child marriage, uh, we, we know that there may be communities where when there are changes contextually, let's say a conflict, displacement of families. Families may begin to cut their daughters earlier because, um, the, the, the, the societies have been destabilized they are marrying off the girls earlier because the context has changed. They can no longer look after their daughters. So sometimes they can be that sort of association we see happening earlier. But there's also communities who practice, um, early child marriage who do not cut their daughters, the communities that cut their daughters into not practice early marriage that our communities with also just noticed who will begin to move away from either early child marriage or FGMC, but not both. What we want to understand is why, like why one and not the other, that's the sort of the final question in, in the report that's just come out.

Jacinta: So that means there is more work to be done and that's the nature of research. You know, you start to answer some questions and as you do that new questions emerge. And the decision has to be made, do we now follow that question? Right? So that's where that is. Uh, and then there is the last research theme where there are gaps, which was a, what would be broadly called the theme is broadly called measurement. And here we're asking ourselves, what are valid measures of change? How do you measure change? How do you know that change has occurred? Um, and it's the complexity here is that, um, we're trying to determine how, you know that there's been a social change cause we talking about this is a social norm. How do we understand that that change has occurred? So those are the four very broad thematic areas of our work.

Jennie: Okay, good. So a lot of it is focused on data and evidence. Um, and that's really important. But can you talk a little bit about why data and evidence is so important to creating a, uh, abandoning these social norms?

Jacinta: What is clear is that a reliable data is essential if you are to understand whether you've made any progress to begin with. Right? So this is actually why data is so important. Data also tells you where you need to work. So that already is an argument for why you need to have data. So you can understand what is working. And data is, yes people might say just mostly numbers, but data is also, and we do both quantitative and qualitative work. So it's both. We're asking people to talk about their experiences and we're also counting what is happening. So it's to put it simply right, it's more complex than that. Um, so it is absolutely important to have it because it, um, is showing us and I think good example is, um, evidence is showing us where shifts are beginning to happen. And really good examples of that evidence is the first one I mentioned earlier, which is medicalization. Because we were looking at data, we were looking at prevalence data, we're looking at trends. We were, we're able to see that there is a move towards medicalizing. So that's a very important finding. Data also tells us who is medicalizing. So that's really important. Data tells us to use the same example of medicalization when you look at Egypt that mothers are or families have handed that responsibility of decision making to doctors. So they'll go to a doctor and say, is it time to cut my daughter. Can I cut my daughter? Will you provide for, uh, the service? So it seems this responsibility has gone onto medical doctors. Where medical doctors are those who advice families when and whether to cut. Um, and that in itself tells us that interventions are going to be directed at doctors as they're going to become a key target for any interventions that we think about. And so our work has already begun to craft what those interventions might look like from given the lessons that we're learning around medicalization.

Jacinta: So that's important data. And I would pick a different country like Sudan and look at what the same medicalization data tell us. It tells us, I said earlier, tells us that it's mostly midwives and nurses. Now when we start talking to people in the field, now to get sort of the qualitative aspects of it, uh, healthcare providers. Um, and when we have this now and record, would say, if I don't provide the service, I will be ostracized. The sanctions are very high for not providing service. This tension is coming from the community. So for health care providers who have an ethic of doing do no harm, you can see the complexity and challenge they face because those sanctions are a very effective sanction, can be as will shed that you will no longer be invited to or be welcomed into community activities. And we know that this community, we know that, uh, in, in the communities in which we work, uh, people are very interconnected cause we are talking about village communities. And in this particular instance, it was a rural community. So how does one conduct their life in the absence of having these relationships with the broader communities in which they live? So it's very effective. Uh, so if the medical, um, the health care provider, uh, chooses not to, they'll just look for one that will. So it means that there's also money in it, right? They're making money from providing the services, not for free.

Jacinta: The other important piece of uh, evidence coming out of the medicalization study, again highlighting the power and importance of evidence is that in Egypt we are seeing that FGMC is being called refinement, right? And then that, and it's more, it's cosmetic. So what does this therefore mean with regards to how we begin to talk about, um, FGMC in those communities. This is the value and the importance of evidence, right? It's bringing this forward, this new information about understanding how that is the change that's happening in Egypt. So change with regards to who is providing cutting and when, when meaning, we see that the age of cutting is also shifting or changing. In many communities, girls are being cut at a younger and younger age. There are communities such as Nigeria where girls have always been cut almost within 10 days of birth. So that is not a consequence of medicalization or a consequence of change. That's just what they've always done. But generally speaking, the age of cutting is dropping. And part of it has to do, and this is the contradiction, it has to do with the fact that we have laws. So this is how it is. So this is one way you make, you can make the issue sort of become invisible or disappear cause girls wouldn't remember they have been cut. They've been cut at such a young age they won't even know they've been cut because for them that's just how the genitalia looks. Right? So that's what will happen there with the decreasing age of cutting. So decreasing age of cutting because we have laws now that are making it more and more difficult. Um, and and also because some parents have said or mothers also say if you cut at a younger age, it's less painful. But that's also one of the other things that we see begin to happen. That's not to say that I'm seeing that's what is true, but that that's what is often sometimes presented. All of those reasons as to why the age of cutting is changing.

