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African Journal of Reproductive Health
Women's Health and Action Research Centre
ISSN: 1118-4841
Vol. 10, Num. 2, 2006, pp. 24-36
Untitled Document

African Journal of Reproductive Health, Vol. 10, No. 2, August, 2006, pp. 24-36

ORIGINAL RESEARCH ARTICLES

Being Victims or Beneficiaries? Perspectives on Female Genital Cutting and Reinfibulation in Sudan

Berggren, V1; Musa Ahmed, S2; Hernlund, Y3; Johansson, E4; Habbani B2, Edberg A-K5.

1Vanja Berggren, Division of International Health Care Research (IHCAR), Department of Public Health, Karolinska Institutet, 171 77 Stockholm, Sweden, and Department of Health Sciences, Kristianstad University, 29188 Kristianstad, Sweden, Telephone: + 46 44204077, Fax: + 46 44204019, E-mail: Vanja.Berggren@staff.hkr.se 2 Ahfad University for Women, Khartoum/Omdurman, Sudan, and Khartoum Centre for Psychological Medicine and Counselling, Khartoum, Sudan, Telephone: +249 15556945 , E-mail: suoadm@yahoo.com 3Department of Anthropology, University of Washington, Seattle, Washington 98195-3100, US, Telephone: +1 2065435240, Fax: +1 2065433285, E-mail: yher@u.washington.edu 4Division of International Health Care Research (IHCAR), Department of Public Health, Karolinska Institutet, 171 77 Stockholm, Sweden, Telephone: +46 851770000, Fax: +46 8311590, E-mail:Eva.Johansson@phs.ki.se 5Department of Health Sciences, Kristianstad University, 291 88 Kristianstad, Sweden, Telephone: +46 44204075, Fax: +46 44204019, E-mail: Anna-Karin.Edberg@staff.hkr.se

Correspondence: Vanja Berggren, Division of International Health Care Research (IHCAR), Department of Public Health, Karolinska Institutet, 171 77 Stockholm, Sweden, and Department of Health Sciences, Kristianstad University, 29188 Kristianstad, Sweden, Telephone: + 46 44204077, Fax: + 46 44204019, E-mail: Vanja.Berggren@staff.hkr.se

Code Number: rh06024

Abstract

Female Genital Mutilation (FGM) or the more value neutral term, Female Genital Cutting (FGC) is widely practised in northern Sudan, where around 90% of women undergo the most extensive form of FGC, infibulation. One new approach to combating FGC in Sudan is to acknowledge the previously hidden form of FGC, reinfibulation (RI) after delivery, when the woman is sewn back so much as to mimic virginity. Based on a qualitative study in Khartoum State, this article explores Sudanese women's and men's perceptions and experiences of FGC with emphasis on RI after delivery. The results showed that both genders blame each other for the continuation of the practices, and the comprehensive understanding of the perceptions and experiences was that both the women and the men in this study were victims of the consequences of FGC and RI. The female narratives could be understood in the three categories: viewing oneself as being "normal" in having undergone FGC and RI; being caught between different perspectives; and having limited influence on the practices of FGC and RI. The male narratives could be understood in the three categories: suffering from the consequences of FGC and RI, trying to counterbalance the negative sexual effects of FGC and striving in vain to change female traditions.
The results indicate that the complexity of the persistence of FGC and RI goes far beyond being explained by subconscious patriarchal and maternalistic actions, related to socially constructed concepts of normality, female identity, tradition and religion in a "silent" culture between men and women. (Afr J Reprod Health 2006; 10[2]:24-36)

Key Words: Women's experiences, men's experiences, Female Genital Cutting; Female genital Mutilation; Infibulation; Reinfibulation