Jacinta: The other shift that we're seeing is in type, meaning the type of cutting. So, as I said earlier, we know there are four types of cutting or circumcision. And in communities and good examples are probably among the Somali community who have type three, which is the most severe form. So one of the things we are seeing in our, in our research, um, is that the community saying we are cutting sort of moving towards less severe forms of FGMC. The problem is we actually don't know whether that's true or what that looks like because you'd have to do clinical examsctually that's what, it's not ethically possible for us to do that. But um, they're, they're also saying that, that, that they're moving towards less of forms because that means it'll create less harm. And this is the contradiction of the work because we have often, and we still do say FGMC is a harmful practice. So that discourse has been a very powerful one and possibly very effective, uh, in the sense that therefore families who cut their daughters, not because they don't love them, they cut them. You know, they would as they argue, because they love their daughters and this is a cultural practice. So they look for means of um, practicing and creating less harm. So sort of harm reduction strategies. That's the medicalization, that's a less severe forms of cutting, that's cutting at a younger age. Now this is not consistent across all communities. I'm sharing that as examples of some of the evidence we seeing in some of the communities where we are exploring this. So there's also the use of the word sooner to imply that it's also less, lesser forms of cutting. But when we ask what is sooner, we find that the responses are extremely varied and diverse. So that means we really do not know actually what sooner is even though that term is being used. And also the, it's problematic to use the term sooner as some religious leaders have told us because that what that does, it seems supportive of the practice. Its as if to say, yes, it is actually you got to support in religious texts. Uh, and the, the other complication linked to that is that there are religious leaders who continue to support the practice and there are also religious leaders who are not in support of the practice. And they've become advocates to end the practice. Um, so those are also, again, just highlighting that the complexities of, um, of this area of work. Um, but complexities that do have to be understood.

Jacinta: The other change that has happened, and again, it is a result of interventions because people are more aware. There's been a lot of creating knowledge and understanding is that a we see a lot of cross border also movement of practices. And what this means is that people will move from one country where the laws are strict and if they're not, then if they are strict or not strict, it's more that there is sort of more followup and enforcement. So People will cross to a place where that is not the right where this less enforcement or where they may not be alone to also cut their daughters. So that says to us, we will need to be looking at these sort of cross border issues to understand them better. Uh, what, what would the nature of the intervention be and the other change that is coming out of...the change that we see manifest when we look at our data is that, that, um, men increasing number of men in the, and this I think we didn't know that our, um, in support of ending the practice or doesn't support on helping interventions to end the practice, uh, as they understand that they don't want this to be a practice that they continue with their daughters or the recognize some of the harms that they can be with regards to their, their own partners.

Jennie: Okay. So we've talked a little bit about what are the impacts of FGMC on women and girls. Did we move, can you maybe dive a little deeper and talk about some of the impacts that um, women and girls are seeing?

Jacinta: We, we recently completed, um, a study that looked at the impact, uh, on, on girls and women, uh, and primarily the health impacts. Uh, and what was important about that is we saw that we, we generally tend to know the physical impacts, right? We know that the pain, the trauma, um, consequences, uh, the bleeding to need to name another example that is a consequence of FGMC. What we haven't paid attention to, uh, in terms of impact is the psychosexual impact of FGMC. So our evidence, so our recent research is beginning to highlight the need to, to be focusing in that area, in that direction. Uh, we know that there are instruments for, for example, to measure, um, the, uh, psychosexual aspects of women's and men's lives. But we also found because of the research we've just done, that those instruments are often not culturally sensitive. And so we are, our evidence is suggesting that there may be need in, in, as we move forward to begin to develop the kinds of tools that would be much more helpful to to health care providers. So that health care providers would also be recognizing what they, what they're faced with. You know, uh, the immediate response will be, how do you manage bleeding? How do you manage pain, uh, and less about what other psychosocial impact of what is just happened and how do you manage that? That takes skill, uh, that will take expertise, that will also take resources. Uh, and so the value of the evidence is that it's pointing in that direction and seeing that this is where we need what we need to see happen. So those are the impacts that you're beginning that we see.

Jennie: Okay. Good. Um, and so you talked a little bit about that we're seeing a decline. Can you talk a little bit about what regions we're seeing these in?