Résumé

Etre victimes ou bénéficiaries? Perspectives sur la mutilation génitale féminine et la reinfibulation au. La mutilation génitale féminine (MGF) ou bien le terme neutre de plus de valeur, l'excision génitale féminine (EGF) est pratiquée un peu partout au Soudan, où environ 90% des femmes subissent le type le plus coûteux de l'infibulation, l'EGF. Une nouvelle approche pour combattre l'EGF au Soudan consiste à reconnaître l'ancienne forme cachée de l'EGF, la reinfibulation après l'accouchement quand la femme est tellement recoussue si tellement comme pour imiter la virginité. Cet article qui est fondé sur une étude qualitative sur l'état de Khartoum explore les perceptions et l'expérience des femmes et des hommes soudanais par rapport à l'EGF, tout en mettant l'accent sur la RI après l'accouchement. Les résultats ont montré que les deux genres s'accusent l'un et l'autre pour la continuation de la pratique et la compréhension totale des perspectives et des expériences étaient que les femmes et les hommes dans cette étude sont victimes des conséquences des l'EGF et de la RI. Les narrations des femmes peuvent être comprises dans trois catégories: s'apercevant comme un être "normal" pour avoir subi l'EGF et la RI; être attrapées entre les perspectives différentes ayant une influence limitée sur les pratiques de l'EGF. Les narrations des hommes peuvent être comprises dans les trois catégories: la souffrance provoquée par les conséquences de l'EGF et la RI, les tentatives de contrebalancer les effets sexuels négatifs de l'EGF et s'efforcant en vain de changer les traditions féminines. Les résultats ont montré que la complexité de la persistence de l'EGF et la RI dépasse l'explication par la subconscient patriarchal et les actions matriarcales relatives aux concepts socialement construits par rapport à la normalité, l'identité, la tradition et la religion dans une culture "silencieuse" entre les hommes et les femmes. (Rev Afr Santé Reprod 2006; 10[2]:24-36)

Introduction

In recent decades, female genital cutting (FGC), also known as female circumcision (FC) and female genital mutilation (FGM), has attracted much attention. This paper will use the term FGC in an attempt to find language that is value neutral, but which adequately describes the nature of the procedure. It is defined as all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons.1 In spite of many years of international campaigns and local activities throughout Africa, around 130 million now living women and girls are estimated to have undergone FGC.1 The motives for FGC are complex and vary between different contexts and within time, and there is still a need for more elucidation of underlying motives, attitudes and the decision-making processes.

Heated international debates surrounding the practice of FGC have often focused on the health risks associated with the different procedures.2 Several physical health complications, for example during childbirth, have been documented, ranging from infections to severe bleeding, shock, prolonged labour and even death.1-7 Most complications are reported in relation to the most severe form of FGC, infibulation (meaning tightening, from Latin fibula) where the clitoris and labia minora are cut away and the raw edges of the labia majora are brought together to fuse, leaving only a very small opening. This form of FGC is the most prevalent one in the Horn of Africa. Sudan is one of the countries with a seemingly constant prevalence of FGC, in spite of national legislation and local campaigns against the practices. FGC, mainly infibulation, is a highly institutionalised custom that is ingrained in Sudanese society.8-10 According to research conducted over the past twenty years, the overall percentage of FGC in the northern states has stayed nearly constant between 89% and 93%.8,11-12 However, previous research has shown that more educated and urban women tend to prefer less severe forms of FGC for their daughters, including clitoridectomy, where only the clitoris or parts of it are cut away.13 There is, on the other hand, evidence that the practice of FGC has been spreading in Sudan to new groups among southerners and other ethnic groups through contact with urban northerners as a form of modernisation.9,14 This development has recently received attention in comprehensive recommendations from the Ministry of Health of Sudan.14

One new approach in the Sudanese national agenda to combat FGC is to acknowledge the previously hidden practice of reinfibulation (RI) as part of the problem.14 Reinfibulation (literally meaning putting right and improving) has been defined as the re-stitching after delivery of the scar tissue resulting from infibulation7,15, but is also described as additional tightening mimicking the narrow introitus of a virgin.8,18-19 Few studies have looked at the prevalence of RI, but already in 1982 El Dareer8 stated that over 50% of Sudanese women (with primary infibulation) underwent RI at least after delivery. Another study from 1983 showed that almost 80% of infibulated married women submit themselves to RI and, of these, over 45% had undergone RI five times or more.5 RI has even been recognised to be performed up to six times yearly by some ethnic groups.17 In previous literature, the motives for RI have been described as purely sexual, emphasising the expected penile pleasure of the husband.8,18-19 There is, however, limited knowledge about how FGC and RI are perceived from a gender perspective.

This study was performed with the aim of exploring Sudanese women's and men's perceptions and experiences of female genital cutting with emphasis on reinfibulation.

Setting and Methods

The study design was descriptive and explorative and based on interviews with men and women in Khartoum State, Sudan, between September 2002 and June 2003.