Jacinta: So for example, the prevalence data currently shows us that, um, overall pre prep prevalence rates could be said to remain high generally. Like you said earlier, we have something like, um, possibly, uh, 30 million girls at risk, right? But when we look now more specifically at countries, we note that a steady declines are evident in Kenya, in Nigeria, in Togo in our current findings. Um, when we look at the countries where the FGMC is universally are practiced, such as Somalia, Guinea, Djibouti, Egypt, and Sierra Leone, we note that in three of them, Somalia and Djibouti and Guinea, there's been hardly any change. But in the other two where, which are universally practiced, meaning the whole country, which is very high prevalence, Egypt and Sierra Leone, we are seeing there's been change over time. Right? So that's what that's positive. Uh, and then there's countries such as Ethiopia or Burkina Faso where the prevalence is high, but we also are noting that there is some actually very positive trends. And this goes back to the point I made earlier about national prevalence rates that they make or visible, uh, understanding actually what's really happening on the ground so that when you go closer, uh, to look at subnational data, you can begin to see that even within one country there'll be communities where it remained universal at 80 or 90%. In the same country there'll be communities who practice where there is a steady decline, uh, in the same country there'll be, there'll be those who stopped the practice. Um, so that's why the national data is often, uh, not very useful in terms of where should we work. The other interesting thing about that is because the subnational data pulls us into countries to look more closely, uh, at communities and to understand where interventions had been in the past and whether they've worked or not worked is that, uh, it also helps us see some of these contradictions. So there are communities, for example, the QC in Kenya, which tend to be relatively very well educated, yet they cut their daughters. And then there's communities such as the Kikuyu who we've seen a steady decline and they too have, arecommunities where there is a higher education of daughters. We've seen it essentially move towards ending the practice and amongst some of them the practice has ended. So the study that we've just concluding now is actually looking at the, of those communities to make sense of, uh, what was it that they have been doing over these past, uh, essentially two decades that has about this change. Then I'll have the, hopefully the answer for you by the end of this year.

Jennie: Great.

Jacinta: And where do we want to go from here given that question around data? Um, and it's true that over the, these past two decades as the period we are focusing on, um, given our earlier work as the council, Population Council that we recognize, yes, there's been progress, especially progress in our understanding and the interventions we, um, that, that we see, not ourselves, but that others have implemented and we're now studying to understand better and increase our own knowledge. The picture still remains and complete, right? So that's why we are here. Uh, but we have something to offer in the sense of saying that to, uh, to, to accelerate this progress, we are going to need to invest more in national data because we do need to begin there. And then especially for missing countries that aren't included. Um, and then move from there to improve subnational data collection so that it's much more, we are more informed about how we target and where it's worked, how we amplify and where we worked with. We can pat ourselves on the back and say, oh, this is what works and this is how we can support communities who are seeking to change. Because even in communities where there is the practice, there'll be individuals who want to change, but for whom it's very difficult. So how do you create the kind of enabling environment that that where that becomes possible for those who are contemplating change. Because those will be those very same communities as there'll be those who are not considering change as there'll be in the same communities, those who have actually stopped, but it's very private still and nobody knows that they're not cutting their daughters. Also what we are learning, the other thing that I want to raise here, but where do we go from here is the need to test interventions. That might sound very sort of maybe research based, but testing interventions means that uh, we are calling for the need for high quality evaluations of interventions. Uh, we're calling for impact evaluations. We're calling to testing what people have actually done so we can learn from it so that we can scale up. That's really where we need to go so we can enhance our understanding of what works and what we can build even more the evidence that informs what we do.

Jacinta: Going forward. The other point about where do we go from here is to be directing resources towards investing in monitoring and evaluation, which means as the interventions themselves are happening, um, but we are building capacities or strengthening the capacities to describe interventions to understand the interplay between the components of interventions as they move forward. Again, that will inform how we move forward because that's really where the work is. And then lastly, you know, uh, with regards to where do we focus efforts without question, where prevalence remains high, but also where change is underway though prevalence remains high because it means that that's an entry point because this we can see change. Uh, we should also focus efforts on where there's a steady and longterm decline, uh, because here we will have lessons that can inform what we are doing. But with caution, when I say that that is, as I said at the start, the practice of FGMC has different, uh, reasons, rationales why it is practiced and how it is practiced. So the lessons, there must be lessons that, uh, we look at critically and reflect upon as we think about would this work here and why would it work. Uh, and then lastly, again, just to repeat, because it's become really important for me every quarter, which is that the subnational hotspots are the ones that will require specific efforts, goes without question. That's where the work needs to be done. Without question. Okay.

Jennie: Great. Well, thank you so much for being with me today,

Jacinta. It's been a pleasure talking to you. Um, thank you.

Jacinta: Well, thank you very much. It's equally been a pleasure for me to be here talking with you.

Jennie: For more information, including show notes from this episode and previous episodes, please visit our website reprosfightback.com. You can also find us on Facebook and Twitter at rePROs Fight Back. If you like our show, please help others find it by sharing it with your friends and subscribing, rating and reviewing us on iTunes. Thanks for listening.

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