Context

Sudan is one of the countries with the highest prevalence of FGC in the world, estimated at 93% in urban northern areas and 89% in rural northern Sudan, including the southern parts where FGC is rarely practised. The overall prevalence of the most severe form, infibulation, is estimated at 65% in the whole of Sudan. As regards the context, as in many other African settings, the population under 15 years constitutes 45% in Sudan. The overall literacy rate is 40% for females and 66% for men. In 2001, the maternal mortality ratio in Sudan was estimated at 763/100,000 live birth and the infant mortality 93 per 1000 births. The life expectancy at birth is 52 years for males and 56 years for females.12

The position of women in Sudan varies from region to region and from one ethnic group to another. Nonetheless, the importance of the family is something that overrides these differences. It is the family that is the principal social unit of Sudanese society; above all, its honour and dignity must be preserved. Dignity and honour depend upon the behaviour of every family member, especially the moral conduct of its women.5 Middle Eastern cultures such as Northern Islamic Sudan are often characterised as sharply distinguishing between the worlds of men and women.20-22

Data collection procedure

Because of the sensitivity of the issue, an initial, cautious feasibility study was carried out in several steps. Feasibility studies are recommended in the design and early testing of a research approach in order to provide clues about likely success and about ways to strengthen or modify the research, as well as to provide methodological guidance. 23

First, two focus groups were arranged, one with men and one with women, in order to obtain more in-depth insights into the issue of FGC and RI and to elaborate questions for the interview guide. The focus groups were organised in accordance with the recommendations for in-depth exploration of sensitive issues by Barbour & Kitzinger.24 Each group consisted of five members, chosen to be heterogeneous with diversity in age and demography. The focus groups embraced discussion of both FGC and RI. The interviewers were four Sudanese female counselling psychologists trained at Ahfad University for Women and working at Khartoum Centre for Psychological Medicine and Counselling, working in pairs. One interviewer tape-recorded the discussions with the consent of the participants and another acted as an observer and took notes about the sequence of talk. Thereafter ten pilot interviews were conducted in order to test the questions that had emerged from the focus groups. Interviews were performed with five women and five men, of different ages and educational backgrounds and coming from different areas in Khartoum State, both rural and urban. The interviews were conducted in an isolated place to minimise interference and to maintain privacy. The participants were asked open-ended questions about their own experiences and their general perceptions, attitudes and practices of primary FGC and RI. Follow-up questions were asked to deepen, develop or clarify the answers.25 The analysis of the pilot interviews formed the basis for the final interview guide regarding perceptions and experiences of men and women towards the following themes: clarifying definitions of practices, attitudes to uncircumcised girls, attitudes and practice of FGC and RI, motives for, perceptions of and experiences of FGC and RI and the decision making process.

The main study

The main study comprised twenty two in-depth interviews, including twelve women and ten men. The participants were selected by purposive sampling with variation in economic status and ethnic group. The intention of this sampling was to document diverse variations in answers and to identify important common patterns, as recommended by Patton.26 Thus the inclusion criteria for the participants were: difference in age, education, ethnicity and geographical area. The participants were selected among staff working in two health-care centres, staff in a university, and from traders in a market, all from four different areas in Khartoum State. In all, twelve women and twelve men were asked to participate, of whom two men declined participation. All participants were married, except one man who was divorced. All participants were Muslims, but they originated from several different ethnic groups.

The female participants were between 19 and 68 years old. Two women were illiterate, one woman had primary education, five had secondary education, two intermediate and two had university education. The female respondents were teachers, nurses or housewives.

The male participants were between 28 and 47 years old. Five men had secondary education, two intermediate and three had university education. The male respondents were working as businessmen, physicians, nurses or gatekeepers.

The interviews were performed by the same interviewers as in the feasibility study and were based on the developed interview guide to collect interview data to saturation or to "find information that continues to add until no more can be found" (p. 56).27 Saturation was reached after interviews with nine women and seven men. In addition, three women and three men were interviewed to confirm the saturation. Each individual interview lasted between one and two hours. All the interviews were performed in Arabic, tape-recorded and transcribed word by word into Arabic. The text was thereafter translated into English.

The participants were assured confidentiality and verbal and written information explaining the nature of the study was given to the participants before each interview. Informed consent was thereafter obtained from the participants, who were informed that they could refuse participation and withdraw from the study at any time.

Analysis

Content analysis is relevant for application to research problems regarding the interaction of culture, social structure, and social interaction in society.28 The text was analysed using manifest and latent content analysis.29 Latent content analysis of the text consists of dialectical movements between the whole and the parts and between understanding and explanation. The analysis focused mainly on patterns in difference and similarities in the perceptions and experiences of the issues studied of women and men respectively. Statements in each topic area were critically analysed and questioned, read and compared in order to achieve reasonability. Lastly, the researchers individually reflected on and thereafter discussed the findings, taking the research questions and their pre-understanding into account, and agreed on the main categories.29 The research team analysed the preliminary findings in Sudan and performed the final analysis in Sweden.

Research cooperation over cultural and language boundaries needs special consideration, and during the whole process this study was conducted in close collaboration between researchers from Sweden and Sudan. Ethical approval for the studies was obtained from the Ministry of Health, Khartoum, Sudan, by Ahfad University for Women, Omdurman, Sudan, and by the Ethical Committee of Karolinska Institutet, Stockholm, Sweden.

Results

The text resulting from the interviews with the men and the women contained descriptions of their personal experiences of FGC and RI, as well as their perceptions of the impact the practice had had on their own lives. All the women interviewed had personal experience of the most severe form of FGC, infibulation, except one who had undergone an intermediate form of FGC. A majority of the women (eight) had submitted themselves to RI after delivery and some also in between deliveries. Seven of the women had daughters who had undergone FGC, and two of them had had all daughters infibulated while five women had let their daughters undergo clitoridectomy or "sunna". Five women had young daughters who had not yet undergone FGC, but four of them planned to let their daughters undergo clitoridectomy/sunna or infibulation later on. Only one mother said that her daughters would not be submitted to any form of FGC.

All the wives of the interviewed men had undergone infibulation, except one who had been submitted to clitoridectomy. Half of the wives of the men interviewed had submitted themselves to RI, at least after delivery. Three of the men had daughters who had undergone FGC, and two of these men's daughters had undergone clitoridectomy. One man had no daughter, five had daughters who had not undergone any form of FGC, and one did not know which form of FGC his daughters had undergone.

All the women were well informed about different types of primary FGC. An uncertainty was observed among at least two of the men concerning the procedures of FGC. One man also said that he only considered infibulation (in Sudanese Arabic: Pharaonic) to be FGC, not the "sunna" type, clitoridectomy.

Concerning RI, all participants were aware of the different repairs after delivery. Their definitions included "Khiata" (literally meaning the repair), suturing to the same size as before delivery and the additional tightening, reinfibu-lation (RI), re-circumcision, or in Arabic El Adel (literally meaning putting right and improving), when a re-suturing is performed on the sides of the vaginal orifice to recreate the size of primary infibulation, a pinhole size. This latter form was the focus of this research

The women stated that it is the midwife who performs the operation after delivery, or in between pregnancies. It is usually performed between two hours and forty days after delivery, either in the hospital or in the home of the woman or the midwife.

The participants' perceptions and experiences of FGC and RI

The narratives contained rich descriptions about perceptions and experiences of FGC and RI and the impact these practices had on participants' personal lives. The female narratives could be understood in three categories: viewing oneself as being "normal" in having undergone FGC and RI; being caught between different perspectives; and having limited influence on the practices of FGC and RI. The male narratives could be understood in three other categories: suffering from the consequences of FGC and RI, trying to counterbalance the negative sexual effects of FGC and striving in vain to change female traditions.

The comprehensive understanding of their perceptions and experiences was that both the men and women in this study were victims of consequences of the practices (Table 1).

The women's perceptions and experiences

Viewing oneself as being normal

The women's narratives involved several aspects of being "normal", expressed in relation to being purified and re-tightened and being sexually restrained. Being sexually restrained was only mentioned in relation to primary FGC, but being purified and re-tightened was mentioned in relation to both FGC and to RI.

The importance of purification and tightening was mentioned both in relation to the primary forms of FGC at a young age, and to RI after and in between deliveries. Tahur/Tahara, the local Arabic words used by the respondents for FGC, have a connotation of purification. The women also described RI as a procedure of purification and re-tightening needed after delivery, to become covered and closed again.

Added to purification and re-tightening, beautification of the genitals was also mentioned by some. Some women further explained that women continue to submit themselves to RI because they are worried about being perceived as "not normal" by other women:

"I know from my own experience what re-circumcision is and why wives do it. The person feels she is not normal and something wide and loose is between her thighs. Another reason is sexual enjoyment for her and her husband. My husband likes re-circumcision, but he knows it is only painful for me so he asks me not to do it." (Woman, 37 years old)

Regarding the social consequences, women described how families that decide not to let their daughters undergo FGC are perceived to be at risk of stigmatisation. They stated that neighbours insult girls who have not undergone FGC, for example by the expression "Ghalpa", meaning that the girl is perceived as smelling nasty. In many of the interviews the uncircumcised girl/woman was described as hypersexual, without ability to control her sexuality. This was considered undesirable for marriage, since a girl who is not circumcised could create problems for the family in getting her married and marriageability was mentioned as important. The purpose of FGC was understood as being to prevent the social shame for the family that might come if a teenage daughter has sexual relations. It was believed that the non-circumcised girl cannot control herself sexually in order to stay a virgin, and there was a notion that female sexuality is controlled or limited by cutting the clitoris.

"I think she can't control her sexual behaviour, because she has a very strong sexual urge. She has a nasty smell and she is not accepted by the men like the circumcised women are." (Woman, 42 years old)

But some women also described female suffering caused by FGC and RI and said that women without FGC probably were healthier and enjoyed their sexual life more.

"My experience is that the circumcised girl suffers a lot, both at the circumcision, at puberty, at marriage and at delivery. Because of all this pain and because all sensitive organs were removed, the circumcision makes the woman hate the sexual act. I have not the experience of course, but I have heard that the uncircumcised woman enjoys her sex life and that she is very pleasurable sexually to the men." (Woman, 32 years old)

Being caught between different perspectives

Different messages emerged from the women's narratives, in between which the women were seen as ambivalent and caught. Two perspectives could be seen; one perspective based on "traditional" arguments, the other one on a desire for change, both of which could co-exist in the same interview.

The traditional perspective put the emphasis on tradition and on male sexuality and the suppression of female sexuality. The women in the study described tradition as a central reason for performing primary FGC in northern Sudan and the main reason for RI as the alleged male sexual pleasure, for which women have to suffer. The woman who said that RI also was a pleasure for women mentioned this after she mentioned the husband's pleasure. However, almost half the women stated that they enjoyed their sexual life, but their reasons were contradictory or missing. Some women added that RI is traditionally perceived as needed to "keep" the husband, to make him happy and prevent him from divorcing or from marrying a co-wife. RI was perceived as a very intimate issue. Sexuality and RI were described by many as something that is not discussed between wife and husband. The couple might argue about the daughters' form of FGC, but RI was perceived as too sensitive to be discussed. The women said that since women peers and older female relatives, such as the mother and aunts, always tell the wives that this is what the husbands want, this is what they are expected to undergo after delivery.

"It is pleasurable for the husband, I do not enjoy sex with my husband. Sexual pleasure is something far away for me. I feel I am just a tool for my husband's sexual pleasure." (Woman, 45 years old)

The perspective of change, building on personal experiences of negative health consequences, emphasised that women questioned the benefits of the practices of both primary FGC and RI after delivery. This is what could be seen as the perspective of change and it also included a desire to achieve mutual sexual pleasure. The women referred to their own suffering from infibulation, which they did not want their daughters to experience. They wanted to let the daughters undergo a less severe form than they themselves had, but several of them wondered whether they could resist the social pressure. Some women also expressed a desire to achieve mutual sexual pleasure, but since they were already infibulated they found this difficult. A few women argued that re-stitching after delivery (Khiata) is sufficient and that there is no need for the additional tightening operation to mimic virginity because of the pain it causes the woman.

"After the deliveries, there are blood and other secretions that have to come out, but the tightness from Reinfibulation (El Adel) prevents this and I myself suffer much from this and it has caused me health problems such as inflammations, but still I do it for my husband. But I just let my daughters undergo sunna, because it is a kind of cleanliness and protection for the girl." (Woman 38 years old)

Having limited influence on the decisions to perform FGC and RI

The women said that they had limited influence on the decision to perform RI. The interviewed women perceived a strong female peer-pressure after delivery, stressing that it is perceived as necessary for women to submit themselves to RI after giving birth. The women pointed to female relatives, older women and especially their own mothers, but also the midwife and the husband as being behind the decision. None of the interviewed women said that it is the woman herself who takes the decision about RI. Some believed that the midwife is a major decision maker since she benefits economically, and a few women stated that the midwife had performed RI on them automatically after delivery. They also stressed that the midwife does not work on her own, but on the insistence of the husband or the mother of the woman. The women also described how the man sometimes shows his appreciation by giving gifts after the woman has submitted herself to RI.

The younger women indicated that the older women are the ones with power and the ones who insist on FGC, preferably infibulation. The few older women interviewed admitted their interference and stressed that it is an important tradition. Several women blamed the silence of the male society for the lack of change in practice. They argued that it is the men who have the influential role in the family and thus can change the painful traditions. On the personal level, all women who decided to resist RI spoke of support from their husbands and some also had personal experience that the father's role was important in the decision about the FGC for the girl.

"We never talked about the RI, but if he asks me not to do it, I will never do it." (Woman, 29 years old)

"I do not ask my sons and daughters, I will compel them to circumcise their daughters whether they agree or not as long as I am alive. After my death it is up to them." (Woman, 65 years old)

Men's perceptions and experiences

Suffering from the consequences of FGC

Also facing the consequences of FGC, the men described both experiences of their own male complications, male sexual dissatisfaction, compassion for female suffering and perceived challenges to their masculinity.

The men disclosed their own physical complications in relation to tight infibulation and re-infibulation, for example problems with penetration, wounds, and inflammations. The men also expressed empathy for the suffering their wives had to undergo because of infibulation and RI, especially in relation to sexual practices. The men also expressed their psychological dissatisfaction and sexual frustration as related both to the problems of penetration and to their compassion for the wives' suffering. In addition, some men explained that they felt frustrated because of the cultural component that Sudanese women are socialised not to express their sexuality.

The men perceived women's expectations that they should be strong and aggressively show their masculinity, and some also mentioned that the power of the man is perceived to be rooted in his sexuality. Some men said that men attain increased sexual pleasure because of RI, but others argued that the men who request this from their wives are exceptions.

In this context, some men also mentioned the lack of sexual knowledge and communication between men and women about sexuality. Others said that the psychological problems created by FGC increase women's reluctance to discuss the issue.

"There are only negative impacts of these traditions, mainly health problems during delivery. There is also suffering for both the woman and the man during sexual practices, such as pain, bleedings and inflammations. I do not think reinfibulation (El Adel) is necessary for sexual pleasure and the evidence is personal when me and my wife enjoy sex without reinfibulation." (Man, 38 years old)

Trying to counterbalance the negative sexual effects of FGC

All the wives of the interviewed men had undergone FGC, but almost all men had had sexual experiences with uncircumcised women as well. They described how the uncircumcised women showed more sexual response, sensitivity, and pleasure, which also increased male sexual pleasure. The men attributed this to "culture", in that women are brought up not to show their sexuality, but also to the fact that parts of the female genitals were irrevocably removed. The men explained how they were trying to compensate for the effects of FGC with additional foreplay and other means of sexual stimulation.

"I have experience of both circumcised and uncircumcised women and I think there are parts of circumcised women which also are sensitive and lead her to sexual pleasure, such as lips and breasts and women can be highly aroused by those." (Man, 45 years old)

Striving in vain to change female traditions

The men offered comprehensive suggestions for change in the practices of FGC and RI. They emphasised the role of the government, education of girls, official policies and laws in combating the practices, and several requested an official standpoint from the religious leaders to show that there is no religious basis for the practices.

On a personal level, concerning their own family, the men said that they had only limited influence. Almost all the men stated that they did not want their daughters to undergo FGC and no man answered that he wanted his daughters to undergo infibulation. Several of the men said that, although they wanted change, they did not feel that there was any sense in trying because the females who make decisions would not listen anyway. However, a few men described how they had taken the decision themselves, in opposition to the wife, not to circumcise their daughters. A few men also described how, when they forbade their wives to undergo RI, they obeyed and did not do it. The men's narratives indicated that it was not often due to the wife?s own desire that RI was performed, but because of pressure from her mother or aunts or the midwife. None of the men considered RI to be a decision by him, or even a request, but they recognised that some other men did not mind and even enjoyed it. Some men said that RI is sometimes requested by men after delivery, because of the damage that already is there because of primary infibulation. The men thought that primary FGC will decrease in the future, because men are starting to look for brides who have not undergone FGC Religion was frequently invoked by the men as arguments both for and against FGC. The close link between religion, culture and tradition was mentioned by several as an obstacle to change. The few men who wanted their daughters to undergo FGC all mentioned that they preferred the "sunna" type (clitoridectomy) and all referred to religion as justification for this form. On the other hand, several of the men who did not accept FGC for their daughters claimed that the background was that it has no basis in the religion.

"It would have been better if my daughters were not circumcised, but I couldn't help it for many reasons; I was not there when they were circumcised and traditions and customs are very strong even if I had been there. I got angry, but there is no point. My wife would get angry if my daughters were not uncircumcised. She did RI for herself even though I did not accept it." (Man, 45 years old)

Discussion

The main results showed that the overall understanding of the perceptions and experiences was that both the women and the men in this study were victims of the consequences of FGC and RI. Regarding victimisation, both women and men clearly expressed how they experienced personal suffering due to the health consequences of FGC and RI. Both genders blamed the other for the continuation of the practices, but neither of them saw themselves as in position to really be able to change anything. Regarding being beneficiaries, this study confirmed previous research in that the prevailing reasons for FGC and RI are complex and interwoven with socially constructed concepts of normality, culture/tradition/religion, gender and sexuality.

Concerning the law and FGC, it is stated that the girl child is a victim of a crime according to the national law of Sudan.30 The girls who undergo primary forms of FGC are also victimised according to the United Nations Crime Victim Declaration 31. It may be argued that this victim perspective of the comprehensive understanding of the narratives is an expression of a western and outsiders' interpretation. However, both in the local and in the international literature the documentation of the severity of the health complications following the primary forms of FGC are numerous and accurate.1,4-6, 9 For outsiders, this victim perspective is often overwhelming and it is hard to see how the ancient practices could persist in spite of all in detail documented complications. The analysis of this study indicate that there also are perceived benefits of the practices, that promotes and partly might explain the persistence of FGC, prolonged by RI.

At the same time as the women could be seen as beneficiaries of belonging to a perceived normality, they can also be viewed as its victims. The women in this study particularly complained about the strong peer-pressure from the female hierarchy ruled by the older women, which was seen in all the female categories. This particular female social pressure and concern could be summed up in the term maternalism. Maternalism has diverse meanings; according to Sklar32, historians have used it to denote the purely female version of paternalism, meaning some form of interference with another person's preference regarding their own good with the aim of benefiting her.33 According to Weiner34 maternalism is a way to explain variations in the social, political and cultural behaviour of women. Here maternalism implies women aiming at doing good for other women, in a context of male domination. The role of maternalism in FGC (prolonged by RI) in Sudan could be understood in relation to both the overall patriarchal context and the subordination between older and younger women and between mothers and daughters. Al-Sa?dawi describes what it is like to grow up as an Arabic woman: "But my mother rules over my life, my future, and my body, even down to the locks of my hair" (p.116 ).35 These unequal power relations embedded in the maternalistic relations might contribute to sustaining the traditions of FGC and RI. The maternalistic relation between mother and daughter might promote the old attitudes to the coming generation, to the new generation of grandmothers who might be attracted by the power relationship that is linked to being the one deciding about FGC for the daughters, and as mothers of married women, being the one deciding about RI for the newly delivered woman. However, there might be a recent change in family patterns, especially in urban settings.

Olatunbosun36 confirms that the ancient practices of FGC are sustained by a collusion of women, within the existing patriarchal system. Other research has also acknowledged that RI and infibulation are performed in the context of a patriarchal system that emphasises virginity at marriage and marital fidelity in the interest of legitimate heirs and male honour.37,38 For example, the practice of polygamy in northern Sudan might affect the women's reception of the pressure from the female peers concerning RI. As expressed in the findings of this study, women might fear that their husband will divorce them or take a co-wife if they do not submit themselves regularly to RI. Overall in the women's results, the men were seen as the main beneficiaries both of primary FGC, because of increased marriageability and preserved social honour for the family, and of RI, because of its alleged increased male sexual satisfaction. The alleged sexuality on male terms has also been emphasised as a core contribution to both FGC and RI in previous research.8-9,17,39 However, the results of the women's narratives also contained paradoxes concerning sexuality. Half of the women said that they were satisfied with their sexual life, but clear reasons were contradictory or missing. In Gerais and Bayoumi?s study9 in Sudan, almost half of the women and over half of the men (961 respondents) were of the opinion that RI was necessary for sex. In another study, by Ahmed Mageed & Ahmed Musa10, investigating the impact of FGC on the psychosexual state of the Sudanese women, the conclusion was that FGC affected sexual intercourse negatively and deprived women of feeling sexual pleasure. FGC also affected the women's sexual desire negatively because sex and marital life were associated with fear and pain. There is however always a risk of a cultural bias in missing answers from the women, because of the surrounding culture where women are not expected to express their own sexual desire verbally, and are socialised to subjugate it.

The main motives for primary FGC were increased marriageability and tradition. Several other studies have likewise stressed the role of tradition for performing FGC.5,9,39-40 For example, when asked about the main motive, over half of the respondents answered tradition or social custom in a recent national survey. 12. In previous literature, the importance of marriageability16,40 and the value of gender identity20,40-41 have also been described in relation to FGC.

The men themselves could also, but on another level, be seen as victims because of their expressed suffering of the negative health consequences of FGC and RI and the perceived domination of females in the decision-making process. Actually the men claimed that they were hardly involved at all in the decision to perform either FGC or RI. No international or national study has been found where men, whether as fathers, brothers or sons, have shown to be involved in the decision for the girl to undergo FGC. The men in this study claimed that it is not until they are newly married that men get involved when meeting the irrevocable consequences of their wives' primary FGC. Several men in this study expressed a wish that the wife had not undergone primary FGC, which they related both to their premarital sexual experiences and to the negative health consequences of FGC for both women and men. Some men explained that in general men might request RI after delivery because of the form of FGC (implying infibulation) needed this physically, because the damage of primary infibulation is already there. This actually secondary request might confirm women's alleged expectations that men want tight (infibulated) brides and influence the decision-making process for FGC for the daughters.

The men in this study spoke about active male participation in the decision not to perform either primary FGC or RI. It should however be noted that the men in this study were more educated than the women, and more than the average of Sudanese men. It could further be argued that when women interview men, there might be a tendency to present a favourable image, the socially desirable response that refers to giving the answers that are consistent with prevailing social mores. This problem is in some way shared with a great deal of other qualitative research and is difficult to combat.23 In this study we tried to alleviate this bias by having professional psychologists from the same culture as the interviewers, using subtle, indirect and delicately worded questions. The fact that men show attitudes contradictory to the expected one has previously been shown in other studies.5,9,42 Some men explained also in these studies that they leave their disapproval unspoken because, after all, FGC and RI are women's matters. Perhaps, too, as Rushwan, et. al. 5 also mention, they might be reluctant to deviate from the existing stereotypes of Sudanese males. None the less, as both women and men stated in this study: inaction and passive stances by males who are the major decision-makers of the family may be one of the factors in the perpetuation of the practice.

Overall, RI and sexuality were perceived as very intimate issues and both women and men mentioned the silent culture between the sexes as one of the major obstacles for change. On the other hand, the request for a more active role of men against FGC as well as the role of the religious leaders could be seen as important agents for change. These aspects could make a difference for the future, together with awareness-raising campaigns emphasising education of girls and educated women as role models for change of practice.

Acknowledgements

The authors would like to thank the women and men who participated in the research. We would like to thank the vice president of Academic Affairs of Ahfad University for Women in Khartoum/Omdurman, Amna Badri, for encouraging the research project from the very beginning. We would also like to thank Professor Ahmed Mageed at Ahfad University for Women; Dr Asma El Dareer, Khartoum University; Professor Farouk Abdel Aziz, Khartoum University and Ahfad University for Women; Professor Osman Mahmoud Hassanein, El Nilain University, and Mubarak Yahia Abbas, Executive Director, United Nations Association Sudan, for their help and advice in conducting the research. We are also very grateful for the assistance from Khartoum Centre for Psychology, Counselling and Medicine and direct special thanks to the psychologists Negod Babiker, Nihad Airahman, Omima Elsadiq, Suzan Badwi and Swsan Sidiq. We would also like to thank the staff at Ahfad University for Women's excellent library for facilitating the research. We also thank Alan Crozier for revising the language. This study was funded by the Swedish International Develop-ment Cooperation Agency (Sida), Department for Research Cooperation (SAREC).

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